First of all, we want to acknowledge your courage in reaching out for support. At Emovere, we understand that you may have been through a lot of pain and discomfort before arriving here now. Navigating your out-of-network (OON) insurance benefits for services can feel overwhelming. Our intention with this guide is to help demystify the process.
Before you call your health insurance, make sure to have your insurance card, name, date of birth, address, phone number or possibly social security number of the cardholder or person for whom the services are for, and a notepad and pen!
Here are a few questions to ask:
- Do I have out of network benefits for mental health with this policy?
- What is my out-of-network deductible? This will let you know how much you’ll need to spend before your benefits kick in.
- How much of my out-of-network deductible has been met? This will help you determine how much more you’ll need to spend in order to meet your deductible. For example, if you have an OON deductible of $1000 but have already spent $750, you’ll only have $250 before your benefits kick in.
- What is my policy period? This is the date range your policy covers. It may be different from the calendar year that starts on January 1st. This is an important consideration when factoring in how much more time you have to meet your deductible.
- How do I submit for reimbursement? Typically you’ll need to obtain a Superbill from your therapist at Emovere. A superbill is a document that includes dates of service, a diagnosis code, a CPT code and your therapists NPI and EIN numbers. Insurance companies have different ways to submit the Superbill, so you’ll want to find out your insurance company’s procedures.
- How long do I have to submit my Superbill? You’ll want to find out if there is a time period after the date of service to submit your Superbill to your insurance company. On average, this ranges anywhere from 30-180 days.
- What are the requirements to use out-of-network benefits? Is prior authorization required?
- What is my coinsurance? This is the percentage amount that your insurance company will reimburse you for each visit (after your out-of-network deductible is met).
- What is the usual and customary rate covered for outpatient psychotherapy services? Insurance companies cover a percentage of what they deem is acceptable for a therapy session, not necessarily your therapists full rate. This is often referred to as “customary rate” or “allowable amount”. Each plan in each insurance company allows a different amount. For example, your session is $120, but your insurance company decides they will “allow” $100 per session. If your coinsurance is 30%, your insurance company will reimburse you 70% of $100 (the allowable amount), not your therapist’s full fee of $120.
- Does my policy cover these services? CPT code 90791 (Individual diagnostic evaluation), 90834 (Psychotherapy 45- min), 90837 (Psychotherapy 53+ min), 90853 (Group Therapy) and what is the usual and customary rate for each?
- Is there a session limit? If yes, what is the limit and how many sessions do I have left?
Lastly, be sure to keep note of the date you called, the name of the service representative you spoke with and a reference number for the call.
As a reminder, this guide is provided to assist you with calling your insurance company to check on your out-of-network benefits. Emovere, LLC is not responsible for the information obtained using this guide.
If you have questions, we are here to help you! Call us today to schedule a no-cost consultation.