Understanding Out of network benefits and reimbursement

Jul 23

Using Your Out-of-Network Insurance Benefits for Therapy Services: A Comprehensive Guide

Navigating the world of health insurance can be confusing—especially when it comes to using out-of-network benefits for mental health services like therapy. If your therapist at Still Minds Psychology isn’t in your insurance network, it doesn’t necessarily mean you have to pay the full cost out of pocket. Many insurance plans offer out-of-network (OON) coverage that can significantly reduce your expenses.

What Does "Out-of-Network" Mean?

When a healthcare provider, such as a therapist, does not have a contract with your insurance company, they are considered "out of network." Unlike in-network providers, who have negotiated rates with your insurer, out-of-network providers set their own rates. However, many insurance plans—especially PPO (Preferred Provider Organization) plans—still offer partial reimbursement for these services.

Step 1: Understand Your Insurance Plan

Before scheduling a session, it’s helpful to understand your specific benefits. Call the member services number on the back of your insurance card or log into your insurance provider’s online portal to find out:

Whether your plan includes out-of-network mental health benefits
What your deductible is for out-of-network services
The reimbursement rate (usually a percentage, e.g., 50%-80%)
Any session limits or pre-authorization requirements
Whether you need a diagnosis code for reimbursement

Step 2: Pay the Therapist Directly

With out-of-network providers, you must pay the therapist directly at the time of service. Meghan Cromie LPC charges $175 per individual session:

You will usually pay the full session fee upfront
Upon your request I will provide you with a superbill—an itemized receipt required for insurance reimbursement

Step 3: Submit a Superbill for Reimbursement

A superbill includes all the necessary information your insurer needs to process a claim, such as:

Therapist’s name, license number, and NPI (National Provider Identifier)
Diagnosis and CPT (service) codes
Session dates and duration
Session fees

You can submit this superbill through your insurance provider’s member portal or via mail/fax, depending on their claims process.

Step 4: Receive Reimbursement

Once your claim is processed, your insurance provider will reimburse you based on your plan’s OON rate. For example:

If your therapist charges $150 per session
And your plan reimburses 70% after a $500 deductible
You might receive around $105 per session after meeting your deductible

Reimbursement can take anywhere from a few days to several weeks, depending on the insurer.

Additional Tips

Track Your Claims: Keep records of what you’ve submitted and what’s been reimbursed.
Appeal Denied Claims: If your reimbursement is denied, you have the right to appeal.

Why It’s Worth It

Using out-of-network benefits can open up a broader range of therapists, giving you more choice in finding the right fit for your needs. While the process involves a bit of extra work upfront, the financial and emotional benefits often make it worthwhile.

meghan cromie