Out of Network Reimbursement Information

Insurance Reimbursement Tips and Questions

These are some tips on how to get reimbursed for my services, but please keep in mind that these are just tips and every insurance company is different. If you are having difficulties, please

contact member services at your health insurance company.

General Tips:

● Have a pen and paper handy. Always write down the number you called, the name(s) of the person/people you spoke to, the date, start time, and end time of the call, and relevant notes of the call, including reference numbers and case numbers.

● Be patient. The system can be overly complicated and the customer service representatives are doing their best. If there is something you don’t understand, ask them to clarify it for you.

● Get a name and reference number for the call.

Out-of Network Questions:

● Call the member services or customer service number located on the back of you member card.

● Select the option about benefits and/or eligibility and do your best to get a live person.

● When speaking to a live person, state that you are "looking to see an out-of- network provider" for "outpatient psychotherapy" and want to know your "out-of-network benefits for psychotherapeutic services". You are not looking for inpatient services or medical services.

● They will then tell you what the benefits are. Write those down. If you do not have any out-of-network benefits, you will generally not be able to be reimbursed for the services.

Ask the following questions:

● Are the following codes are covered: (add the service codes you use here)

○ 90834 Individual psychotherapy 45-53 minutes.

○ 90837 Individual psychotherapy 54-60 minutes

○ 90847: Couples therapy - If applicable

● Is a diagnosis required for reimbursement?

● Do they cover psychotherapy via telehealth?

● Is a Licensed Marriage and Family Therapist a covered provider? You can provide them with the following information if necessary: Lindsey Stewart, LMFT, LPCC npi 1477755742

● How much will you be reimbursed? Is there a deductible? Write this information down. If applicable, ask them how much of your deductible has been met to date and what date does the deductible start/end (usually Jan 1 to Dec 31).

● Is there a maximum out-of-pocket limit and if so, once you reach that, what is the reimbursable amount and will they cover 100% after you reach that?

● Is any prior authorization, pre-certification, or approvals needed? Who needs to make these (doctor, the therapist, psychiatrist?)

● Is there a visit limit?

● How you get reimbursed. Do I need any special forms? Do I submit by paper, online?

● Within how many days after the date of service do you need to submit.

● Tell them you will be paying the provider up front and ask them how you make sure that

● the provider does not get paid. This is a common mistake that insurance companies make: paying me, and not you.

Some additional tips

● Some insurance companies will try to encourage you to use an in-network provider before giving you information. As you know, you are welcome to find an in network provider, and they should be able to provide you with a list of current in-network providers.

● However, it is your right to use your OON benefits. You generally should not have to provide details about why you want to use your OON benefits. Insurance companies must provide you with the details of your benefits, including answering the specific questions on this form

● If you feel the representative does not know how to help you, or is withholding benefit information, you can ask to speak to another representative.

● Please note, I do not offer Single Case Agreements. I should not have to provide anything to the insurance company for your claims to be accepted.

● Recently, some insurance companies are no longer covering Telehealth for OON benefits, or they want providers to use a certain Telehealth platform that requires contracting.