There are three categories of health insurance plans: Health Maintenance Organizations (HMO); Preferred Provider Organizations (PPO); and Exclusive Provider Organizations (EPO). As a rule, HMO plans will not reimburse for services provided outside of their network. If your plan is a PPO or EPO, you may be eligible to request reimbursement from your insurance carrier. The therapists at Pacific CBT do not participate as in-network providers with any insurance plans.
Your insurance company will confirm your eligibility and benefits. Here are questions to guide your discussion with the insurance customer service representatives:
“Does my health plan allow outpatient, out-of-network behavioral health coverage?”
“Is pre-approval or prior authorization needed? If so, who needs to provide the prior authorization?”
“Do I need to satisfy my annual deductible? What is the annual deductible? How much have I satisfied so far this year? When does the year begin for my plan (some plans don’t go by the calendar year)?”
“Once I’ve satisfied the annual deductible, how much of the out of network fee will be covered? They will likely say a –% of the “allowed” or “usual and customary” amount. Ask them what the “allowed” or “usual and customary” amount is for out of network, outpatient, psychotherapy (CPT codes 90791 for the first session and 90834 for the other 50-minute sessions).”
“What are the limits to the coverage, i.e. number of sessions per year, maximum benefits?”
“How do I submit claims, i.e. mail, online via website, fax, etc.?”
“Is there anything else I need to know about the coverage that will affect the amount of reimbursement I get?”
The answers to these questions will give you a sense of what you can expect to pay out of pocket and how much the insurance will reimburse. You will pay the fee at the time of service. Your therapist will provide you a monthly “super bill” which has all the information that insurance requires for their purposes. You will submit the super bill on a claim to the insurance. It typically takes the insurance 2 – 4 weeks to process claims. The clinicians at Pacific CBT can assist with insurance reimbursement.
John Montopoli is no longer an in-network provider for Aetna insurance.
The California Coalition for Mental Health is an agency that advocates for mental health coverage for California residents. They provide resources that may be useful in navigating the complex insurance system.