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QUESTIONS TO ASK YOUR INSURANCE CARRIER ABOUT YOUR OUT-OF-NETWORK BENEFITS

  1. What type of plan do I have? A PPO, POS, HMO or EPO?

  2. Do I have out-of-network benefits for mental health?

  3. Does my plan require a referral from my PCP in order to see a specialist?

  4. Do I need prior authorization for my provider to use CPT codes 90834 or 90837?

  5. Do I have an out-of-network deductible for my mental health coverage? If so, what is it, and how much of it remains for me to pay this year?

  6. What is my coinsurance?

  7. Do I have an out-of-network out-of-pocket maximum?  If so, what is it, and how much of it remains for this year?

  8. What is the “Usual, Reasonable and Customary” or “Allowable” amount for my therapist in zipcode 10028, using CPT code 90834?

  9. Is there a maximum number of mental health sessions that are covered per year?

  10. What is the process of filing a claim for reimbursement, and how long will it take for me to receive my reimbursement?

  11. Can you confirm that once my out-of-network out-of-pocket maximum is reached, I will be reimbursed 100% of the “Usual, Reasonable and Customary” or “Allowable” amount?

  12. If you are still unclear about how much of my services your insurance will cover, consider asking: If I saw a therapist in zipcode 10028, using CPT code 90834, and charging $250/session for 20 sessions, what would my out-of-pocket expenses be, and what would my insurance cover?

IMPORTANT NOTICE FOR SELF-PAY CLIENTS

No Surprise Act: Good Faith Estimate

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The "No Surprises" Act requires health care providers to provide current and new patients who are uninsured or self-pay with a "Good Faith Estimate" (GFE) of cost for treatment. This regulation attempts to provide patients with transparency regarding their health care costs.

 

Many factors make it difficult to provide an estimate given that the length of therapeutic services is dependent on the individual client and their goals for treatment. Ultimately it is the patient who may decide to stop treatment at any time.

 

If you are uninsured or using self-pay, I will provide you with a GFE in writing. The example below may help give you an idea of the financial expectations for starting therapy with me; however, this is variable based on the session fee, duration and frequency of therapy. The GFE is neither binding nor a guarantee that you and I will work together. The following example of a GFE is for a 12 month period:

 

Individual 50 minute session: $250

Weekly 50 minute session for 52 weeks: $13,000

Bi-weekly 50 minute session for 52 weeks: $6,500

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