EMI, PEHP, Select Health & DMBA*
* We are not participating providers with DMBA , however, we will submit claims to your insurance on your behalf. You will be responsible for what DMBA does not cover.
Out of Network
As written in the financial policy, we require payment in full at the time of service for any out-of-network services. We will provide you with a “superbill” to submit to your insurance company if you desire reimbursement for services.
The following are tips that may help you to understand your benefits and the necessary steps for navigating your insurance policies and obtaining reimbursement. If we are an in-network provider with your insurance, you may disregard the following information as you will simply owe your co-pay at the appointment, and your insurance company will be billed for the remainder.
Checking Your Benefits
We strongly encourage you to contact your insurance carrier to find out the benefits of your particular plan before coming to our office. It is very helpful to know what to expect financially so that you and your family can make the best decisions about treatment. By looking at your insurance card, you can find out if there is a separate mental health number to call to check on your benefits.
It is important to note that mental health benefits are sometimes different from your medical plan. It is likely that you will have separate deductibles to be met. You will need to find out what your mental health deductible is, and if you have met this deductible to determine your payment at the time of service. You will be required by your insurance company to meet the deductible before your plan will reimburse you for the services. After the deductible is met, your plan may reimburse a certain percentage of what they deem a “usual and customary” amount. You should ask what maximum charge they allow, and what percentage they will reimburse. Some policies also have a maximum benefit per visit.
You will want to ask what your “out of network” mental health benefits are. Here is a list of questions we recommend that you ask your insurance company:
- How much is my co-pay?
- What is my deductible for out of network services?
- How many visits are allowed per year?
- Is there a separate individual and family deductible that must be met?
- What percentage will the plan pay after the deductible is met?
- Is there a maximum dollar amount the plan will pay per visit?
- What are the maximum charges allowed for the following codes?
90791: 90834: 90837: 90847:
It is very important to check with your insurance company to find out if you need to have any prior authorization for services before coming to your first appointment. Lack of obtaining prior authorization can result in immediate denial for payment by insurance companies. The initial visit will be an initial diagnostic interview with the CPT code being 90791 or 90792. This code may be helpful when calling to get prior authorization with your insurance carrier. They will usually need the provider’s name and licensure, as well as the date of the scheduled appointment. Please be sure to follow up with your insurance company and check to see if the services have been authorized before the appointment actually takes place. For subsequent visits, CPT codes can be provided after the initial appointment. These codes may be needed to obtain prior authorization for the subsequent visits.
Insurance companies often require the providers to send in treatment update forms indicating progress in treatment and their recommendations for ongoing services. It is your responsibility to make sure authorizations for ongoing services are current and that you provide us with the information required by your insurance company.
Here is another list of questions to ask your insurance company:
- Does my plan require prior authorization for the initial visit?
- Does my plan require prior authorization for continuing services?
There may be times when the provider or family will find it necessary and beneficial to meet for a therapy session without the patient present. It is important to ask your insurance company if this type of visit is covered or excluded on your policy so you will know what to expect financially. Furthermore, it is important to find out if there are any diagnosis exclusions or psychological conditions that are not covered on your particular policy. Please note that some policies will cover only up to the point of diagnosis and will not cover treatment for certain conditions. This can be helpful in knowing what to expect once claims are filed for your services.
Hopefully this information is helpful in easing the way for you to receive quick and accurate reimbursement from your insurance company. If you have any other questions, please do not hesitate to ask.