At Crown Counseling, we understand that navigating insurance benefits can be challenging. This guide is designed to help you understand and effectively use your out-of-network benefits for mental health services.

Understanding Out-of-Network Benefits

Out-of-network benefits allow you to see healthcare providers who are not in your insurance plan’s network. While you may pay more upfront, you can often receive reimbursement from your insurance company.

Key Terms:

• Deductible: The amount you pay for healthcare services before your insurance begins to pay.
• Coinsurance: Your share of the costs of a covered healthcare service, calculated as a percentage.
• Out-of-pocket maximum: The most you have to pay for covered services in a plan year.

Guidelines for Using Out-of-Network Benefits

1. Verify Your Coverage: Contact your insurance company to confirm your out-of-network benefits for mental health services.
2. Understand Your Deductible: Know the amount you need to pay before your insurance starts covering costs.
3. Check Reimbursement Rates: Ask your insurance about the percentage of out-of-network costs they’ll cover.
4. Request a Superbill: We’ll provide you with a detailed receipt (superbill) for each session to submit to your insurance.
5. Submit Claims Promptly: File your claims as soon as possible to ensure timely reimbursement.
6. Keep Records: Maintain copies of all submitted claims and correspondence with your insurance company.

What to Ask Your Insurance Company

When contacting your insurance provider, ask the following questions:

1. Do I have out-of-network benefits for mental health services?
2. What is my out-of-network deductible, and how much have I met so far this year?
3. What is my out-of-network coinsurance for mental health services?
4. Is there a limit on the number of sessions covered per year?
5. Do I need pre-authorization for mental health services?
   

CPT Codes to Discuss with Your Insurance:

1. Initial Intake Appointment: 90791 (typically 60 minutes).
2. Treatment Sessions: 90834 (45 minutes), 90837 (60 minutes), 90846 (family therapy without the patient), 90847 (family therapy with the patient present).
3. Group Therapy: 90853 or 90849.
4. Telehealth appointments: 90791 (95), 90834 (95), 90837 (95), 90846 (95), 90847 (95).

Important Claims Submission Notes: When submitting claims, ensure that reimbursement checks are issued to you, not the provider. We cannot process checks made payable to our company and will return them to the insurance company.

1. What information do I need to include when submitting a claim?
2. What is the deadline for submitting claims?
3. How long does it typically take to process a claim and receive reimbursement?
4. Can claims be submitted online, or do they need to be mailed?

Our Process at Crown Counseling

1. You pay the full session fee at the time of service.
2. We provide you with a superbill containing all necessary information for insurance submission.
3. You submit the superbill to your insurance company for reimbursement.
4. Your insurance company processes the claim and sends you reimbursement based on your out-of-network benefits.

Understanding Your Superbill

A superbill is a detailed receipt that includes all the information your insurance company needs to process your claim. Here’s what you’ll find on your superbill:

1. Provider Information: Our practice name, address, and tax ID number.
2. Patient Information: Your name, address, and date of birth.
3. Diagnosis Code(s): The ICD-10 code(s) for your diagnosis.
4. Procedure Code(s): CPT codes for the services provided.
5. Date of Service: The date of your therapy session.
6. Charge Amount: The fee for the session.

Tips for Successful Claims Submission

1. Submit claims regularly, ideally after each session.
2. Double-check all information for accuracy before submitting.
3. Keep copies of all submitted claims and correspondence.
4. Follow up with your insurance company if you haven’t received a response within 30 days.
5. Be prepared to appeal if a claim is denied.

Stay Informed

Insurance benefits can change annually or even mid-year. We recommend verifying your benefits at the beginning of each year and any time you receive notification of changes to your plan.

Need Help?

If you have any questions about using your out-of-network benefits or need assistance with the process, please don’t hesitate to contact our office office@crowncounseling.com.