Many people with employer insurance have out-of-network mental health benefits they've never used. Here is how to find out what you have and how to get reimbursed, step by step.
In short: Call your insurer to confirm your out-of-network mental health benefits, pay your therapist directly, ask for a superbill, and submit it to your insurer as a claim. What you get back depends on your plan.
Step 1: Find out what your plan covers
Call the member-services number on your insurance card, or check your plan's online portal. Ask:
- Do I have out-of-network outpatient mental health benefits?
- Do I have a separate out-of-network deductible, and how much have I met?
- After the deductible, what percentage is reimbursed, and is it based on my therapist's full fee or on an “allowed amount”?
- Is there an annual session limit?
- Do I need a referral or pre-authorization?
- How do I submit claims, and how long do they take?
Write down the date, the representative's name and what they tell you.
Step 2: Understand the “allowed amount”
Many plans reimburse a percentage of an “allowed amount” (sometimes called usual and customary), not your therapist's full fee. For example, if your plan reimburses 60% of an allowed amount that is lower than your therapist's fee, you are reimbursed 60% of the allowed amount, not of what you paid. Ask your insurer for the allowed amount for psychotherapy so you can estimate your real cost.
Step 3: Pay your therapist and get a superbill
With an out-of-network therapist you generally pay at the time of the session. A superbill is an itemized receipt for those sessions. It includes the dates, the service codes, a diagnosis code, the provider's license information and what you paid. In my practice, I send superbills automatically each month.
Step 4: Submit the claim
- Check your insurer's claim form or portal; many let you upload the superbill directly.
- Attach the superbill and any form your plan requires.
- Keep a copy and note the date you submitted it.
- Follow up if you haven't heard back within the time your insurer quoted.
Common reasons a claim is denied or reduced
- The out-of-network deductible hasn't been met yet.
- The plan has no out-of-network mental health benefits, as with some HMO and EPO plans.
- Missing information on the claim, or the claim was submitted after the filing deadline.
- The plan applies a session limit or requires pre-authorization.
Using an HSA or FSA
Psychotherapy is generally an eligible expense for health savings accounts and flexible spending accounts. You can often pay with the card directly, but confirm with your plan administrator.
What about privacy?
When you submit a claim, it includes a diagnosis code, and your insurer will have a record of the claim. You decide whether to file one. If privacy is a concern, ask your insurer how mental health claims are recorded before you decide.
How this works with me
I accept Aetna employer (non-marketplace) plans in Florida, Pennsylvania, and California. For other plans I'm out-of-network and provide monthly superbills. See Insurance & Superbills for the details, or book a free 15-minute consultation.
This article is general information, not insurance or legal advice. Coverage depends on your specific plan; confirm benefits with your insurer.