Step 1. Call your insurance company to learn about your coverage.
When you call ask specifically for “mental health” services or behavioral health. Your insurance company is supposed to inform you of what your coverage covers in general terms. For example, they might inform you that your policy covers 80% of services they consider to be customary and reasonable.
For example if your insurance company only considers $100 to be customary and reasonable for psychotherapy, they will pay 80% of that or $80 so long as you have met your deductible.
Step 2. Have your insurance company inform you about how they will calculate your reimbursement.
Sadly, most insurance companies will not divulge what they consider to be customary and reasonable services. They will often claim that this is proprietary information.
What you can do is tell them the fee that your provider charges, for a specific service in a specific zip code.
So, if you call about what to expect for reimbursement for my services, that would be:
- You’ll be submitting claims for “Individual Psychotherapy, Outpatient, 60 minutes,” also referred to as CPT code 90837.
- My current fee for CPT code 90837 is $150. If you commit to a minimum of a 6-session treatment plan, then it becomes $100 per session.
- My Zip code is 85710 (reimbursement varies based on location).
- I’m a licensed professional counselor, and I am a non-participating provider (meaning that I have chosen not to have a “contract” with any insurance companies).
Then ask them if my fee is above their reimbursement for customary and reasonable services. When you ask them, if they say anything, they’ll typically only say “yes” or “no” — so you won’t know if the fee is only $5 more, or $100 more than what they claim is reasonable and customary.
Step 3.Understand the laws regarding insurance companies.
To get a good idea about how your insurance company is to reimburse you, go to the Fair Health Consumer website. This website gives you a good estimate on what insurance companies agree are customary and reasonable procedures. On the website you will enter the zip code of where you live, the cpt code for psychotherapy, which will give you a good estimate of what and if your insurance will reimburse for.
As of June 18, 2018, when I used the site, and entered for out of network provider, with a zip code of 85710 and a CPT code of 90837, the out of network price I received was for $178 and the in network price I received was for $99.
I hope this information helps.