What are out-of-network benefits?

Out-of-network benefits are part of many health insurance plans. They may help reimburse you for therapy with a provider who does not have a contract with your insurance company.

In-Network vs. Out-of-Network

In-network providers have a contract with your insurance company and agree to accept a negotiated rate.

Out-of-network providers do not have a contract with your insurance company. You pay the provider directly and may be able to submit claims to your insurance company for reimbursement, depending on your plan.

How Out-of-Network Benefits Work

Depending on your plan, you may have an out-of-network deductible that must be met before reimbursement begins. Some plans do not have a deductible.

Your out-of-pocket cost will depend on your deductible, your coinsurance, and your insurance plan’s allowed amount. The allowed amount is the maximum amount your insurance company recognizes for a specific service. This may be lower than the provider’s actual fee.

In general, the process works like this:

  1. You pay your therapist directly.

  2. Your therapist provides a superbill.

  3. You submit the superbill to your insurance company.

  4. Your insurance company may reimburse you for part of the cost, depending on your plan.

Example

If:

  • The session fee is $200.

  • Your plan reimburses 60% of an allowed amount of $200.

  • Your coinsurance responsibility is 40%.

  • You have already met your out-of-network deductible.

Then:

  • Insurance reimburses 60% of $200, or $120.

  • Your out-of-pocket cost is $80.

If your insurance plan’s allowed amount is lower than the session fee, you may be responsible for the difference between the allowed amount and the fee, in addition to any deductible or coinsurance.

 
 
 
 

What to ask your insurance about out-of-network benefits

When contacting your insurance company, you may want to ask:

  • Do I have out-of-network mental health or behavioral health benefits?

  • Do I have an out-of-network deductible?

  • How much of my deductible has been met this year?

  • What percentage is reimbursed after the deductible is met?

  • What is the allowed amount, recognized amount, or maximum reimbursable amount for outpatient psychotherapy, CPT code 90834?

  • What is the process for submitting claims for reimbursement?

  • Are there any limits, authorizations, or documentation requirements?

This page is for informational purposes only and does not represent a financial agreement or practice policy. You are responsible for confirming the details of your policy directly with your insurance provider.