How to Check Your Coverage

Let’s be honest, figuring out what’s covered and when and why and how can be a headache. I hope the suggestions below can help you get the answers you need.

  1. Make sure you have a pen and paper to write down the information you’ll be hearing.

  2. Find the number to use on the back of your insurance card. Take down the name of the representative you speak with, the time, and the date. Ask if there is a reference number for the call and write that down.

  3. Ask if you are covered for telehealth appointments with an out-of-network psychotherapist. If you are, great! Continue with step 4. If you are not, you will not be eligible for any reimbursement through your insurance company for our sessions. Note: your insurance company representative may encourage you to use an in-network therapist before providing information about out-of-network coverage. As you know, working with an in-network provider is always an option, and your insurance company can give you a list of in-network providers.

  4. Find out if you have an out-of-network deductible, when the period of the deductible starts and ends, and how much of it you have met.

  5. Ask whether you have an annual out-of-pocket maximum, and if so, what it is.

  6. Find out how much you can expect to be reimbursed for CPT Code 90791 (for your initial evaluation appointment) and either CPT Code 90834 (45-minute session) or 90837 (60 or 75-minute session), depending how long a session you anticipate wanting to schedule. Ask whether they reimburse a set amount, or a percentage of the provider’s fee.

  7. During this conversation give yourself permission to ask all the questions you need to fully understand, and be patient with the representative you’re talking with. If they don’t seem to have the information you need, know that you can ask to speak with another representative. You have a right to a clear and accurate explanation of your benefits, and sometimes persistence is required to get it.

  8. Ask whether there is a cap on the number of sessions per year allowed for the CPT code for the session length you expect to use.

  9. Find out whether your plan requires pre-approval or pre-certification before you can work with me, or before you can meet for a longer session, if that’s what you desire (i.e. a 60-75 minutes, not including initial evaluation appointment). If pre-approval or pre-certification is required, ask for a step-by-step explanation of who needs to complete what steps, so that you feel very clear what is required. IMPORTANT: note that I am unable to participate in any “Single Case Agreement.”

  10. Tell them you will be paying your therapist directly for services, and that the insurance company will be sending reimbursement directly to you. Ask how to submit your claim for out-of-network service reimbursement, and how long after a claim is submitted you can expect to receive a check.

I will provide you with a receipt for services (“superbill”) each month that you can use to submit your claim to insurance. Please note that payment for your sessions is due at the time of service. Your insurer will process your claim and send you a check for the portion they cover.