Insurance Guide: Navigating Out-of-Network Benefits
Life Edit Therapy has partnered with Mentaya to help clients use their out-of-network benefits to save money on therapy. Use this tool below to see if you qualify for reimbursement for my services.
If you prefer to contact your insurance company directly to clarify your out-of-network benefits, use the guide below
Step 1: Gather Information
If you choose to contact your insurance directly, have the following ready:
Your Information
Insurance Phone Number:
Client’s Name:
I.D. # on Card:
Insured’s name:
Insured’s I.D. #:
Relationship to Insured:
Group/Account Number:
Insured’s Date of Birth:
Client’s Date of Birth:
Insured’s Employer
Life Edit Therapy Insurance Information
Mental Health Provider’s Name: Marla Field, MA, LLP
Provider’s Business Address: Life Edit Therapy, 9383 Klages, Road, Brighton, MI 48116
Provider’s National Provider Number (NPI): 1285177881
Provider’s Employer Identification Number (EIN): 85-2649422
CPT Codes that May be Used: 90834, 90837, 90846, 90847, 90791 (You may want to ask if these are covered.)
Location: 10- Telehealth in Client’s Home or 02 - Telehealth Outside of Home
Modifier Used: 95
Step 2: Call Insurance with These Questions
1. Does my plan include out-of-network, telemental health (online video) coverage?
If yes, continue to the following questions.
2. Do I have a deductible for out-of-network telemental health?
Is there a separate deductible for in-network services and out-of network services?
How much is it (or how much are they)?
When does the deductible (or deductibles) reset?
How much of my deductible has already been met? (If you have a deductible for in-network and out-of-network services, ask how much of each one has been met.)
Is the deductible (or deductibles) currently being waived due to COVID-19?
If yes, until when?
3. Do I have a copay or coinsurance for out-of-network telemental health?
If yes, what is my copay or coinsurance?
4. What is the telehealth modifier my provider needs to use on the superbill?
5. If you have coinsurance, ask what the allowable amount is for the following:
90791 (Intake Session)
90837 and 90834 (Individual Sessions)
If you are seeking couples counseling, also ask about the following regarding coinsurance:
90847 (Family Therapy)
90846 (Family Therapy without the patient present)
6. If you have coinsurance: also ask Is it currently being waived due to COVID-19?
If yes, until when?
7. Do I need pre-authorization for telemental health services that are out-of-network?
If yes, what is the process for getting a pre-authorization?
Will I be limited to a certain number of sessions?
(If services are authorized, make note of the number of sessions authorized along with the expiration date.)
8. Do I have an out-of-pocket maximum?
If yes, what is my out-of-pocket maximum?
When does it reset?
9. What is the easiest or most efficient way for me to submit my claims?
If you can submit by paper only, make sure to ask where you can find the forms.
If you can submit online, clarify the web address where you can submit claims.
The information above was in part based on the work of Barbara Griswold, LMFT
Author, Navigating the Insurance Maze: The Therapist’s Complete Guide to Working With Insurance
www.theinsurancemaze.com
Insurance Definitions
Provided by: www.healthcare.gov
Allowable Amount
The maximum amount a plan will pay for a covered health care service. May also be called “eligible expense,” “payment allowance,” or “negotiated rate.”
If your provider charges more than the plan’s allowed amount, you may have to pay the difference
Copay
Let's say your health insurance plan's allowable cost for a doctor's office visit is $100. Your copayment for a doctor visit is $20.
If you've paid your deductible: You pay $20, usually at the time of the visit.
If you haven't met your deductible: You pay $100, the full allowable amount for the visit.
Coinsurance
The percentage of costs of a covered health care service you pay (20%, for example) after you've paid your deductible.
Let's say your health insurance plan's allowed amount for an office visit is $100 and your coinsurance is 20%.
If you've paid your deductible: You pay 20% of $100, or $20. The insurance company pays the rest.
If you haven't met your deductible: You pay the full allowed amount, $100.
Deductible
The amount you pay for covered health care services before your insurance plan starts to pay. With a $2,000 deductible, for example, you pay the first $2,000 of covered services yourself.
Out-of-Network Coinsurance
The percentage (for example, 40%) you pay of the allowed amount for covered health care services to providers who don't contract with your health insurance or plan. Out-of-network coinsurance usually costs you more than in-network coinsurance.
Out-of-Network Copayment
A fixed amount (for example, $30) you pay for covered health care services from providers who don't contract with your health insurance or plan. Out-of-network copayments usually are more than in-network copayments.
Out-of-Pocket Maximum/Limit
The most you have to pay for covered services in a plan year. After you spend this amount on deductibles, copayments, and coinsurance for in-network care and services, your health plan pays 100% of the costs of covered benefits.
The out-of-pocket limit doesn't include:
Your monthly premiums
Anything you spend for services your plan doesn't cover
Out-of-network care and services
Costs above the allowed amount for a service that a provider may charge