How to Get Reimbursed for Out-of-Network Psychiatry Visits
So you’ve found a psychiatrist that seems like a great fit, but they’re “out-of-network” - what now? Let’s break it down.
What are “out-of-network” benefits?
Out-of-network benefits are provided as part of some insurance plans that let you see clinicians who may not be in your insurance company’s network. Instead of the insurance paying the clinician directly, they reimburse you for a portion of the cost after you submit their required documentation. Usually, this requires a “superbill” or an itemized receipt of services provided.
The amount you are reimbursed depends entirely on your plan, but many plans will reimburse up to 50-80% of the allowed amount for psychiatry visits after meeting the out-of-network deductible.
What do these words mean?
A deductible is a certain amount that must be paid prior to reimbursement kicking in, such as $1000/year.
An allowed amount is insurance reimbursing a percentage of what they consider a “reasonable and customary” fee, often based on Medicare reimbursement rates. It may not necessarily be reflective of what you paid.
Example: You pay $400, but the insurer’s allowed amount is $300, so reimbursement would be 50-80% of $300.
How do I find out what my plan covers?
Before starting treatment, it’s helpful to call your insurance provider. Use the number on the back of your insurance card and ask the following questions:
Do I have out-of-network benefits for mental health?
Do I need prior authorization? If so, how do I obtain it?
What is my deductible, and how much of it has been met? Do I have a co-pay?
What percentage of the fee will be reimbursed once I meet my deductible?
Where do I send claims for reimbursement? Can I do it online or by mail?
Do I need a specific claim form? Where can I access it?
Before ending the call, make sure to write down the name of the representative, the date, and a reference number for the call.
Reimbursement at EZ Psychiatry?
At EZ Psychiatry, we believe in thoughtful, individualized psychiatric care. By choosing not to work with insurance companies, we can focus solely on delivering the highest standard of care without the limitations often imposed by third-party payers. Read more about our philosophy.
Patients pay directly at the time of service, then, upon request, we can provide a superbill that contains the necessary details for insurance reimbursement. This typically includes
Diagnosis codes (ICD-10)
Procedure codes (CPT)
Session date, time, and fees
Clinician credentials and contact information
What are the most commonly billed services?
CPT code 90792 - Psychiatric diagnostic evaluation with medical services
CPT code 99214 - Evaluation and management of an established office patient
CPT code: 99214 + 90836 - Evaluation and management of an established office patient with 45-minute psychotherapy
CPT code: 99214 + 90833: Office or other outpatient visit for the evaluation and management of an established patient and psychotherapy, 30 minutes
Why do people choose out-of-network care?
Choosing out-of-network care gives clinicians the freedom to prioritize what matters most — your care. Without the constraints of insurance, you often benefit from longer sessions, more individualized attention, greater privacy, and a more flexibility in your treatment plan.
Still have questions?
Contact us at info@ezpsychiatry.com or visit www.ezpsychiatry.com to learn more about our specific services, fees, and what to expect from your first visit.
