Using Out-Of-Network Insurance Benefits

What does “out of network” mean?

Insurance companies contract with certain therapists and healthcare providers to create a network.

An in-network provider has a contract with your insurance company and has agreed to accept the insurance company’s negotiated rates and billing requirements.

An out-of-network provider does not have a contract with your particular insurance plan. You pay the provider directly for services, but depending on your plan, your insurance company may reimburse you for part of the cost.

Out-of-network benefits can give you greater flexibility in choosing a therapist, particularly when you have found a clinician whose experience, approach, or availability is a good fit for you.

Does my insurance plan include out-of-network benefits?

Not every insurance plan includes out-of-network coverage. PPO and POS plans are more likely to include these benefits, while many HMO and EPO plans do not.

The best way to find out is to contact your insurance company using the member services number on the back of your insurance card. You can ask:

Does my plan include out-of-network benefits for outpatient mental health counseling?
Do I have an out-of-network deductible?
How much of my deductible has already been met?
What percentage does the plan reimburse after the deductible is met?
Is reimbursement based on the therapist’s fee or on the insurance company’s “allowed amount”?
Are there any limits on the number of outpatient mental health visits?
Is preauthorization or a referral required?

It can also be helpful to ask specifically about coverage for outpatient psychotherapy.

How does out-of-network reimbursement work?

The exact process depends on your insurance plan, but it commonly works like this:

1. You receive counseling and pay the fee in full.
Because we are not contracted with your insurance plan, payment for the session is made directly to Rockport Counseling.

2. We submit the insurance claim for you.
With your authorization and insurance information, we can submit a claim to your insurance company requesting that your out-of-network benefits be applied.

3. Your insurance company processes the claim.
If you have an out-of-network deductible that has not yet been met, the eligible amount may be applied toward that deductible.

Once your deductible has been satisfied, your insurance company may reimburse you for a percentage of its allowed amount for the service.

4. Reimbursement is paid to you according to your plan.
Depending on your insurance company and plan, reimbursement may be issued directly to you by check or through another payment method established by your insurer.

We can submit your claims for you

Some therapists provide clients with a “superbill” and leave it to the client to submit reimbursement requests to their insurance company.

At Rockport Counseling, we can take care of that step for you.

You pay us the full fee for your counseling session, and we submit the out-of-network claim to your insurance company on your behalf. Your insurer can then process the claim, apply eligible expenses toward your out-of-network deductible when applicable, and issue any reimbursement you are entitled to under your plan.

This means you can use your out-of-network benefits without having to complete and submit insurance claims after every appointment.

An example

Suppose your therapy session costs $130.
You pay Rockport Counseling $130 at the time of your appointment. We then submit the claim to your insurance company.
If you have not yet met your out-of-network deductible, your insurer may apply some or all of its eligible amount toward that deductible.
If your deductible has already been met and your plan provides out-of-network reimbursement, your insurance company may reimburse you for a portion of the eligible cost.
The amount reimbursed varies considerably between insurance plans.

Important things to know

Out-of-network benefits are determined entirely by your insurance plan. Rockport Counseling cannot guarantee that a claim will be covered or how much your insurance company will reimburse.

Your insurance company may calculate reimbursement using an allowed amount that is different from the amount you paid for the session. Deductibles, coinsurance, exclusions, visit limits, and other plan rules may also affect your reimbursement.

For that reason, we recommend contacting your insurance company before beginning treatment if using out-of-network benefits is important to you.

Questions about using your insurance?

If you are considering counseling with Rockport Counseling and would like to use out-of-network benefits, we can help you understand the information your insurance company will need and explain how our claim-submission process works.