How to Talk to Your Insurance Provider About Out-of-Network Benefits

Though I don’t take insurance directly, that doesn't necessarily mean you're on your own. Many insurance plans include something called out-of-network benefits — a way to get reimbursed for some of what you pay, even when your provider isn't in the insurance company's network. 

Here's how to find out what you're entitled to and what to ask.

Start with the number on the back of your card

Call the member services number on your insurance card and tell them you're looking into your out-of-network mental health benefits. You don't need to mention a specific therapist or have anything figured out yet. You're just gathering information.

Questions to ask

These are the specific things you want to find out:

Do I have out-of-network benefits for outpatient mental health? Some plans don't include them at all, so this is the first thing to confirm.

Do I have a deductible, and have I met it? A deductible is the amount you pay out of pocket before your insurance starts contributing. If you haven't met it yet, you'll be paying the full fee until you do.

What is my coinsurance after the deductible? This is the percentage your insurance covers once your deductible is met. A common arrangement is 70/30 or 80/20 — meaning insurance pays 70 or 80 percent and you pay the rest.

What is the allowed amount or usual and customary rate for outpatient therapy? Insurance companies don't always reimburse based on what your therapist charges — they reimburse based on what they decide is a "reasonable" fee for your area. This number matters because it's the ceiling your reimbursement is calculated from.

Is there an out-of-pocket maximum? This is the most you'll pay in a given year before insurance covers 100 percent. Once you hit it, you stop paying coinsurance.

Do I need prior authorization or a referral? Some plans require you to get approval before starting treatment. Find this out before your first session.

Does the insurer accept supervisory billing ? As an licensed master social worker (LMSW), I am allowed to work under the supervision of a licensed clinical social worker (LCSW). Most insurers, but not all, accept this so it’s good to check in advance.

How reimbursement actually works

I will give you a document called a superbill — an itemized receipt with the billing codes insurance needs. You submit it to your insurance company, and they reimburse you directly, usually by check or direct deposit. The timeline varies, but a few weeks is typical.

Don't be discouraged if it's confusing

Insurance calls can be frustrating. Representatives sometimes give incomplete answers, and the language is genuinely opaque. If something doesn't make sense, ask them to explain it again, or call back and try a different representative.

The effort is usually worth it. Out-of-network benefits can make therapy more affordable — and that's worth a phone call.