Paying for Therapy
Out-of-Network Therapy and Superbills, Explained
Out-of-network benefits are the part of some health plans that pays back a share of what you spend on providers who have no contract with the plan. A superbill is the itemized receipt you send in to claim that money: you pay for sessions, submit the superbill, and your plan decides what, if anything, to reimburse.
What Out-of-Network Benefits Are
Health plans sign contracts with some providers at agreed rates. When you see a provider without one, many plans still cover part of the cost, but the money comes to you after you have paid the provider yourself. These benefits are more common on PPO and POS plans, while many HMO and EPO plans cover out-of-network care only in emergencies.
Out-of-network benefits often come with their own deductible. Once it is met, the plan reimburses a percentage of its allowed amount, which is the price it has set for that service. Some plans call this the maximum allowed amount or the usual and customary rate. If the allowed amount is lower than your fee, the percentage applies to the lower figure, so you get back less than that percentage of what you paid.
What a Superbill Includes
Vanessa can provide a superbill if your health plan offers benefits for out-of-network mental health care. Filing it is up to you, and whether the plan pays, and how much, is the plan's decision.
A superbill is an itemized statement with the details a plan needs to process a claim. It usually lists:
- Your name, date of birth and the date of each session
- The therapist's name, credentials, license number and National Provider Identifier (NPI)
- Procedure codes for the type and length of each session, plus a telehealth code
- A diagnostic code (ICD-10), which plans need before they consider payment
- The fee for each session and the amount you paid
Questions to Ask Your Plan First
Call the member services number on your insurance card, or log in to your plan's member portal, and ask about outpatient mental health benefits for out-of-network providers. Plans generally require a diagnostic code on every claim, and some will not reimburse codes that describe a relationship problem rather than a mental health condition, which can matter for couples sessions.
Note the date, the representative's name and a reference number for the call, and ask:
- Do I have out-of-network benefits for outpatient therapy, including sessions held by video?
- What is my out-of-network deductible, and how much of it have I met?
- After the deductible, what percentage of the allowed amount do you reimburse?
- What is the allowed amount for a 60-minute session with a licensed marriage and family therapist?
- What is the deadline for submitting a claim?
- Which diagnoses qualify for reimbursement, and is pre-authorization required?
How to Submit a Superbill, Step by Step
With those answers and the session fee from your free consultation with Vanessa, you can estimate your share before the first appointment. Some people submit after every session and others once a month; sending claims regularly keeps them inside the deadline and shows you early how your plan is handling them.
Plans differ in the details, but the process usually runs in this order:
- Confirm your benefits and the claim deadline with your plan.
- Ask Vanessa for a superbill covering the sessions you want to claim.
- Check whether your plan wants its own claim form attached.
- Submit through the member portal, by mail or by fax, as the plan directs, and keep copies.
- Read the Explanation of Benefits when it arrives; it shows what was allowed, applied and paid.
Why Reimbursement Varies From Plan to Plan
Reimbursement depends on your plan: whether it covers out-of-network mental health care, whether you have met the deductible, what it allows for the service and whether the claim meets its rules. Vanessa can give you an accurate superbill, but no one can say for certain what a plan will pay until it processes the claim.
Filing also sends a diagnostic code and your session dates to your plan, which some people weigh before deciding. The article on private-pay therapy covers that choice, and clients who pay privately can also ask for a Good Faith Estimate of their costs.
Questions
Frequently Asked Questions
It depends on the plan. Some plans treat video sessions the same as any other outpatient visit, and some set separate rules for telehealth. Ask directly whether out-of-network telehealth sessions with a licensed marriage and family therapist are covered. The superbill shows that your sessions took place by video, so the claim will match what you were told.
Usually, if the service is covered. Until your out-of-network deductible is met, the plan typically applies the allowed amount toward it and pays nothing. That is why filing from the start of the plan year can matter: those early claims are what move you toward reimbursement later. If you never file, the plan has no record of what you spent.
Start with the Explanation of Benefits, which gives the reason. Denials often come from something correctable: a missing detail, a deductible not yet met, a pre-authorization the plan wanted, or a filing deadline that passed. Call the plan, ask exactly what it needs, and resubmit, or file an appeal if you disagree with the decision. Keep notes on every call.
Related Pages
Private-Pay Therapy
How paying privately for therapy differs from using insurance: who sets the rules, what goes on record, superbills and the Good Faith Estimate.Read More
Fees and Payment
Read MoreGood Faith Estimate
Your right to a written estimate of the cost of care when you are not using insurance.Read MoreFAQ
Read MoreA gentler next step
You don't have to know exactly what to say.
A free 15-minute phone consultation is a simple place to begin.