Using an "Out of Network" provider

Psychotherapy Specialists does accept direct payment from insurance companies. In order to assist you in determining your own reimbursement from your insurance provider, we have outlined the steps you may take in order to ascertain the actual benefits available to you.

Make sure you keep careful records of your conversation in the event you need to appeal a future decision by the insurance company. 

Call the number on the back of your insurance card for the Benefits Department and ask the following questions: 

  1. What is the representative's name and extension number? 
  2. Does my policy cover an Out of Network, Licensed Clinical Social Worker?
  3. My therapist is willing to provide a statement of Session Dates Attended, the CPT code, and the diagnosis. Is this acceptable to the insurance company?
  4. Does my policy cover Individual Psychotherapy? (CPT code 90834)
  5. What mental health diagnoses are NOT reimbursable?
  6. How many session are covered per year?
  7. What is the lifetime maximum for mental health benefits? 
  8. What is my Out of Network deductible?
  9. What is the allowed amount of the fee?
  10. What percent of the allowed amount will be reimbursed? 
  11. How do I file a claim?
NOTE: Many insurance companies will reimburse a percentage of the total fee paid. For example, your company may reimburse you 80% of the total fee paid. ($160 of the total fee of $200.) Other companies will substitute the $200 fee for what they deem appropriate, regardless of what you paid. For example, your company may say that they will reimburse you 80% of the "allowed amount of the fee." You paid $200 for an individual session, but your insurance company only allows $100; therefore you will be reimbursed 80% of the $100 or $80. They may try to withhold this information from you and can legally do so. Ask to speak to a supervisor and convey to them that you cannot plan your medical expense budget without this number.