Out-of-Network Insurance Coverage

Questions you might want to ask when calling your insurance and other things to consider:

1. WILL MY INSURANCE PAY FOR THE TREATMENT OF _____(my particular issue)?

2. WILL MY PLAN REIMBURSE ME IF I GET TREATMENT FROM AN OUT-OF-NETWORK PROVIDER?  IF SO, WHAT IS THE REIMBURSEMENT RATE?

3. WHERE WOULD I SUBMIT MY CLAIM FOR REIMBURSEMENT?  WHAT IS THE ADDRESS, FAX NUMBER, EMAIL ADDRESS OR LINK?  ARE THERE ANY FORMS I MUST SUBMIT ALONG WITH MY CLAIM?  

4. IS THERE A SEPARATE DEDUCTABLE FOR GOING OUT-OF-NETWORK?  IF SO, WHAT IS IT?

INDIVIDUAL CLIENTS:

If your issue interferes with daily life, your insurance will usually pay for counseling.  Most plans cover problems that interfere with daily functioning, such as feeling overwhelmed, hopeless or having trouble concentrating. They will also cover treatment if you are experiencing anger, worry or grief that seem out of proportion to the triggering event.  

Some people's concerns may not be distressing enough to be covered under their insurance plan. In these cases, counseling may still be fully justified, especially if you don't really have anyone to turn to, but the insurance company won't pay for it.
Figuring out if your situation meets the criteria for a specific diagnosis is the job of a licensed therapist. This is something your therapist will be doing from the get-go.  Your therapist will discuss this with you during your first session if you have indicated in your intake forms that you are requesting a Super Bill statement for reimbursement.

COUPLES:

 There are two different ways couple's counseling might be covered by your health insurance.

• If you are lucky, your insurance coverage includes coverage for "partner relational problems", which has a diagnosis code of Z63.0.
• If not, then if the relationship issues cause one partner enough distress that it merits an individual diagnosis and the appropriate treatment for the problem is to have both partners in the room working on it together, then many (but not all) insurance plans will cover counseling. The difference in this case is the diagnosis is only for the individual and the procedure code is 90847 (family therapy with patient present).  NOTE: Even if you and your therapist agree that couple's therapy is appropriate, the insurance company has the right to deny your claim for reimbursement if they determine your treatment was not medically necessary

To see if your insurance might cover you in either category, when you call make sure to ask: (a.) "DO I HAVE COVERAGE FOR A DIAGNOSIS OF Z63.0?" and (b.) "AM I COVERED FOR A PROCEDURE CODE 90847?" Don't ask "Do you cover couple's counseling?" since you need to know more precisely what kind of coverage applies.