PPO Insurance

I believe you should be fully informed in order to make the best decision for yourself regarding insurance. Please be aware that most insurance plans require a mental health diagnosis to qualify for insurance coverage. This diagnosis is shared with your insurance and becomes part of your medical record. Certain diagnoses on your medical record may affect your eligibility for (1) certain jobs requiring high clearance levels, or (2) future medical insurance due to a “pre-existing condition.” Knowing this, many people still choose to use insurance benefits to help pay for therapy.

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1. Ask if your deductible has been met and when it will reset.

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You will not be reimbursed for the session fee until your deductible is met. Paying my fee will contribute toward your deductible. Please note that at the end of each year your deductible is reset and you’ll need to reach it again in order for your insurance to reimburse you. Make sure to find out exactly when it will reset.

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2. Ask if your plan covers “mental health” or “behavioral health” services with out-of-network providers. Be sure to specify that the services you’re interested in will be provided online, called “telehealth,” and ask if they are covered.

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Most insurances cover mental health. Many cover telehealth, as long as it is provided through video.

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3. Ask if you need a referral and/or pre-authorization to see a mental health provider.

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Though uncommon for PPOs, some will require a referral or a pre-authorization before mental health services are covered. If you are told that you need one or both, ask who the referral and/or pre-authorization needs to come from.

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4. Ask if there are dollar or visit limits for your mental health benefits.

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This is important to know because if there are limits and you exceed them, your insurance will stop reimbursing you.

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5. If you have an existing diagnosis, ask if it is covered. Otherwise, ask if they can provide you with a list of covered and uncovered diagnoses.

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Many insurance companies can choose whether to cover certain mental health diagnoses, or only allow certain types of therapy for specific diagnoses. For example, I’ve heard of an insurer that only covered EMDR treatment if the client had a diagnosis of PTSD.

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6. Tell them you want to work with an out-of-network provider and give them the following information:

• CPT Code: 90834 (individual psychotherapy, outpatient, 45 minutes)

• License: LMFT and LPCC

• NPI: 1629401740

• Zip code: 90813 ​

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Your insurance company should tell you what percentage they cover of the “usual, customary, and reasonable” fee, or UCR. For example, if your policy covers 70% of the UCR and the insurer has decided that the UCR is $200, they’ll pay $140. However, insurance will not typically share what they have determined the UCR to be; they may tell you that it is “proprietary information.” You might be able to get around this in Step 7.

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7. Ask if my fee is above their UCR.

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There is very little regulation for insurance companies to determine UCR, so it’s your job to be informed. Click here to go to Fair Health Consumer, an objective consumer rights website that lists customary rates by zip code. Input zip code 90813 and CPT code 90834. At the time of this writing, the customary rate for CPT code 90834 in 90813 was $200. Usually, insurance companies will use the 80th percentile of customary rates in the area as the determining factor for UCR.

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8. Ask if you need to submit anything other than the superbill to get reimbursed.

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I will provide you with an itemized statement, called a “superbill,” for you to file a claim with your insurer. Some insurance companies require that you fill out an additional form to complete the reimbursement process.

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9. Document all the information you receive and ask for the representative’s full name and/or ID number.

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I have heard of clients being told one thing over the phone, and then being surprised when their reimbursement arrived and it was not what they expected. That's when having this information comes in handy.

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10. Submit for reimbursement with your insurance provider.

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Even though you are using your out of network benefits, you will pay me directly and then submit for reimbursement with the superbill I provide you. The standard amount of time to receive reimbursement is around 30 days, but it can be longer.

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11. Once you receive reimbursement, check it against your own records to make sure that all your submissions have been accounted for.

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Sometimes insurance companies make mistakes and skip over an item or two. If something is amiss, you’ll need to make an appeal to your insurance company. Be sure to document, document, document!

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These steps should help guide you in navigating your PPO benefits. If you need further assistance with this process, I’m happy to help!

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