What to Ask Your Insurance: Out-of-Network Benefits

This is Part 2 of a 3 Part Series
Using your out-of-network benefits can expand which providers you might have access to see.
What to Ask Your Insurance and Why
Out-of-Network Benefits
If your outpatient mental health services are subject to your deductible and you have not yet met your deductible, you are responsible for the full fee that the therapist is charging per service. Once you have met your deductible, your insurance will start covering at the reasonable and customary amount, minus your co-pay or co-insurance. You will most likely be responsible for the full fee upfront. In some cases, you will be provided an itemized list of services provided, or Super bill, which you will submit directly to the insurer for reimbursement. Some therapists may submit a claim on your behalf.
Questions to Ask
Out-of-Network Benefits
Do I have “out-of-network” coverage for outpatient mental health visits?
Do I need a referral from an in-network provider or primary care physician or prior authorization to see [therapist name/NPI number]?
What is the policy year (calendar or plan)? I.e., When does my deductible/out-of-pocket max reset?
Is there a limit to the number of sessions my plan will cover per year? If yes, how many sessions?
What is my out-of-network deductible for outpatient mental health visits?
How much of my deductible has been met this year? I.e., What remains for me to pay out-of-pocket before my insurance kicks in?
How much is my out-of-network co-pay (dollar amount) or co-insurance (percentage)?
What are the reasonable and customary fees for Multnomah County for the following outpatient mental health services/CPT Codes?
- 90791 – Intake Appointment
- 90837 – Individual Psychotherapy, 60 minutes
- 90834 – Individual Psychotherapy, 45 minutes
- 90847 – Couples/Family Psychotherapy, conjoint with patient present
- 90846 – Family Psychotherapy, without patient present
- 90839 – Crisis Psychotherapy
Do I have a limit on out-of-pocket expenses per year (out-of-pocket max)? If yes, how much is it and how much remains to be met?
How do I submit claims for out-of-network reimbursement?
Calculating Your Responsibility
Out-of-Network Benefits
To estimate your responsibility, you would add your co-insurance (% of the reasonable and customary fee) plus the difference between the full fee and the reasonable and customary fee.
For example, if you have met your out-of-network deductible, your co-insurance is 20%, the therapist’s full fee for a 60 minute session is $200, and the reasonable and customary amount provided by your insurance for Multnomah County is $150 for a 60-minute session:
Co-insurance (20% of $150) = $30
Insurance Responsibility ($150 – $30) = $120
Full Fee and Reasonable Customary Fee Difference ($200 – $150) = $50
Your Responsibility [Co-insurance + Difference] ($30 + $50) = $80