Questions to ask your PPO

I do not accept insurance, but you might be able to get reimbursed for a portion of your therapy sessions from your insurance company’s out-of-network reimbursement plan. The way it works is at the end of each month I can give you a medical receipt called a “superbill,” and you can submit it directly to your insurance provider.

Your eligibility for reimbursement, and the amount of reimbursement you can expect to receive, varies depending on the details of your plan. I recommend calling your PPO first, and asking the questions below so there are no surprises later. The phone number should be on the back of your insurance card under “behavioral health” or “mental health,” or just call the member customer service and ask to speak to someone about your Outpatient Mental Health Benefits.

When you call, the representative might give you a ton of information all at once, so take your time with them, and familiarize yourself with the questions below to make sure you are clear.

1. Do I have out-of-network mental health coverage? Make sure they understand you’re asking about out-of-network coverage.

When you ask this question, the representative may ask you for the “CPT code” or “service code.” Here are the codes for services I provide:

Initial Intake Assessment (first session) - 90791
Individual Therapy Session (just you coming for therapy) – 90834
Family Therapy Session (you coming to therapy with your significant other or a family member) – 90847

If they say NO – Your coverage will not reimburse you. You can either come to therapy sessions and pay in full without expectation of reimbursement, or you can ask the representative to help you find a therapist on your plan.

If they say YES – Perfect! Here are some more questions you’ll want to ask:

2. Do I have a deductible?

A deductible is an amount of money that you are required to pay in a given year before insurance will pay for anything.

If they say YES, you’ll want to ask: How much is it, and how much do I still need to pay?

For example: If they say your deductible is $500, you would just pay me per session, and whatever you pay me is going toward that $500 deductible. Once that’s fulfilled, your insurance will then offer a certain percentage of reimbursement (see next question).

You may also want to ask when does my deductible start over? This will tell you when you will have to pay your deductible again. For example, if you have a $500 deductible that resets every January and you schedule your first session in December, you will be paying into your deductible for your first few sessions in December, and then you will have to pay the $500 again in January before your insurance reimburses you some money.

4. What is my co-insurance?

A co-insurance is the percentage of the fee that you will be responsible for. For example, if you have a 20% co- insurance, your insurance will reimburse you for 80% of your fee and you will still be responsible for 20% of your fee. IMPORTANT: If your insurance company tells you that they will reimburse you for a certain percentage of the Usual and Customary Rate or Allowed Amount Rate, that amount may differ from my fee, so you should ask how much it is in order to anticipate how much you will be reimbursed by your insurance company.

When you ask how much the Usual and Customary/Allowed Amount Rate is, your insurance company may ask you for the zip code of the therapy practice. My zip code is 90026.

5. Is there a limit to how many mental health visits I may receive per calendar year?

If yes, ask how many visits you have per year.

6. Do I need an authorization for my visits?

If yes, ask for an authorization number and number of sessions authorized.

7. Can you tell me the procedure and address to submit a superbill and receive out-of-network reimbursement?
If you encounter any problems or have any questions about this process, I would be happy to answer them for you. Please note that I am unable to guarantee out-of-network insurance reimbursement.