Determining Your Out-of-Network Benefits

Download Out-Of-Network Benefit Guide

How to check your out-of-network coverage and possible out-of-network benefits:

Plan for 15-30 minutes of your time available to call your insurance company

  • Make sure to have this information ready before your call:
    • Insurance card
    • Name, date of birth, address, phone number, or possibly social security number of the cardholder or person for whom the services are for
    • Pen and paper/notepad
  • Questions to ask:
    • Are there out-of-network benefits for this policy?
    • Do I have a mental or behavioral health policy with out-of-network benefits?
    • What are the requirements to use out-of-network benefits?
    • Is prior authorization required?
    • Is a referral required from my primary care physician?
    • Do I have an out-of-network deductible?
      • If yes:
        • What is my out-of-network deductible?
        • How much of my out-of-network deductible has been met?
        • What is the start date of the calendar year my out-of-network policy is based on?
  • In addition, ask the representative if your policy covers these services (use the CPT codes provided below). How much is the insurance company’s “usual and customary fee” and what percentage do they cover?

• Other questions to ask:

o Is there a session limit?

 If yes:

What is the session limit?

How many sessions do I have left?

o What percentage of services is covered/what is my co-insurance?

• At the end of the call make sure to have:

o Date/time you called

o Representative’s name

o Reference number for the call

Information that will be provided on your superbill:

• Provider’s name

• Provider’s NPI

• Provider’s license number

• Federal Tax ID number

• DSM-5 and ICD-10 diagnosis codes

• CPT or Procedure codes