OUT OF NETWORK INSURANCE CONSIDERATIONS
It is HIGHLY recommended that you obtain information about your insurance coverage before your first appointment . That will help you make a sound fiscal decision about your ability to cover costs to work with me. Payment in full is required at the time of service unless prior arrangements have been made.
I am an “Out-Of-Network Provider” with ALL POLICIES EXCEPT Humana, Tricare and Medical Mutual of Ohio insurance companies. Most insurance companies offer “Out-Of-Network” benefits for treatment for licensed mental health providers. I am a licensed in the State of Ohio by the Board of Marriage, Family Counseling and Social Work as an IMFT: Independent Marriage and Family Therapist.
While I do not file your insurance claims I am happy to assist your filing insurance claims. I will provide you with a payment receipt that contains all the information you need to submit a claim to your insurance company. Please keep in mind that your health insurance is a contract between you, your employer, and your insurance company. I am not a party to that contract and therefore I am not responsible for the disposition of any insurance claims.
Information about insurance coverage can be obtained by calling the customer service number on your insurance card. When you are connected with a service representative ask to speak with someone who can answer questions about mental health/behavioral health benefits. I suggest that you take verbatim notes regarding who you speak to and what they tell you. Keep this information in case actual claim payments differ from what they told you. It also helps to share the information with me when we meet so I know any restrictions of your policy and can try to stay in their guidelines.
The following are some questions you may want to ask to help you make decisions:
Date of call: ______Number called: ______
Person who provided information (Name/ID number): ______
- Do I have out-of-network benefits? Yes or No
- Do I have a deductible?______$ Individual, ______$ Family.
- Is there a separate deductible for in and out of network benefits? Yes or No
What are the specifics of my mental health out of network coverage?
4. What is the “Usual Customary Rate” for an initial evaluation (CPT code 90791) ?______$
“Usual customary rate” is the rate at which they would reimburse you for services. Generally it is lower than my actual cost. The difference in costs of their rate and my services will need to be paid by you.
The Initial Evaluation is covered at ______% of usual and customary rate.
- For follow-up treatment, CPT 90834, 45 minutes, what is the usual customary rate? ______$
Covered at ____%.
- Is CPT 90837, 60 minutes, covered? At what usual customary rate? ______$ covered at _____%.
- Is family therapy covered (90847)? Yes or No
- Family therapy is covered at ______% of usual and customary rate?
- Is there an annual limit on number of sessions covered?______
- Annual calendar year starts what month?
- Are there any other authorizations required or other limits I should know?