How do I get out-of-network reimbursement for therapy?

Out-of-network reimbursement is common for many insurance companies, but not all. The only way to tell is to call your insurance provider and confirm. Because this can be overwhelming, this page is here to help you make sense of this.

Call your customer service line (on the back of many insurance cards) and ask:

A. What the allowable amount or “Usual and Customary Rate” is for that particular service (CPT Code 90834=individual, 90847=couples, 90853=group) for an LCSW therapist in zip-code 94102. My NPI # is 1386202679 in case they need it.

B. What percentage% of the allowable amount they reimburse.

C. What your out-of-network deductible is.

D. How much you have left before you reach the deductible.

E. Is there a session limit to reimbursement.

Here’s the equation:

Once you reach your deductible, Take the allowable amount (A) x percentage reimbursed (B) and subtract this amount from my full fee.

Example: Let’s say your insurance company’s allowable amount (A) for Individual Therapy (CPT code 90834) for me is $150, and the percentage they will reimburse (B) is 80%, that means they will reimburse you 80% of $200 = $120 for each session with me. This results in making sessions virtually $80/session after you receive your reimbursement. But this reimbursement is only if you have these benefits and after you have met your out-of-network deductible.