Checking how much your insurance will reimburse you
Getting Started
Set aside 30 minutes — you may be on hold for a while.
Find your insurer’s customer service phone number on their website or on your insurance card.
When you dial them up, you’ll likely first get an automated prompt and you’ll want to choose an option like “Benefits” or “Eligibility.”
You want to talk with a real person, so opt-out of any automated systems they offer.
Info You May Need
My name: Brandon Zahl
Provider NPI: 1003448051
Organization NPI: None
Organization EIN/Tax ID: 86-2806996
Service type: Mental Health - Outpatient
CPT Code/Procedure Code/Service Code: 90837
Diagnosis: F41.1 (we’ll figure out your actual diagnosis later)
Questions to Ask
1. Are out-of-network mental health services covered?
Your insurer will also want to know more information on the type of service you're wanting coverage for. They'll probably ask for a "CPT code", “procedure code” or "service code." For individual, 53-minute talk-therapy sessions, the CPT code is 90837. If they want to know a diagnosis code, use F41.1 as an example, which is for generalized anxiety disorder.
2. What is my remaining deductible for out-of-network services?
Careful! Out-of-network deductibles may potentially be tracked separately from in-network deductibles. If your insurer does this, you may be in a situation where you have met your in-network-deductible yet still be 100% responsible for out-of-network charges until you reach that separate deductible. Please check to see how your insurer tracks this and remember that deductibles typically reset each year.
3. Is there a co-insurance rate?
Co-insurance is the percentage of fees that your insurer expects you to pay. Premera Blue Cross of Washington, for example, has some plans with a co-insurance rate of 30%, meaning you pay 30% and they pay 70%.
5. Is there a limit to how many mental health visits I may receive per calendar year?
If you'd like to see me for more visits than your insurance will reimburse me for, please know you will be responsible for the full session fee. If you're in this situation, let me know up front and we can plan accordingly.
6. Do I need an authorization for my CPT Code 90837?
If yes, ask for an authorization number and number of sessions authorized.
7. Are services delivered via telehealth covered?
Whew! All done. Now take a well-deserved break :)