How to Use Out-of-Network Benefits for Therapy

If your therapist doesn’t accept your health insurance, you may still be able to use your insurance benefits to help pay for therapy.

The Center for Growth is an out-of-network therapy practice. This means you pay us directly for therapy. If your health insurance plan includes out-of-network mental health benefits, your insurance company may reimburse you for a portion of the cost.

We can provide appropriate documentation for you to submit to your insurance company.

This guide explains how out-of-network therapy benefits work, what to say when you call your insurance company, what questions to ask, and which therapy and diagnostic codes your insurer may ask you about.

An out-of-network therapist is a mental health professional who has not contracted with your insurance company to provide services at its negotiated in-network rate.

Instead of your therapist billing your insurance company, you pay your therapist directly.

If your plan includes out-of-network mental health benefits, you can then submit documentation to your insurance company and request reimbursement.

Depending on your plan, your insurance company may reimburse a significant portion of the cost, a small portion, or nothing at all.

The Center for Growth cannot determine or guarantee your reimbursement. Your insurance company is the best source for information about your individual benefits.

The basic process is relatively simple:

Call your insurance company before beginning therapy and ask about your out-of-network mental health benefits.
Find out whether you have an out-of-network deductible and how much of it you have already met.
Ask exactly how reimbursement is calculated for psychotherapy.
Begin therapy and pay The Center for Growth directly for your sessions.
Obtain the appropriate documentation for your treatment.
Submit your claim to your insurance company.
If the service qualifies for reimbursement, your insurance company reimburses you directly according to the terms of your plan.

Call the member-services or behavioral-health number on your insurance card and say:

“I’m considering seeing an out-of-network therapist for outpatient mental health treatment. I’d like to understand my out-of-network mental health benefits and how much I would be reimbursed for psychotherapy.”

Then ask:

Do I have out-of-network mental health benefits?
What is my out-of-network deductible?
How much of that deductible have I already met?
After I meet my deductible, what percentage will you reimburse?
Is reimbursement calculated from the therapist’s actual fee or your allowed amount?
What is the allowed amount for the CPT code I expect to use?
Do I need preauthorization or a referral?
Is there a limit on the number of therapy sessions covered each year?
Are telehealth psychotherapy sessions reimbursed?
Is couples or family therapy reimbursed?
How do I submit an out-of-network claim?
What documentation will I need?
How long do I have after receiving treatment to submit my claim?

Write down the answers. If possible, also ask for the representative’s name and a reference number for the call.

Our standard psychotherapy session is 53 minutes.

This matters when speaking with your insurance company because reimbursement can depend upon both the service provided and the length of the session.

When calling about individual psychotherapy, you can say:

“I will be seeing an out-of-network therapist for 53-minute psychotherapy sessions. Can you tell me my reimbursement for CPT code 90837?”

Insurance companies identify psychotherapy services using CPT procedure codes.

Common codes used in psychotherapy include:

90837 — Individual psychotherapy, 53 minutes or longer

90847 — Family psychotherapy with the patient present, which may be applicable to some couples and family therapy services

90853 — Group psychotherapy

The actual CPT code on your documentation will reflect the service you receive.

When you call to determine your out-of-network benefits, the insurance representative may ask for a possible ICD-10 diagnosis code before providing a reimbursement estimate.

Below are examples of diagnoses that may be encountered in psychotherapy.

These codes are provided to help you communicate with your insurance company and estimate possible benefits. They are not a menu of diagnoses. Your therapist determines the appropriate diagnosis, if any, based upon your individual clinical presentation.

Anxiety, OCD and Trauma-Related Concerns

F41.0 — Panic disorder
F41.1 — Generalized anxiety disorder
F42 — Obsessive-compulsive disorder
F43.10 — Post-traumatic stress disorder

Adjustment, Relationship and Mood Concerns

Z63.0 — Relationship distress with spouse or intimate partner
F43.21 — Adjustment disorder with depressed mood
F43.22 — Adjustment disorder with anxiety
F34.1 — Persistent depressive disorder (dysthymia)
F31.11 — Bipolar I disorder, current or most recent episode manic, mild

Eating Disorders

F50.01 — Anorexia nervosa, restricting type
F50.2 — Bulimia nervosa

Sexual Concerns

F52.21 — Male erectile disorder
F52.22 — Female sexual interest/arousal disorder
F52.31 — Female orgasmic disorder
F52.32 — Delayed ejaculation

Common Child and Adolescent Diagnoses

Children and teenagers may come to therapy for anxiety, depression, behavioral concerns, school difficulties, family changes, trauma, or emotional regulation problems.

Some diagnoses that may be encountered in child and adolescent psychotherapy include:

F90.2 — Attention-deficit/hyperactivity disorder, combined presentation
F91.3 — Oppositional defiant disorder
F93.0 — Separation anxiety disorder of childhood
F41.1 — Generalized anxiety disorder
F43.22 — Adjustment disorder with anxiety
F43.23 — Adjustment disorder with mixed anxiety and depressed mood
F32.1 — Major depressive disorder, single episode, moderate

This is not an exhaustive list. There are many other diagnoses that may be appropriate for adults, adolescents, or children depending upon their symptoms and circumstances.

It can.

Insurance benefits are generally designed to reimburse treatment for covered healthcare conditions. Some services or diagnoses may not qualify for reimbursement under a particular plan.

For example, someone may seek therapy because of difficulties within a marriage or intimate relationship. Relationship distress does not necessarily qualify for reimbursement under every insurance policy.

If you are seeking couples therapy, ask your insurance company specifically about CPT code 90847 and the circumstances under which your plan reimburses that service.

Never assume that “mental health coverage” automatically means that every type of psychotherapy will be reimbursed.

The diagnostic codes on this page are here for one reason: to help you have a more informed conversation with your insurance company before beginning therapy.

Your therapist will not choose a diagnosis simply because your insurance company reimburses it.

Any diagnosis appearing in your clinical record or reimbursement documentation should accurately reflect your clinical presentation and the treatment being provided.

Similarly, the procedure code must reflect the actual service you received.

Your deductible is the amount you may need to pay toward eligible healthcare expenses before your insurance company begins reimbursing covered services.

Your out-of-network deductible may be completely different from your in-network deductible.

For example, imagine that your insurance plan has a $1,500 out-of-network deductible. You may need to pay $1,500 toward eligible out-of-network healthcare expenses before reimbursement begins.

After meeting the deductible, your insurance company still may not reimburse the entire cost of therapy.

That’s why you also need to ask about your reimbursement percentage and allowed amount.

This is one of the most important questions to ask your insurance company.

Your insurer may not calculate reimbursement based upon your therapist’s actual fee. Instead, it may establish an allowed amount for a particular service.

For example:

Therapist’s fee: $200

Insurance company’s allowed amount: $150

Your plan reimburses: 70% after your deductible

70% of $150 = $105 insurance reimbursement

Your effective out-of-pocket cost in this hypothetical example would therefore be approximately $95.

This example is for illustration only. Your actual reimbursement depends upon your individual policy, deductible, allowed amount, diagnosis, procedure code, and other plan requirements.

A superbill is a document containing information you may need when requesting reimbursement from your insurance company for healthcare services you paid for directly.

Depending upon the circumstances, a superbill may include:

Client information
Provider information and credentials
Date of service
Length or type of service
CPT procedure code
Diagnosis code
Amount charged or paid

Receiving a superbill does not guarantee insurance reimbursement. Your insurance company determines whether the service is covered and how much it will reimburse.

Every insurance company has its own process.

Many insurers allow you to submit claims through an online member portal or mobile app. Others may require an out-of-network claim form and supporting documentation.

Ask:

“Where do I submit an out-of-network behavioral health claim, and exactly what documentation do you require?”

Keep copies of everything you submit.

If your claim is denied, contact your insurer and ask for the specific reason. Sometimes a claim can be corrected or additional documentation can be provided. Your insurance company can also explain its appeal process.

Using insurance benefits generally requires sharing certain information with your insurance company.

This may include identifying information, dates of treatment, procedure codes, diagnosis information, and other information required to process or review the claim. Depending upon the circumstances and the insurer’s requirements, additional clinical information may be requested.

If you pay privately and do not submit claims for reimbursement, your insurance company is not involved in paying for or reviewing that treatment.

For some clients, maximizing reimbursement is the priority. For others, maintaining greater separation between psychotherapy and their insurance company is particularly important.

You can learn more about this issue on our Do You Accept Insurance? page, including why The Center for Growth has chosen to remain an out-of-network practice and our approach to privacy and confidentiality.

Many clients use Health Savings Account (HSA) or Flexible Spending Account (FSA) funds for eligible mental health expenses.

Eligibility and documentation requirements can vary. Check with your HSA or FSA administrator regarding your individual plan.

If finances are a concern and you do not have out-of-network benefits, The Center for Growth offers lower-fee therapy options.

Depending upon availability, clients may work with our Interns, Fellows, or Associate Therapists at significantly reduced rates.

Interns are graduate students completing master’s-level clinical training.

Fellows have already earned a master’s or doctoral degree and are pursuing additional specialized clinical training.

Associate Therapists have graduate-level clinical training and are developing additional expertise and/or working toward independent licensure.

Their clinical work is supported and overseen by experienced senior clinicians.

This allows us to offer therapy at different fee levels while maintaining our commitment to thoughtful training and high-quality care.

There isn’t one answer that’s right for everyone.

Before deciding whether to use your insurance benefits, find out:

How much will my insurance company actually reimburse?
What deductible must I meet first?
What information will I need to share with my insurance company?

Once you understand the financial benefit and the information required, you can decide whether submitting claims makes sense for you.

The Center for Growth is an out-of-network psychotherapy practice providing individual therapy, couples therapy, family therapy, sex therapy, and other mental health services.

We offer in-person therapy in Philadelphia, Pennsylvania; Ocean City, New Jersey; Providence, Rhode Island; and Mechanicsville, Virginia, as well as telehealth services where clinically and legally appropriate.

We do not determine your insurance benefits and cannot guarantee reimbursement.

But we can make understanding the process easier.

Before your first appointment, take out your insurance card, call the member-services number, and use this page as your out-of-network therapy insurance cheat sheet.

Knowing your deductible, allowed amount, reimbursement percentage, and coverage for a 53-minute psychotherapy session can give you a much clearer picture of what therapy will actually cost.

The Center For Growth Approach