Navigating Insurance Benefits with Out-of-Network Providers

An out-of-network (OON) provider is a healthcare professional who is not contracted directly with any insurance company. In other words, OON providers do not bill your insurance directly for services – you as the client pay upfront for services and seek reimbursement from your insurance. Our clients choose this option for the privacy, flexibility, and freedom it provides compared to insurance-based therapy. Learn more in our recent blog.

Understanding key terminology can help you better maximize your available benefits! Here are the most important terms to know: 

• Out-of-Network Provider: A provider who is not contracted with your insurance company for direct billing.
• Out-of-Network Benefits: The portion of services reimbursed by your insurance when you see an out-of-network provider.
• Reimbursement: Compensation from your insurance provider for a portion of costs you’ve paid to your out-of-network provider. 
• Deductible: The amount you must pay out-of-pocket for services before your insurance begins covering costs.
• Claim: A request for payment sent to your insurance company for services you have already paid for.
• Superbill: An itemized bill provided by your out-of-network provider, which you submit to your insurance company for reimbursement. A Superbill includes all necessary information for your insurance provider to process the claim, such as session details, provider information, and procedure codes.

Though CCG is an OON provider, many of our clients are able to get some level of insurance reimbursement through their insurance plan. Follow the steps to determine what your plan’s specific benefits look like: 

1. Contact your Insurance Provider 

Call your member services department using the number on the back of your insurance card. This number will connect you with a representative who can provide specific details about your insurance plan and benefits.

2. Ask Detailed Questions

When speaking with your member services representative, it’s important to ask targeted questions. Some questions to start with are:

• What are my out-of-network benefits for mental health services? 
• What are the reimbursement rates/percentages for the services I’m seeking? These are often identified by procedure codes. The most common are:
  • 90791 – Intake Session 
  • 90834 – Individual Psychotherapy (45 min)
  • 90847 – Family Psychotherapy
  • 90853 – Group Therapy 
• Do I have a deductible to meet before my plan would provide reimbursement?
• How can I submit a claim for reimbursement?
• The cost of the out-of-network provider that I want to see is _______, given my current coverage, what should I expect to pay out of pocket, and how much can I expect to be reimbursed?
• What is my Maximum Out of Pocket Expense (MOOP) if I decide to go out-of-network?

Due to Medicaid opt-in/opt-out restrictions, CCG cannot bill clients with Medicaid. Our intake coordinators can help you explore other options for services. 

For clients with Medicare, CCG can provide services, but please note that Medicare will not accept claims from out-of-network providers, so costs would be fully out-of-pocket. 

At CCG, we want to do our part to help make the process for reimbursement as simple as possible. We offer 2 options, depending on what makes the most sense for you and your family:

Option 1: Self-Service Superbills 

CCG will provide a superbill at the start of each new month. Clients can access their superbill by logging on to their client portal account.  You can submit this superbill directly to your insurance provider, as it includes all necessary claim information.

Insurance providers may have different methods for submitting claims. If you have questions about the submission process, your insurance provider’s member services representative can direct you.

This option is best for individuals who prefer to handle claims paperwork themselves, allowing complete control over the process. 

Option 2: Courtesy Claims Submission

CCG will submit initial claims directly to your insurance provider on your behalf at the start of each new month at no extra cost. Any further correspondence or reimbursement would still go to you directly. Our practice can provide this option for most major insurance providers, excluding Medicare/Medicaid.

This option is best for individuals who prefer not to handle claims paperwork themselves. It offers a streamlined, consistent submission process with less paperwork! 

You can rely on CCG to provide support and guidance, while helping you navigate the changes you want in your life. Our goal is always to help you uncover your true potential and lead a life that is worth celebrating. Call us today to book an appointment.