Insurance, out-of-network benefits and superbills

Start with the provider’s network status

An in-network provider has a contract with the plan and ordinarily submits claims under the contract’s rates and rules. The client may owe a copayment, coinsurance, deductible or another plan-defined amount.

An out-of-network provider has not contracted with the plan for that service. The client commonly pays the provider’s full fee and may submit a claim for possible reimbursement. Some plans provide no routine out-of-network benefit. Others reimburse only after a separate deductible is met.

Texas-regulated health plans are subject to state requirements, while many large-employer plans are self-funded and primarily regulated under federal law. The letters “TDI” or “DOI” on an insurance card can help identify a Texas-regulated plan. The plan administrator should state which rules and appeal process apply.

Five variables control the result

Deductible

The amount the member must pay for covered services before the plan begins paying under the applicable benefit. A plan may use separate in-network and out-of-network deductibles.

Allowed amount

The amount the plan recognizes for the service. It may be lower than the therapist’s fee.

Coinsurance

The percentage assigned to the member after the deductible, usually calculated from the allowed amount rather than the therapist’s full charge.

Copayment

A fixed member amount, more common for in-network care. It may not apply to out-of-network services.

Claim deadline

The period in which a claim must be filed. Missing it can eliminate reimbursement.

Medical necessity

A plan standard used to decide whether a service qualifies for coverage. Coverage may require a diagnosis and other clinical information.

A superbill is evidence of a charge, not payment

A superbill is an itemized statement from a health-care provider. For psychotherapy it usually includes the client and provider identifiers, date and place of service, fee, procedure code, diagnosis code, provider license information and National Provider Identifier. A client may use it to submit an out-of-network claim.

A superbill does not make an out-of-network therapist “covered,” and it does not determine the payment. The insurer may apply the claim to a deductible, pay a percentage of an allowed amount, request more information or deny the claim. The diagnosis and service information becomes part of the claim record.

Run the math before treatment begins

Assume a therapist charges $180. The plan recognizes an allowed amount of $130 and pays 60 percent after the out-of-network deductible. If the deductible has been met, the plan’s payment could be $78—60 percent of $130—not 60 percent of $180. The client’s net cost would then be $102. Before the deductible is met, the plan might pay nothing while crediting the allowed amount toward that deductible.

This is an illustration only. Plans calculate claims differently, and an insurer’s telephone estimate is not a guarantee of adjudication.

The basic formula

Possible plan payment = allowed amount × plan percentage, but only after the applicable deductible and subject to the plan’s coverage rules. The therapist’s charge above the allowed amount ordinarily remains part of the client’s cost in an out-of-network arrangement.

Understand the claim sequence

1. The client pays the therapist according to the practice agreement.
2. The therapist issues a superbill or other claim information.
3. The client submits the claim before the plan’s filing deadline.
4. The insurer adjudicates the claim: covered, applied to deductible, partly paid, held for information or denied.
5. The explanation of benefits states the allowed amount, plan payment and member responsibility. It is not a bill from the therapist.
6. If the claim appears inconsistent with the plan, the member requests the reason and follows the applicable appeal route.

Make the insurer answer a complete question

Call the number on the insurance card and ask the representative to answer each question for outpatient mental-health psychotherapy. Record the date, representative’s name and call-reference number.

1. Does this plan cover routine out-of-network outpatient psychotherapy?
2. What is the out-of-network deductible, and how much remains this plan year?
3. What coinsurance applies after the deductible?
4. How is the allowed amount determined for the relevant procedure code?
5. Is prior authorization, a referral or a specific diagnosis required?
6. Are online sessions covered at the same level as office sessions?
7. Are there visit limits or review requirements?
8. What is the filing deadline, and how are member-submitted claims filed?
9. Will payments go to the member or the provider?
10. What internal appeal and external review rights apply if a claim is denied?

Parity is not universal out-of-network coverage

Mental-health parity concerns the comparability of covered mental-health and medical or surgical benefits, including financial requirements and treatment limitations. It does not require every plan to contract with every therapist, remove all deductibles or provide an out-of-network benefit that the plan otherwise lacks.

The Texas Department of Insurance publishes consumer information for Texas-regulated plans and routes for complaints and appeals. For a self-funded employer plan, the plan document and federal benefit administrator may control the process.