Reimbursement for out-of-network therapy

If your therapist isn't in your insurance network, reimbursement is how your plan pays its share: you pay for the session, submit a claim, and the plan pays part of it back. How much comes back depends less on your therapist than on which side of your plan the claim is processed under.

How out-of-network reimbursement works

1. You pay your therapist's fee at the time of the session, the same as any private-pay client.
2. Your therapist gives you a superbill: an itemized receipt with their NPI number, the dates of service, the procedure and diagnosis codes, and what you paid.
3. You submit a claim to your insurer, usually through its member portal or a paper claim form, with the superbill attached. Plans set a deadline for this, so check yours.
4. Your plan processes it and sends an Explanation of Benefits showing what it paid you and why.

Why so many people get back little or nothing

The claim isn't paid on your therapist's fee. It's paid on a chain of plan rules, and each one takes a cut:

• The allowed amount. Your plan decides what a session is worth for benefit purposes, and that figure is typically lower than what your therapist charges. The difference is yours to cover.
• The out-of-network deductible. This is the one people miss. Out-of-network care usually has its own deductible, set much higher than the in-network one and tracked separately from it. Until you've paid through it, claims are processed and pay you nothing, however good your coverage looks on paper.
• Out-of-network coinsurance. Once the deductible is met, the plan pays its share of the allowed amount, and that share is lower out of network than in network.
• No out-of-network benefit at all. Many HMO and EPO plans don't cover out-of-network care, so there's nothing to reimburse.

What to ask your insurer

Before counting on reimbursement, call the member services number on your card and ask:

• Do I have out-of-network benefits for outpatient mental health care?
• What is my out-of-network deductible, and how much of it have I met this year?
• What coinsurance applies once it's met, and how is the allowed amount set?
• Is there a separate out-of-network out-of-pocket maximum?
• Do I need pre-authorization, and what's the deadline to submit claims?

If the answers add up to very little coming back, that's the point to look at the in-network side of your plan instead.

Getting reimbursed at your in-network level instead

When your plan has no adequate in-network option for your need, you can ask it for a network gap exception: an agreement to apply your in-network benefits to your out-of-network therapist. You keep seeing the same therapist and keep paying their fee, but your claims are processed as if they were in-network:

• Your in-network deductible applies, which is usually lower and often already partly met by the rest of your medical care.
• Your in-network cost-sharing applies, so the plan pays a larger share.
• What you pay counts toward your in-network out-of-pocket maximum, not a separate, higher one.

It also works on plans with no out-of-network benefit, where it creates coverage that wasn't there. What it doesn't change is the allowed amount: you're still reimbursed on the plan's figure, not your therapist's full fee. In a smaller number of cases a plan will only grant in-network benefits through a single case agreement, a rate contract with your therapist that fixes your cost up front instead.

Who can get one

A gap exception rests on a real reason your plan's network can't serve you:

• No adequate in-network therapist for your need, including one who speaks your language or shares your culture, or has an opening within a reasonable distance or wait.
• Continuity of care: you're in treatment that's working, and switching would set you back.
• A specialized approach the network can't match.
• An urgent need that can't safely wait.

Federal parity law backs these requests up: a plan can't make mental health care harder to access than medical care. If your insurance is through an employer, you're in the group this works best for.

Doing it yourself vs. having it handled

You can request a gap exception yourself. Our step-by-step guide covers what it involves. It takes documenting the network gap, a letter of medical necessity from your therapist, a formal request letter, and persistent follow-up. Inclara does that work for you and pushes your insurer until it answers. You only pay if your coverage is approved.

Frequently asked questions