How to Check Your Out-Of-Network Insurance Benefits
I am an in-network provider for Highmark, Aetna, Geisinger, Optum/United, etc. If you have out-of-network benefits included in your insurance plan, we can provide you with a “superbill” which you can use to get partial reimbursement. We have included details below on how to ask and understand your out-of-network benefits.
Check Zaya Health
I am currently an out-of-network providers with most insurances. However, I work with Zaya Health, which will automatically file out-of-network claims for you and help you potentially get partial reimbursement for our services. You can use this tool below to check your insurance and see if you are eligible for these benefits. You can also reach out to them through email to learn more information. (Services from interns are not eligible for reimbursement.)
Call Your Insurance Provider
If your insurance does not work with Zaya, or you simply want to check on your own, you’ll need to call your insurance provider directly. Look for the Customer Service number on your insurance card or the provider’s website.
What to ask the representative
- Do I have out-of-network benefits for behavioral health services?
- Is there an annual deductible that needs to be met and when does that deductible amount reset?
- What is my out of network coinsurance after my deductible is met?
- What is the allowed amount per session?
- Is there a limit on how many sessions I’m allowed each year?
Understanding the terms
Deductible – This is the amount that you have to pay out of pocket before insurance starts paying.
Coinsurance – This is the percentage of the full session fee that you are responsible for per session.
Allowed Amount – This is the maximum amount your insurance company will cover per session. You will be responsible for everything above this amount in addition to your coinsurance.
Example of benefits
$500 deductible – pay this amount out of pocket first, before insurance will cover anything
30% coinsurance – after your deductible is met, you will pay 30% of the full session cost
$130 allowed amount – insurance only covers a max of $130 per session and you need to pay the difference ($170 – $130 = $40) in addition to your coinsurance (30% x $170 = $51). Your total will be $91 per session