Get Reimbursement For Out-Of-Network Therapy Using Superbills

Equilibrium Psychotherapy is an out-of-network (OON) mental health provider. This means that we are not connected to your insurance carrier and sessions will be paid out-of-pocket. Your therapist won't submit claims for payment to your insurance company, however your insurance may cover a portion of out of network therapy costs. A superbill is given to you by your therapist and you in turn provide this to your insurance carrier for reimbursement. This superbill will show an itemized list of services that you have received in the form of a detailed invoice or receipt.

Common Insurance Providers For Mental Health Services In Madison, WI

The first step is to contact your insurance provider to learn if you have out-of-network benefits. Below I provided phone numbers for several common insurance providers in Wisconsin. When you give them a call remember to have your member information on hand.

• Blue Cross Blue Shield: 1-855-690-7800
• Quartz: 1-800-362-3310
• Dean Health Plan: 1-800-279-1302
• Molina: 1-888-999-2404
• Wisconsin Physicians Service: 1-888-915-4001
• Security Health Plan of Wisconsin: 715-221-9555

What Do I Ask My Insurance Provider To Verify I Have Out-Of-Network Coverage For Therapy?

If you are hoping to submit a superbill for reimbursement, make sure to check with your insurance provider to make sure you have out-of-network benefits. If your insurance provider confirms that you have out-of-network benefits, you may be reimbursed for some of the costs you pay out of pocket. The savings can be substantial, so please check it out! When you call your insurance provider's "Member Services" line, the following questions will provide you your out of pocket costs (total amount paid for therapy) and help you feel confident about your plan.

• What are my out-of-network healthcare benefits for behavioral health in an out-patient setting? Is pre-authorization of my therapist required?
• Will there be a co-payment that I'll be responsible for paying?
• Do I have a deductible I need to hit before payment will be covered by insurance?
• What is today's accumulation toward my deductible?
• Will my co-insurance help? (if applicable)
• Is there a timely filing date that I need to file by after the service?
• If I am to request a superbill, what information do you require to be included?

If pre-authorization is required for your superbill to be accepted, ask the representative to get this started. Many times, they will need to transfer you to the person who can grant the authorization. They will ask for your name, date of birth, and member number, along with the name and address of the mental health professional who will provide the therapy. After the information is completed, the representative will give you the authorization number that is stored in the insurance database. The authorization will provide a time frame: example 8/1 through 12/31 and/or a total number of visits allowed during the time frame.

Who Creates The Superbill?

Equilibrium Psychotherapy will create a superbill for you upon request. After your therapist has generated your superbill, it will be available in your Simple Practice client portal. When you request a superbill, make sure to inform your therapist as to what information is required by your insurance carrier in order to avoid delayed or denied reimbursement.

• Client contact information: This may include name, address, date of birth, phone number.
• Provider information: This may include the therapist's name, location of practice, state license number, phone number, 10-digit National Provider Identification (NPI), Employer Identification Number (EIN), and email address.
• Your diagnosis: Your insurance company needs to know why you needed mental health services. So, a superbill needs to include your diagnosis in the form of an ICD code. The International Classification of Diseases (ICD) diagnostic code shows what a client is being treated for and helps the insurance company validate that treatment is medically necessary.
• CPT code: The Current Procedural Terminology(CPT) code is used to describe specific medical and diagnostic services that a patient receives. This tells insurance companies what kind of services you receive.
• Dates of service: Your therapist will include all dates they worked with you. If there are multiple dates of service on the superbill, the most relevant procedure code should be listed by each date.
• Itemized list of costs: The service amount should be included next to each procedure code. The total balance should reflect the costs of all services performed.

What do you do with your superbill once it's filled out?

Once you have your superbill, you can submit it to your insurance provider. Your insurance provider should give instructions on how to submit a superbill. Follow the guidelines and call your insurance provider if you have any questions. Once your superbill has been accepted, the insurance carrier will send payment. Most of the time, your insurance company will reimburse you directly.

Is there a time limit in submitting my superbill for reimbursement?

Yes, but it depends on your insurance provider. It is important to check with your insurance carrier for their specific time frame.

Do I have to pay out of pocket for therapy up front if I plan to submit a superbill?

At Equilibrium Psychotherapy, you will be charged for therapy, the evening after your session through our Electronic Medical Record, Simple Practice. Any reimbursement from your insurance company will come after your superbill has been submitted and approved.

How much can I expect to be reimbursed after I submit my superbill?

Your insurance company will process your reimbursement according to the details of your plan. Based on your insurance carrier's policies and your plan, several factors determine how much you may be reimbursed. These factors include:

• The amount allowed for a therapy service based on what your insurance company would pay for an in-network therapist
• Your out-of-network benefit level
• Whether you have met your out-of-network provider deductible for the year
• Your coinsurance rate for out-of-network providers (the percentage of charges your insurance company expects you to pay)

Below is an example of how insurance factors will affect your reimbursement:

• You paid your therapist $150 for a 60-min therapy session out of pocket and submitted a superbill to your insurance carrier.
• Your insurance company decides the amount allowed for this service is $100, which is the maximum they will consider for reimbursement.
• Your plan determines that your coinsurance is 40% for this therapy session (or $40).
• You have met your deductible for the year and are therefore eligible to be reimbursed.
• When processed, your insurance carrier will reimburse you $60 for your therapy session.

What happens if my insurance company denies my superbill?

If your insurance company denies your superbill, first find out why. Your insurance company is required to inform you of why your superbill was denied. Often it can be explained by the following:

• Missing information on the superbill
• Incorrect billing or diagnosis codes
• Claim was submitted outside the time limit
• Lack of coverage for submitted services
• Determination that the services aren't medically necessary

If your claim for reimbursement is denied, you have several options. If your superbill or claim was missing information, you may need to resubmit a corrected claim. Then, your insurance company can reprocess it. You can also appeal a denied claim. Your insurance company must let you know the process for appealing the decision. First, you'll appeal to your insurance company. This formally asks your health plan to reconsider your claim. If your insurance carrier denies your claim again, you may have the option to appeal to your state's insurance regulators. This allows you the opportunity to have your claim reviewed by an independent party.