Guide to Calling Your Insurance Company about Out-of-Network Benefits
Most health insurance companies have in- and out-of-network providers (providers = doctors, psychologists, etc.). Providers at Spectra Therapies are out-of-network with all insurance companies. Depending on your policy you may or may not have out-of-network coverage. If you do have an out-of-network policy, there are varying levels (partial or total) of coverage for our services. It is best for you to call your insurance company before you schedule an appointment with Spectra Therapies.
Depends on your provider at Spectra Therapies:
Some of our students are not billable under insurance companies. Please double-check with us to have a clear understanding if your provider may or may not be covered by your insurance company. All licensed providers are billable under insurance.
How it works at Spectra Therapies:
Payment is due at the time of service, unless another payment plan has been agreed upon. Therefore, first the client pays the fee out-of-pocket with cash, check or credit card. Second, at the end of every month, we can provide you with a receipt of payment for completed and paid services. This statement has all the necessary information for you to send to your insurance company. Third, the client submits this receipt of payment to his/her insurance company. Fourth, depending on the coverage, the client may receive the reimbursement check directly to them. Note – there are some cases that require pre-authorizations, special assessments, and single-case agreements that require additional steps. Please speak directly to your Spectra Therapies provider for these cases; an informed consent may need to be signed in order for us to help you through these more detailed agreements.
We would like you to be informed about your out-of-network coverage before making your appointment.
Here are the steps to understand your OUT-of-NETWORK mental or behavioral health policies. Spectra Therapies is NOT responsible for the information you obtain by using this guide.
Carve out 10-30 minutes to call your insurance company
Have the following information ready before you call, including your card
Take detailed notes
Do not hesitate to ask questions
Ask the representative to confirm the requirements to use out-of-network benefits
You are asking about your out-of-network mental or behavioral health policy
Below is some information that the insurance company may need from you to provide you with accurate information.
Name, date of birth, address, phone number, or sometimes social security # of person who holds the primary account (“insured”)
Name, date of birth, or sometimes social security # of person for whom the services are for. Some benefits have exclusions based on age or diagnosis.
Spectra Therapies Information:
The following information will be provided on your receipt of payment. Insurance companies do not usually need this information to help you understand your benefits.
Phone Call Notes:
Date that you called:
Call confirmation #:
Guideline of Questions to Ask:
Do I have out-of-network benefits? Yes / No
Do I have a mental or behavioral health policy with out-of-network benefits? Yes / No
What are the requirements to use out-of-network benefits?______________________________
Is authorization required? Yes / No
Is a referral required? Yes / No
Do I have an out-of-network deductible? Yes / No
(If yes) What is my out-of-network deductible?: ______________________________________
(If yes) How much of my out-of-network deductible has been met?: ______________________
(If yes) What calendar year is my out-of-network policy based on?: _______________________
Ask the representative if your policy covers these services (give them the CPT code), how much is the insurance company’s “usual and customary fee” and what percentage do they cover?
||Insurance company’s usual and customary fee
||Percent covered (after deductible met)|
|Psychiatric interview – a 75 minute intake session||90791|
|Group therapy session||90853|
|Individual therapy : 45-minutes||90834|
|Individual therapy : longer than 45-minutes||90837|
|Testing and evaluations||90791, 96137, 96136, 96130, 96131|
Is there a session limit?: Yes / No
(If yes) What is the session limit?: ____________________________________________
(If yes) How many sessions do I have left?: _____________________________________
What % of services are covered/what is my co-insurance?:
Address for submitting claims: _____________________________________________________