Image by Scott Graham

How to file for insurance reimbursement

Filing for reimbursement for psychotherapy is actually very simple! You can do it online, or by mail. Here’s how. Most of the more skilled and experienced psychotherapists are “out of network” providers, meaning you’ll pay directly, and then submit a claim for reimbursement from your insurance company.

Filing your claim online

It is very likely that you can file your claims for reimbursement online, on your insurance company’s website.

  1. Sign in to your account on your health insurance company’s website.
  2. Find “Submit a claim online”.

  3. Fill in the info they request.

  4. Scan and upload a copy of your psychotherapist’s bill.

 

That’s it!

Here’s the info they’ll request – all of this will be on the statement your therapist gives you:

  • Provider’s name and address

  • Provider’s tax ID number (might be TIN, EIN, FEIN, or SSN)

  • Diagnosis code (“ICD”) – for example, “F41.1” for Generalized Anxiety Disorder

  • Procedure code (“CPT”) – for example, “90834” for Individual Psychotherapy, 45 minutes

Here’s an example of a page from an online claim, showing some claim information filled out:
Example-of-an-online-claim-.png

Filing your claim by mail

If you aren’t able to file your claim for reimbursement online, you’ll fill in a paper claim form, attach a copy of your therapist’s bill, and mail it to your insurance company.

You can find the claim form on your insurance company’s website, where you can print it out.

 

(Some insurance companies use a different claim form for psychotherapy – it might be called a “behavioral health” claim form.)

Helpful Hint: If you’ve already paid your psychotherapist, and you’re filing for reimbursement, write in bold letters (and highlight) on the claim form, “PATIENT HAS ALREADY PAID PROVIDER – PLEASE REIMBURSE PATIENT”.

Diagnosis. You’ll enter this as a code, which will be on your therapist’s invoice, probably next to the abbreviation “ICD-10” – for example, “ICD-10: F41.1”.

Place of service. For psychotherapy in your therapist’s office, the code will typically be “Office,” which is code “11.”

Description of Services, or CPT. “CPT” is the code for what kind of service your therapist provided, and should be on your therapist’s invoice. For example, “Individual Psychotherapy, 45 minutes” is “CPT 90834.”

Your therapist’s NPI number. If your therapist has one, it’ll be on their invoice. If they don’t, the insurance company will still process your claim; just write “none.”

Provider’s signature. Fill this in with “See attached invoice.” Most of the time, this is sufficient.

Assignment. Don’t sign anything that says “authorize assignment”, since you’ve already paid your therapist and are filing for reimbursement. If you authorize or assign your benefit, that means the insurance company will send payment to your therapist instead of you.

If your insurance company is really kickin’ it old school…

The old standard “universal” insurance claim form is called a HCFA (“HICK-fah”) form, or CMS-1500 form, you can download it below.

Getting Fair and Accurate Insurance

Reimbursement for Your Psychotherapy

1. First, get informed!

Here’s an important thing everyone with insurance needs to understand: Insurance companies use some “creative” ways to determine the basis of what they’ll cover. It’s not just that your plan says it’ll cover, say, 80% of the cost of psychotherapy — it’s 80% of what they say psychotherapy costs. That’s an important number.

(They get crafty about how they come up with that number, and even what they call it, by the way. Sometimes they use something called Usual, Customary, and Reasonable (“UCR”). Or reasonable market value… a number they can basically just make up. Or they’ll use a percentage of Medicare rates as the basis for how much they’ll pay — even if you aren’t eligible for Medicare, which is specially negotiated insurance for people 65 or older, younger people with disabilities, and people with End Stage Renal Disease.)

Keep in mind that they use that number — what they say psychotherapy costs — to calculate your reimbursement. For example, if your insurance plan says it covers 80% of psychotherapy fees, what that really means is they’ll pay 80% of what they say the typical fee for psychotherapy is.

The catch is that there are very few regulations for how they determine that number. And, they usually won’t tell you (their customer!) what that number even is — calling it “proprietary information.”

Good news, though! Thanks to numerous class action lawsuits, and legislative work on healthcare laws, there’s a consumer rights website where you can see what an objective source says the typical fees are in your area.

The site is Fair Health Consumer, and here’s how to use it to look up the Typical Provider Charge (Fair Health’s term for UCR) for psychotherapy in your area:

  1. Enter the Zip code of your therapist.
  2. Enter the procedure code; 90834 is the procedure code for individual outpatient psychotherapy, 45 minutes, or you can ask your therapist what code they’ll use.

  3. Click “See Out-of-Network Reimbursement”.

  4. Scroll down to “Cost Breakdown” (ignore the first few rows you see on the page — those includes other charges like hospitalization).

There you have it! Now you know the real typical cost for psychotherapy in your area, and you’re armed and ready to call your insurer.

2. Call your insurance company

When you call, they’ll first let you know what your insurance plan covers in general terms — for example, 80% of “the UCR.”

(So, for example, if your insurer considers $200 to be the UCR for psychotherapy, and you have 80% coverage, they’ll cover $160.)

Now you’ll want to ask about what to expect for reimbursement for psychotherapy. For example, if you were to call about reimbursement for psychotherapy with me, you’d tell your insurer this information:

  • You’ll be submitting claims for “Individual Psychotherapy, Outpatient, 45 minutes,” also referred to as CPT code 90834.
  • My current fee for CPT code 90834 is $230.

  • My Zip code is 20036 (reimbursement varies based on location).

  • I’m a licensed psychologist, and I’m a non-participating provider (meaning I’ve chosen not to have a “contract” with any insurance companies).

Then ask them if your therapist’s fee is within the range of what they use to determine reimbursement. If they say anything, they’ll typically only say either “yes” or “no”.

If they say no, or that they can’t tell you that, you can tell them you’ve used the Fair Health Consumer site to look up the Typical Provider Charge for psychotherapy in your area, and that the amount is $_____ (whatever you’ve found using Fair Health). Then ask them if that figure is what they use to determine reimbursement — and if not, why not!

3. Ask your psychotherapist for help and guidance

Clearly, insurance companies prefer to skew the “game” to their advantage, not to patients, and all therapists are aware of this. Therapists should also be able to help if insurance companies aren’t playing fair, and guide you about the ins and outs of getting the reimbursement you’re due.

Like many healthcare providers, my patients pay me my fee directly, and then file for reimbursement. If my patients run into any snags, I’m there to help and guide them, whether it’s with CareFirst, United HealthCare, Aetna, Cigna, or any other insurance carrier.