For many clients seeking psychological services, navigating the intricacies of insurance can be a daunting task. While I operate as an out-of-network provider, I strive to make the reimbursement process as straightforward as possible. This guide will walk you through understanding and submitting superbills to ensure you get the maximum reimbursement you’re entitled to from your insurance provider.
What is a Superbill?
A superbill is an itemized form that details services provided to a client. Unlike a standard receipt or invoice, a superbill contains specific information insurance companies require to process a claim. This includes diagnostic codes, procedure codes, the provider’s details, and more.
Why Do You Need a Superbill?
If you have insurance that covers mental health services from out-of-network providers, you can submit a superbill to your insurance company for potential reimbursement. The reimbursement rate will depend on your insurance plan’s specific benefits and coverage for out-of-network mental health services.
Steps to Submit Your Superbill:
- Obtain the Superbill: After your psychotherapy session, ask your provider to provide you with a superbill either in print or via email, depending on your preference.
- Review the Superbill: Make sure all the details, such as the date of service, type of service, and fees charged, are accurate.
- Submit to Your Insurance Provider:
- Find your insurance company’s claim mailing address or online submission portal. This can typically be located on the back of your insurance card or on the company’s website.
- Fill out any required claim forms from your insurance provider. Some companies might have specific forms to accompany the superbill.
- Mail or electronically submit the superbill along with any necessary claim forms.
- Monitor Your Claim: Once your superbill is submitted, the insurance company will process it. You’ll typically receive an Explanation of Benefits (EOB) in the mail detailing the amount they covered and any remaining balance you might owe.
- Follow Up: If you don’t hear back within a few weeks, or if the reimbursement seems lower than expected, don’t hesitate to call your insurance provider. Sometimes claims are delayed, misplaced, or additional information might be required.
Tips for Successful Reimbursement:
- Understand Your Plan: Every insurance plan is different. It’s essential to know your plan’s specifics regarding deductibles, out-of-network benefits, and reimbursement rates.
- Deductible: This is the amount you pay out-of-pocket for health services before your insurance benefits kick in.
- Out-of-pocket max: This is the maximum amount you pay with your own money for covered healthcare services. Once this maximum is reached, the insurance company pays for 100% of all covered costs for the rest of the year. Deductibles, co-insurance, and co-payments count towards this maximum, but plan premiums and out-of-network care and services do not.
- Co-insurance: Basically, the same as co-payments but instead of a fixed dollar amount, it is the percentage of that amount. For example, if a session costs $100 and a person has a coinsurance rate of 20% after meeting their deductible, they would pay $20 for the session ( so the reimbursement would be $80).
- Superbill and claims: A superbill is a document that generates a claim to prove to the insurance company that services were necessary. A therapist can provide a superbill to their client, who can then file the claim with their insurance company.
- Reimbursement: Insurance includes reimbursement policies in which you may pay out of pocket for a service, but can receive money back after submitting a claim. Plans differ on their reimbursement policies, so it’s important for clients to understand their individual benefits.
- Allowable amount: This is the maximum amount an insurance company will pay for a specific healthcare service. Can also be known as eligible expense, payment allowance, or negotiated rate.
- Timely filing limit: Another way to say the deadline for submitting a claim to an insurance company for reimbursement of a covered healthcare service. The time limit varies from 90-365 days, depending on the insurance plan.
- Keep Copies: Always keep a copy of any documents you send to your insurance, including the superbill.
- Consistency: If you attend sessions regularly, consider submitting superbills monthly rather than after each session. This can streamline the process.
- Inquire About Electronic Submission: Some insurance companies allow electronic submission of claims, which can be quicker and more efficient than mailing them.
Frequently Asked Questions (FAQs)
1. How do I find out my therapist’s contracted rate?
If your therapist is an out-of-network provider, they may not have a “contracted rate” with your insurance company. This rate is usually a predetermined amount that insurance agrees to pay in-network providers. However, you can call your insurance provider directly and ask about their usual reimbursement rate for out-of-network mental health services. Remember, even if you get a figure, it might not cover the therapist’s full fee.
2. Can I know how much I’ll be reimbursed before my therapy session?
It’s challenging to know the exact amount of reimbursement before the therapy session. However, you can call your insurance company and ask about their typical reimbursement rates for out-of-network providers offering the specific services you’ll be receiving. They might give you a percentage (e.g., 60% of the allowable amount) or a fixed dollar amount. However, the actual reimbursement could vary based on multiple factors like deductibles, out-of-pocket maximums, or specific plan provisions.
3. Why is there a difference between the therapist’s fee and the insurance’s reimbursement rate?
Therapists set their fees based on various factors, including their expertise, the local market rate, operational costs, and more. Insurance reimbursement rates, on the other hand, are set based on agreements with in-network providers and typical rates for out-of-network providers. The difference arises from these two independent calculations.
4. What happens if my claim gets denied?
If your claim is denied, you’ll receive a notice from your insurance company explaining the reason. You have the right to appeal this decision. Start by reviewing the denial reason, ensuring all information on the claim was correct, and then follow your insurance company’s appeal process. Sometimes, a simple error or omission can lead to a denial, so it’s worth reviewing everything closely.
5. How long does it usually take to receive reimbursement?
The timeline can vary based on the insurance company and the accuracy of the provided documentation. Typically, once you’ve submitted the superbill and all necessary forms, you can expect to hear back anywhere from a few weeks to a couple of months. If you haven’t received any communication (like an Explanation of Benefits) after two months, it’s a good idea to follow up with your insurance provider.
Special acknowledgment: Portions of the information for this post were sourced from Heard’s comprehensive guide on out-of-network billing for therapists.
Dr. Katiah Llerena, PhD 