Out of Network Benefits with Passion Lab Pittsburgh
How to Determine if You Have Out-of-Network Benefits (OON)
TLTR: Too Long To Read, so here’s a recap
How to know if you have OON
Call your insurance company.
Use CPT code(s) to see if you qualify.
If you do, then provide your diagnosis.
If you want a superbill, let me know.
One of our most frequently asked questions is about out-of-network benefits. Some clients may have out-of-network (OON) benefits through their insurance company, but it depends on the insurance company and their specific plan. Unfortunately, I can’t determine for you whether or not you have out-of-network benefits. That is something you have to contact your insurance to find out.
For example, if you have Highmark or UPMC, telling me you have insurance from either of those companies does not tell me whether or not you specifically have out-of-network benefits. There are so many different kinds of insurance plans and tiers within those plans, it’s impossible to know about them all.
Not sure whether you have OON benefits?
If you’re not sure whether you have OON benefits, you’re welcome to send me a PDF document of your benefits package. I can look through it and see what I find. However, I cannot give a guarantee that I will be able to find the information, nor can I determine what that means in regard to what your reimbursement rate would be. Your best bet to get a solid answer on if you do have out-of-network benefits is to ask your insurance company. When you call your insurance company, they may ask for a CPT code.
CPT CODES
CPT codes, or Current Procedural Terminology, are universal healthcare codes that your insurance company or healthcare uses for all reporting and billing. Your insurance company may want more information before determining whether or not you have out-of-network benefits that would cover the services. This could be your diagnosis and the type of service provided.
3 CPT codes Passion Lab uses
First intake diagnostic (90791)
Individual therapy (90837)
Relationship counseling with all partners present (90847) OR relationship counseling with the identified clients or identified patient(s) not present (90846).
The last one means that when someone is using their insurance, they are considered the identified patient or client. So if, for example, I have a session with your partner and you are not in the session because I'm having a one-on-one conversation with your partner, then that would be when relationship counseling without identifying the client present is being used.
Diagnosis
For insurance to be used, people need a valid mental health diagnosis. Meagan needs to assess this. Communication building and improving the relationship isn't enough. Insurances want to cover medically necessary services. For a diagnosis to be valid to use insurance for relationship counseling or sex therapy to be valid, it has to cause a significant and medically necessary level of distress or disorder. Otherwise, you can pay out of pocket.
If you already see a therapist using insurance, you have a diagnosis. However, if you would like to work with me at Passion Lab Pittsburgh in tandem with working with your individual therapist or your other therapists, Passion Lab cannot use the same diagnosis.
For example, if your individual therapist has diagnosed you with major depressive disorder, I would not be able to use that same diagnosis because that can potentially cause issues. In addition, the insurance company may flag and question why you, the client, need two different therapists to manage the same treatment. So on top of that, if there is no other valid, accurate diagnosis besides the ones they are using with their primary therapist, then I would not be able to diagnose you.
SUPERBILLS
If you end up having out-of-network benefits, I can send a superbill. Superbills are typically sent at the beginning of the following month. So let's say you, the client, had four sessions with me in October. At the beginning of November, you will receive a document that lists all rendered services for October in one bill called a "superbill." The client, you, can send that to your insurance company. Your insurance company will reimburse you directly based on whatever the insurance company has determined as the amount to reimburse. That is up to the insurance company and Passion Lab Pittsburgh, nor do I have control over that.
If you want to know if you would qualify for that or how much that would be, you need to find out from your insurance company. I cannot guarantee insurance reimbursement. If you, the client, believe that you have out-of-network benefits for the services requested, and you find out from the insurance company that you don't, I will not refund my services. So clients have to consent to potentially not getting reimbursement back without a refund from me.
Do You Still Have Questions?
If you are still unsure or have questions, email me here I would love to help out.