Navigating insurance

Insurance can be complex and it is important for clients to understand the terms and coverage of their policy. While we aim to help, it is ultimately the client’s responsibility to be informed. If the insurance does not cover the sessions, the client will need to pay for them.

1. Call the number on your insurance card for customer service. Choose the option to speak with a customer service representative, not an automated system.
2. Write down their answers to all of these questions and share the information with your provider at Embodying Compassion.
3. Ask the insurance representative about your psychotherapy/behavioral health benefits, which CPT codes are covered and if they require specific diagnoses and modifiers.
4.  After asking generally, ask specifically if they cover a 90837 CPT code (a 53min outpatient visit) and if that visit requires a referral, or a specific diagnosis in order to be covered.
5. Inquire if there is a visit limit per year and the amount.
6. Find out if you have a deductible. If yes, ask about the amount of the deductible and how much has already been met.
7. Find out if you have a copay or coinsurance and what the amount is.
8. Check if your policy requires pre-authorization for outpatient psychotherapy services. If yes, ask if they have one on file.
9. Determine if your policy requires a written prescription from your primary care physician. If yes, ask if a prescription from any MD/physician or a specialist referred by your PCP will be accepted.
10. If you have out of network coverage inquire about the percentage of reimbursement you have and if there is a limit on number of sessions in addition to asking the above questions. If you have out of network benefits we can provide you with a superbill or invoice. Clients using out of network benefits typically pay for their services at the time of session and then get reimbursed directly from their insurance by submitting the invoice or superbill we provide you with.

Additional information

• You need to satisfy your deductible before the insurance company will cover therapy expenses. Keep all bills to help reach the deductible amount.
• If you have an office visit copay, the insurance company will deduct that amount from the percentage they will pay, and you are responsible to directly pay the provider the remaining copay.
• Common Copayment definition: is a fixed amount of money that an insured person must pay for certain healthcare services or prescriptions at the time of service. This amount is predetermined by the insurance plan and is typically a relatively small portion of the total cost of the service or medication.
• Common Coinsurance definition: sharing of costs between the insured individual and the insurance company. When a person has a coinsurance clause in their policy, it means that they are responsible for paying a percentage of the total cost of a covered service or treatment, while the insurance company will pay the remaining percentage.
• Common Deductible definition: a specific amount of money that an individual must pay out of pocket before an insurance company will begin to cover certain expenses. It is important for individuals to understand their insurance deductibles and how they work in order to make informed decisions about their coverage and financial responsibility.