Understanding In-Network vs. Out-of-Network Insurance
When using health insurance, it's important to know the difference between in-network and out-of-network providers. This distinction affects how much you pay for services and how your insurance company processes your claims.
In-Network Providers
These are doctors, clinics, or facilities that have contracted with your insurance company to provide services at pre-negotiated rates. Choosing an in-network provider generally means:
Lower out-of-pocket costs
Simplified billing (the provider usually bills your insurance directly)
You only pay your copay, coinsurance, and deductible as outlined in your plan
Out-of-Network Providers
These are providers who do not have a contract with your insurance company. If you choose to see an out-of-network provider:
You may pay higher fees
You might have to pay upfront and then submit a claim for partial reimbursement
Your insurance may cover a smaller percentage, or in some cases, nothing at all
Balance billing is possible (you could be billed for the difference between the provider's fee and what the insurance covers)
Why It Matters
Understanding your network status helps you:
Know what your costs will be
Maximize your insurance benefits
Make informed decisions about where to seek care
How to check your out-of-network insurance benefits
Step 1: Call the Member Services Number on Your Insurance Card
Flip your insurance card over and look for the Customer Service or Member Services number. This is the best place to start.
When you call, ask to speak with a representative about your outpatient mental health benefits.
Step 2: Ask These Key Questions
Here are specific questions to ask your insurance representative:
Do I have out-of-network benefits for mental health services?
Is there a deductible I must meet before reimbursement begins?
If yes, ask: How much is the deductible? How much have I met so far this year?
What percentage of the session cost is reimbursed after I meet my deductible?
What is the “allowed amount” or “usual and customary rate” for CPT code 90837 (or 90834) in my area?
This helps you estimate how much you’ll be reimbursed per session.
Is there a limit on the number of sessions per year?
Do I need any pre-authorization or a referral from a primary care provider?
How do I submit a claim for reimbursement?
Online, by mail, or via app?
Step 3: Take Notes and Request a Summary
Write down the answers, including the representative’s name and reference number for the call. You can also ask them to email or mail you a written summary of your benefits for your records.
Step 4: Ask Your Provider for a Superbill
Once you begin care, ask your out-of-network provider for a superbill (an itemized receipt), which you’ll need to file your claim.
Tip: Know the CPT Codes (billing codes)
Common CPT codes for therapy:
90791 – used for the first session
90834 – 45-minute session
90837 – 53+ minute session
Knowing these helps when calculating expected reimbursement.
Benefit and Reimbursement Services:
There are several companies who will check your benefits for you and process reimbursement requests for a small fee:
Mentaya, and Reimbursify are two popular options. Nirvana offers a reimbursement calculator you can use to estimate your insurance reimbursement.
How Out-of-Network Insurance Reimbursement Works
If you choose to see a provider who is out-of-network with your insurance plan, you may still be able to get partial reimbursement for your care. Here’s how the process typically works:
2. Request a Superbill
Ask your provider for a superbill — a special receipt that includes:
Provider’s name, credentials, and tax ID number
Date(s) of service
Type of service (e.g., psychotherapy)
Diagnosis code (if applicable)
CPT (procedure) code
Amount paid
This is what you'll submit to your insurance company.
4. Wait for Reimbursement
If your plan offers out-of-network benefits, they’ll typically reimburse you a percentage of what they consider a “reasonable and customary” rate (not necessarily what you paid).
For example:
Session fee: $150
Insurance “customary rate”: $120
Plan covers 70% of that rate
You may be reimbursed $84, and the remaining $66 is your responsibility.
3. Submit the Superbill to Your Insurance
Each insurance plan is different, but most allow you to submit claims via:
An online portal
A claims form by mail
A mobile app
Check with your insurance company for specific instructions.
Step-by-Step: Getting Reimbursed for Out-of-Network Care
1. Pay for Services Upfront
Since the provider is not contracted with your insurance company, you will usually pay the full session fee at the time of your appointment.
5. Receive Reimbursement
If approved, the insurance company will send a check or direct deposit to you—not your provider.