If we are out-of-network, that means we do not have a contract with your insurance company. You may still be able to use out-of-network benefits to pay for care.
When you or your child gets care from an out-of-network provider, you pay the entire cost of the session upfront. Then, either we or you file a claim with your insurance company, and they reimburse you for some of the money you spent. Filing a claim means filling out paperwork about the care your child received and sending it to the insurance company, usually by mail. We will give you a document called a superbill to include with your claim. A superbill shows the company exactly what kind of care your child got.
There are several factors to consider when looking at the cost of out-of-network care:
- Insurance companies usually cover less of the cost of an out-of-network provider. For example, you might have to pay a $25 copay if you see an in-network provider, but a $35 copay if you see an out-of-network provider.
- Insurance companies do not usually reimburse you based on the amount you actually paid. Instead, they reimburse you based on what’s called the allowable amount for the service you or your child received. The allowable amount is the amount that your insurance company has decided it is reasonable for a provider in your area to charge for a specific service. For example, your insurance company’s allowable amount for one hour of an evaluation may be $80. If we charge you $100 for that session, your insurance company will still reimburse you as if the cost were $80.
- The deductible still applies for out-of-network care. You will not be reimbursed for you or your child’s care until your deductible for the year has been met.
The downside is that getting care using out-of-network benefits may be more expensive. You have to pay for the evaluation upfront, and getting reimbursed by your insurance company can be complicated and time-consuming.
You could also consider using a service that deals with claims for you, like the Reimbursify app. These services charge a small fee in exchange for helping you get reimbursement from your insurance company, so they may help you get more money back in the long run.