Insurance, Out-of-Network Benefits, and Reimbursement

How out-of-network works

You pay your provider directly. Your provider gives you a superbill, which is an itemized receipt with the codes your insurer needs. You submit it to your plan, and your plan reimburses you directly according to your out-of-network benefits. At The Haven Family Center I provide monthly superbills on request.

Call your insurer and ask these questions

• Do I have out-of-network benefits for outpatient behavioral health or behavior analytic services?
• What is my out-of-network deductible, and how much of it have I met this year?
• After the deductible, what percentage of the allowed amount is reimbursed?
• Is there a limit on visits per year?
• Is pre-authorization or a referral required for reimbursement?
• How do I submit a superbill, and what is the filing deadline?
• Is there a separate policy for autism services, and does it differ from general behavioral health?

Write down the answers

Record the date, the representative's name, and a reference number for the call. If a claim is later denied, that record is the fastest way to resolve it.

If your claim is denied

• Ask for the specific reason in writing.
• Common fixes include a missing diagnosis code, a missing referral, or the wrong claim form.
• You can appeal. Most plans allow at least one internal appeal and then an external review.

Other ways to offset cost

• HSA and FSA funds can often be used for behavior analytic services.
• Some employers offer caregiver or dependent-care benefits that cover part of the cost.
• Keep all superbills and receipts for tax purposes and ask your tax preparer about medical expense deductions.

A note on what I can and cannot promise

I am not able to guarantee reimbursement. Coverage depends entirely on your individual plan. I will give you the documentation you need and answer questions about what I provided.