Insurance Coverage for Mental Health Services

- Most health insurance plans include mental health services as well. If you have health insurance, you should call the number on the back of your card or log into your account on the insurance provider’s website to inquire of your benefits. Remember to have your member or subscriber number at hand (it should be on your card) if you plan on calling them directly. After the customer service representative confirms your identity, you would ask if you have “mental health coverage”.

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- The customer service representative will then outline your benefits. Most plans have a yearly deductible (amount). For these plans, insurance coverage will not come into effect until after the deductible has been met/ paid. Be sure to also find out how much your copay (copayment) is for mental health coverage as well.

Your insurance carrier has a panel of “in-network” service providers (clinicians) who are contracted to provide services at specific rates. These specific clinicians will be covered under your plan and you would need to book an appointment with one of these specific clinicians in order to stay in network (be covered). You would need to call the insurance company for these specific in-network clinician’s contact information; sometimes your insurance company can help you book with these providers directly, otherwise, you would need to contact these specific clinicians yourself to book the appointment. But our experience has been that these specific providers are all full, not taking any clients or have very long waiting lists. Esperanza Family Counseling is always open to serve.

- Any provider not paneled with a specific insurance company is considered an “out-of-network” provider. Some insurance companies, depending on your plan’s coverage and benefits, do not cover out-of-network mental health services or offer out-of-network benefits. In that case, you would be responsible for the full cost of services, or may need to reference the insurance company’s list of in-network providers (sometimes called “preferred providers”) to find a counselor who is in-network. 

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- Many (but not all) PPO plans do offer some out-of-network benefits. If your insurance plan does include out-of-network benefits, you could receive partial or full reimbursement for the services at Esperanza Family Counseling. However, associate-level clinicians are usually not covered as out-of-network providers; only fully licensed clinicians (LMFTs, LSCWs, LPCCs, etc.) are eligible out-of-network providers. You should check with your insurance carrier to see if your plan offers out-of-network benefits BEFORE assuming it does and to check and see how much of the services are reimbursable (full or partial). If you find that you DO have out-of-network benefits and would like to use them here at Esperanza make sure you let us know so that we can provide you with a superbill in order to receive your reimbursement.

You should know that not all services and appointments are covered by insurance companies whether In-Network or Out-Of-Network. Most insurance companies do not cover couples or family therapy, unless there is an identified patient (IP), who is covered in the insurance plan with a “serviceable” diagnosis receiving treatment under the guise of couples or family therapy. Some diagnoses are NOT covered by In-Network or Out-Of-Network benefits, including most “v-codes” and “z-codes”, which include problems like “relational issues, academic problems, acculturation difficulties, phase of life problems, adjustment disorders” and others.

• Here is a list (not exhaustive) of some of the most common insurance terms 

  • Allowed amount: The amount recognized by the insurance company that is approved to cover. With out-of-network benefits, you are responsible for any amount the insurance company does not cover, but this will be paid upfront since your insurance company will not be directly billed. 

  • Benefits: These are the services that your insurance plan provides

  • Copay: For in-network coverage, it is the amount you pay out-of-pocket for each visit. It is typically the same amount each time.

  • Coverage: These are the benefits included in your purchased plan through your insurance company. 

  • Deductible: This is the amount you bill your insurance company that you pay out-of-pocket before your coverage can begin. 

  • Diagnosis: This is the term used to describe the specific problem you are experiencing. The clinician is the one who determines the diagnosis and the insurance company decides whether they will pay for it or not. Most insurance companies will pay for common diagnoses like depression and anxiety disorders.  

  • Diagnostic code: This is specific code that contains (starts with) a letter and numbers with decimals that coincide with a specific diagnosis. These codes are used by the insurance company to confirm whether the diagnosis is approved to be covered by the insurance company (e.g. F41.1 is the code for Generalized Anxiety Disorder).

  • Eligibility: These are the services that you are authorized by the insurance company to receive as included in your plan

  • Explanation of Benefits (EOB): This is a document that is produced in response to an insurance claim submission which contains the date(s) of service, service code (i.e., individual, group, or family session), allowed amount, copay, deductible, payment amount, and other information.

  • In-network: These are the clinicians/ service providers who have signed a contract with an insurance company to be considered a “preferred” provider or paneled with the insurance company.

  • NPI number: This stands for “National Provider Identification”. This is a number that is required for all clinicians who work with third party (insurance companies) payers for their services, whether they are In-network or Out-of-network. Once a clinician applies for and receives their NPI number, it can be included in their superbill or other insurance documentation for billing and reimbursement purposes. 

  • Out-of-network: These are clinicians/ service providers who have not signed a contract with an insurance company, who are not covered by your insurance and whose services are not eligible to be billed directly to your insurance company.

  • Preferred Provider: This is synonymous with an “in-network” provider

  • Service Code: This is a five digit numerical code used by insurance companies that represents the type of service received (e.g. 90834 is code for an individual psychotherapy session); also called a Current Procedural Terminology (CPT) code.

  • Superbill: This is a document that is similar to a receipt or statement that is provided to you by your service provider which includes your date(s) of service, diagnosis code, service codes, amount you paid for the services, and the clinician’s information (license number, address, phone number, etc.).