Insurance Out-of-Network Guide

Disclaimer: Select providers at Upside Therapy and Evaluation Center are in-network with Blue Cross Blue Shield (BCBS) but out-of-network with all other insurance companies. This guide is provided to assist you with calling your insurance company to check on your out-of-network benefits for those that do not have BCBS insurance. Upside Therapy is not responsible for the information obtained using this guide.

Payment at Upside Therapy:

At each session payment is due, unless another payment plan has been established. Thus, the client will pay their fee with cash, check, or credit card. Clients have an option to request an itemized receipt of payment for services which will be fulfilled at the end of each month. This may be used to submit to your insurance company. It is the client’s responsibility to handle this submission.

How to check your out-of-network coverage and possible out-of-network benefits:

• Plan for 15-30 minutes of your time available to call your insurance company
• Make sure to have this information ready before your call:
  • Insurance card
  • Name, date of birth, address, phone number, or possibly social security number of the cardholder or person for whom the services are for
  • Pen and paper/notepad
• Questions to ask:
  • Are there out-of-network benefits for this policy?
  • Do I have a mental or behavioral health policy with out-of-network benefits?
  • What are the requirements to use out-of-network benefits?
  • Is prior authorization required?
  • Is a referral required from my primary care physician?
  • Do I have an out-of-network deductible?
    • If yes:
      • What is my out-of-network deductible?
      • How much of my out-of-network deductible has been met?
      • What is the start date of the calendar year my out-of-network policy is based on?
    • In addition, ask the representative if your policy covers these services (use the CPT codes provided below). How much is the insurance company’s “usual and customary fee” and what percentage do they cover?

Service	CPT Code	“Usual and Customary fee”	Percent covered, after the deductible is met
Diagnostic Interview: 75-90 minutes	90791
Individual Therapy: 31-50 minutes	90834
Brief Individual Therapy: 15-30 minutes	90832
Group Psychotherapy	90853
Psychological Testing, including scoring, interpretation, and report writing (not all of these codes will be used, but please ask about each code specifically to ensure your understanding of benefits)	96110 96112 96113 96116 96121 96127 96130 96131 96132 96133 96136 96137 96138 96139 96146

• Other questions to ask:
  • Is there a session limit?
    • If yes:
      • What is the session limit?
      • How many sessions do I have left?
    • What percentage of services is covered/what is my co-insurance? 

• At the end of the call make sure to have:
  • Date/time you called
  • Representative’s name
  • Reference number for the call

Information that will be provided on your requested receipt of payment:

• Provider’s name
• Provider’s NPI
• Provider’s license number
• Federal Tax ID number
• DSM-5 and ICD-10 diagnosis codes
• CPT or Procedure codes

Although we do not accept Medicare, we will print a receipt of service which you can submit for reimbursement. Here is a link to instructions and the Medicare Part B Claim Form: https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/Downloads/CMS1490S-ENGLISH-Instructions-PartB.pdf

This guide is provided to assist you with calling your insurance company to check on your out-of-network benefits. Upside Therapy is not responsible for the information obtained using this guide.

You may download this form as a PDF to use as a checklist here.