Out-of-network insurance benefits demystified

Looking to use your out-of-network insurance benefits for your mental health therapy appointment? Tia is here to help!

Here's what you need to know

If you choose to receive services from a provider that is not in-network for your insurance, you may still be eligible to file a claim for an out-of-network reimbursement. Don't know if you have out-of-network benefits? Call the number on your insurance card or check your insurance portal for an explanation of your plan’s benefits to confirm if you are eligible.

If your insurance offers out-of-network benefits for mental health therapy, you will need to submit a superbill to your insurance to file your claim. [What’s a superbill? A superbill is an itemized form with all of the information needed for your insurance company to process your claim.]

Good news? Tia will create a superbill for you! To request a superbill, simply start a chat with a care coordinator via your patient portal and ask us to send you a superbill for your latest appointment. From there, you can submit the superbill to your insurance company for reimbursement.

Let's talk a little bit about how the reimbursement process works

When you file a claim for an out-of-network service, you will pay the full amount upfront and you will be reimbursed* by your insurance company once you file your claim and submit your superbill.

*The amount insurance will reimburse you may depend on your progress towards a deductible and out-of-pocket maximum, as well as your insurance company's “allowed amount” for the services you receive - to be explained below!

Interested in finding out how to calculate your patient responsibility? Here are the key inputs you need to know for the calculation

  • From Tia:
    • Appointment cost - 1:1 Therapy appointments at Tia cost $180/session

  • From your insurance company: Call the number on your insurance card or check your insurance portal for an explanation of your plan's benefits
    • Deductible amount - the amount you pay before insurance coverage kicks in (healthcare.gov for more information)
    • Coinsurance rate - The percentage of covered service costs that you pay (healthcare.gov for more information)
    • Allowed amount - The maximum amount your insurance will pay for a service (healthcare.gov for more information)

It’s important to remember that out-of-network benefits will only initiate after you’ve met your deductible. That means that you’ll pay the full price of services (without reimbursement) until your deductible is met.

[A quick note on deductibles: Deductibles can range significantly (from $0 to $2,000 and up!), and some plans have different deductibles based on whether you’re applying it to in-network or out-of-network services. To confirm your deductible amount, call the number on your insurance card or check your insurance portal for an explanation of your plan’s benefits.]

Let’s see it work with an example and assume the following

Note this is just an example! Your insurance company can assist you in determining your final patient responsibility:

  • The cost of your Tia 1:1 Therapy appointment is $180
  • From your insurance…
    • Your out-of-network deductible is $500 and you’ve already met it
    • The allowable amount for therapy is $140
    • Your coinsurance rate is 30%
    • Your insurance reimburses you 70% (100% - 30% coinsurance rate = 70%)

Your patient responsibility:

Your patient responsibility will be (appointment cost - allowed amount) + (allowed amount * coinsurance rate) = $82

Insurance Coverage:

Insurance will reimburse you 70% of the allowed amount = $98

If you have any questions, please reach out to your care team via your patient portal.