What out-of-network benefits are
An in-network therapist has a contract with your insurer and accepts its allowed amount. An out-of-network therapist does not. Many people assume that means insurance is useless for that therapist. For some plans, that is close to true. For others, the plan still pays a meaningful share.
Blue Cross Blue Shield of Michigan explains the general pattern: HMO plans do not include out-of-network benefits for non-emergency care, while PPO plans do, though you usually pay more. Its example is a plan that pays 80% in network and 60% out of network. Many plans also have a separate, higher deductible for out-of-network care, so read that line of your benefits summary carefully.
The catch: the allowed amount
The percentage your plan pays is a percentage of its own allowed amount, not of the therapist's fee. Blue Cross notes that out-of-network providers have not agreed to accept that amount, so you are responsible for the difference between the full charge and the allowable amount, which it calls balance billing.
Here is how that plays out with made-up numbers. Say a therapist charges $200, your plan's allowed amount for that service is $120, and you have met your out-of-network deductible. If the plan pays 60% of the allowed amount, it reimburses $72. Your cost for that session is $128, not $80. Until the out-of-network deductible is met, the plan may reimburse nothing at all.
Insurers decide their allowed amounts in different ways. Ask how yours is set, because the method matters more than the percentage.
What a superbill is
"Superbill" is the common name for an itemized statement a clinician gives you so you can file an insurance claim yourself. It is not a special form. Insurers ask for different things, but a statement for psychotherapy usually includes:
- The clinician's name, credentials, license number, National Provider Identifier (NPI), practice address and tax ID
- Your name, date of birth and address
- Each date of service, the procedure code for the session and its length
- A diagnosis code, because most plans pay only for care of a diagnosed condition
- The fee for each session and what you paid
Ask any therapist you are considering whether they provide this kind of statement and how often (after each session, monthly or on request). Practices differ, and not every clinician provides one.
A note on diagnosis codes
To reimburse you, an insurer generally needs a diagnosis on the claim, and that diagnosis becomes part of your claims record. Some people are comfortable with that; others choose to pay privately for that reason. It is a fair question to raise with a therapist at the start.
How to file the claim
Blue Cross Blue Shield of Michigan describes the usual steps, and most insurers work in a similar way. When a provider does not take your insurance and collects payment in full, you send the claim yourself, either online through your member account or by mail with the plan's claim form. The insurer then decides what the plan covers and reimburses you.
- Download your plan's member claim form, or check whether your account lets you upload claims.
- Attach the itemized statement. Make copies first.
- Submit regularly, for example monthly, so claims do not pile up.
- Track the Explanation of Benefits (EOB) for each claim and compare the payment to what you expected.
Deadlines matter. Blue Cross says members submitting their own medical claims have two years from the date of service; other insurers may set shorter limits. Your plan documents say which one applies.
A simple log saves a lot of frustration. Keep one line per session with the date, the amount you paid, the date you submitted the claim and the amount reimbursed. When a payment looks wrong, that log is what customer service will ask for.
Questions to ask your insurer first
Before you count on reimbursement, call the number on your card and ask:
- Does my plan have out-of-network benefits for outpatient mental health visits?
- What is my out-of-network deductible, and how much have I met?
- What percentage do you pay, and of what allowed amount for a 60-minute psychotherapy session?
- Is prior authorization required for out-of-network therapy?
- Are telehealth sessions treated the same way?
- How do I submit claims, and what is the filing deadline?
Parity law applies here as well. The federal Mental Health Parity and Addiction Equity Act treats "outpatient, out-of-network" as its own classification. If a plan covers out-of-network medical care, CMS explains, it must cover mental health care in that classification too, and the cost-sharing cannot be more restrictive than for comparable medical care. Mental Health Parity: What Your Insurance Must Cover in Michigan explains how to raise a concern.
Paying privately and your Good Faith Estimate
If you pay a therapist directly and are not having them bill your insurance, the federal No Surprises Act gives you the right to a Good Faith Estimate of expected charges. Filing your own claim afterward is separate from that right. Good Faith Estimates: Your Right to Know Therapy Costs has the details. An HSA or FSA can often cover the part your plan does not reimburse.
How this applies to Dr. Lehmann's practice
Dr. Lehmann is in network with Blue Cross Blue Shield PPO, so members of that plan generally do not need the out-of-network route. For any other plan, call the office to confirm how billing would work before you begin. The fees and insurance page lists the current fee and payment options. If you are weighing therapy for depression or anxiety and cost is the main question, raise it on the first call.