Out-of-network benefits for therapy: verifying them, superbills, and what the client will really get back

1. Step one: the electronic check

Run an eligibility check for the mental health service types (MH, then A6 psychotherapy or A8 outpatient psychiatric if MH comes back thin). In the 271, out-of-network lines carry EB12 = N. If you see an OON deductible and out-of-pocket maximum with amounts remaining, the plan has an OON benefit; if every line is in network, treat it as "probably no OON benefit" and call. Our guide to reading a 271 shows where each number sits.

Two results end the conversation early:

• An HMO or EPO (EB04 HM or EP): usually no OON benefit except emergencies. The client can still see you self-pay.
• A carve-out: a line telling you another company manages mental health. Check that company's OON benefit, not the medical plan's (see behavioral health carve-outs).

2. The questions to ask the plan

The 271 rarely answers these. Ask the plan's behavioral health line, and write down the rep's name and reference number:

Question	Why it matters
Does this plan have OON outpatient mental health benefits for psychotherapy?	The first gate. Ask for the codes you'll bill (90791 intake, 90834 or 90837 sessions, 90847 family).
What's the OON deductible, and how much is left? Individual and family.	It's usually separate from, and larger than, the in-network deductible. Ask whether in-network spending counts toward it.
What's the OON coinsurance after the deductible?	The client's percent of the allowed amount.
How is the OON allowed amount set for 90837? Can you give the amount for our ZIP code?	The plan's allowance, not your fee, is the base for everything. Some reps will quote it; many will only describe the method. Without it you can't estimate.
What's the OON out-of-pocket maximum, and what's left?	The most the client pays in deductible and coinsurance out of network for the year, if there is one. It never includes the difference between your fee and the allowance.
Is telehealth covered out of network? Which place of service and modifier?	Some plans cover video sessions only in network, or want POS 10 or 02 with modifier 95.
Is prior authorization or a referral needed out of network?	Rare for routine outpatient therapy, common for POS plans. A missing referral can zero out every claim.
Who gets paid: the member or the provider? Does the plan honor an assignment of benefits?	Many plans pay OON claims to the member. This decides whether you collect your full fee at each session.
How do members submit a claim, and by when?	The member claim form, the address or portal, and the filing deadline. A superbill sent after the deadline is worth nothing.

The full call, word for word, is in the VOB call script, and every answer has a box on the printable VOB form.

3. Superbill, courtesy billing or a single-case agreement

Way	How it works	Good for	Watch for
Superbill	The client pays your fee at each session; you give a superbill (usually monthly); the client sends it to the plan with the member claim form; the plan reimburses the client.	Practices that don't want to bill insurance at all.	The client carries the paperwork and the wait. Claims bounce when the dates, codes or fees don't match your records, or the superbill isn't signed.
Courtesy billing	You submit an out-of-network claim (837P or CMS-1500) for the client. The client usually still pays you at the session.	Clients who'd otherwise never file; practices that already have a clearinghouse.	The plan may still send payment to the member. Decide in writing what happens if you're paid and the client already paid you in full.
Single-case agreement	The plan agrees to pay you, for this one client, at an agreed rate, often at in-network cost sharing.	A client who needs your specialty when the plan's network has no one who can provide it nearby or soon.	Get the rate, the dates, the codes and the units in writing before the next session. Our sister site's single-case agreement guide has a sample request.

If you see the same plans out of network again and again, getting in network is usually the fix: credentialing with each plan is the long-term route.

4. What goes on the superbill

A plan treats a superbill like a claim, so it needs a claim's facts. A plain receipt usually isn't enough.

• Your name and credential, individual (Type 1) NPI, group (Type 2) NPI if you bill as a group, tax ID, license number and state, office address and phone.
• The client's name, date of birth and address; the plan's name and member ID help the plan match it.
• Up to four ICD-10 diagnosis codes, the main one first.
• For each session: the date, CPT code, place of service, any modifier, units, your fee and what the client paid.
• Totals, and your signature and the date.

Find Care's free superbill maker builds one in the browser with nothing saved, and Cima EHR makes superbills for practices that use it.

5. A 12-month worked example

Made-up, round numbers to show the mechanics; they are not anyone's real rates. A PPO member starts weekly 53-minute sessions (90837) in January. Your fee is $180. The VOB found: OON deductible $1,500 with nothing met, 40% OON coinsurance, OON allowed amount $110 for 90837, payment to the member, superbills accepted.

Stretch	What the plan does	Client pays you	Plan pays the client	Client's net cost
Sessions 1–13	Applies each session's $110 allowed amount to the deductible ($1,430 after 13)	$180 × 13 = $2,340	$0	$2,340
Session 14	$70 finishes the deductible; 60% of the other $40	$180	$24	$156
Sessions 15–48	Pays 60% of $110 = $66 a session	$180 × 34 = $6,120	$66 × 34 = $2,244	$3,876
The year (48 sessions)	—	$8,640	$2,268	$6,372, about $133 a session

Two things a client rarely expects: nothing comes back for the first three months, and even after the deductible the plan's 60% is of $110, not of $180, so the $70 difference is always theirs. If the OON out-of-pocket maximum were low enough, the plan would pay 100% of the allowance once it's reached, but the $70 per session would still be the client's. Show this table, with their numbers, before the first session.

6. The Good Faith Estimate and the No Surprises Act

• Self-pay clients get a Good Faith Estimate. The No Surprises Act rules require one for clients who are uninsured or who have coverage but aren't seeking to have a claim for your services submitted to their plan (45 CFR 149.610; CMS FAQs). For weekly therapy, one estimate can cover up to 12 months. If the bill comes in $400 or more above it, the client can start a dispute with HHS within 120 days of the bill.
• Superbill clients are a gray area. The rule doesn't say in so many words whether a client who pays you and files their own claim counts as self-pay. An estimate takes a few minutes and protects both of you; many practices give one to every client who pays them directly. Find Care's free Good Faith Estimate maker includes every required element.
• Surprise-billing protections usually don't reach a private therapy office. They cover emergencies and out-of-network providers at in-network hospitals, hospital outpatient departments, critical access hospitals and ambulatory surgical centers (CMS). A client who chooses an out-of-network therapist for planned care isn't in that group, so the difference between your fee and the allowance can be theirs.
• Medicare, Medicaid, CHIP, TRICARE and VA have their own billing rules, and the GFE rule doesn't cover clients using them. Medicare in particular has its own claim-filing rules; check them before you see a Medicare client out of network.

7. Parity and out-of-network therapy

The Mental Health Parity and Addiction Equity Act treats outpatient out-of-network as its own classification. If a plan covers medical and surgical care out of network in that classification and covers mental health at all, it generally has to cover mental health there too, and its deductibles and out-of-pocket maximums have to combine medical and behavioral health spending (CMS on MHPAEA). So when a rep says a PPO with OON medical benefits has "no OON benefit for therapy," ask them to confirm it, and note the reference number. A separate, higher deductible just for OON mental health, on a plan that has one OON deductible for medical care, is worth the same question. Which plans parity covers, and what to ask, are in mental health parity on a VOB call.

8. Texas: which plans follow Texas law

A plan regulated by the Texas Department of Insurance (fully insured, often marked "TDI" or "DOI" on the card) follows Texas insurance law; a self-funded employer plan follows federal ERISA rules instead (TDI). Texas's own surprise-billing law (SB 1264) covers emergencies, care at in-network hospitals, and certain lab and imaging services for TDI-regulated plans (TDI), so like the federal law it rarely reaches outpatient therapy. A client with a complaint about how a TDI-regulated plan handled a claim can go to TDI's complaint line.

9. What to tell the client

"Your plan does have out-of-network benefits for therapy, but they start after a separate $1,500 deductible, and you've used none of it this year. Until then you'll pay my $180 fee and get nothing back. After that, the plan pays you 60% of what it decides a session is worth, which it told us is $110, so about $66 a session. I'll give you a superbill each month to send in. Here's the whole year in writing. If that's more than you planned, I'm happy to help you find an in-network therapist, or we can ask your plan for a single-case agreement."

For the in-network version of this conversation, see deductible vs out-of-pocket maximum. When the first reimbursement comes, the client's EOB shows whether the plan used the numbers you verified; our guide to reading an EOB walks through it line by line.

How Quick VOB helps

Quick VOB shows the deductible and out-of-pocket in and out of network, individual and family, with what's left of each. When a plan lists no OON amounts it says so, HMO, EPO and narrow-network plans get a warning, and "Log the call" keeps the rep's answers on the allowed amount, telehealth and who gets paid with their name and reference number.

Questions

Does insurance pay for an out-of-network therapist?

Only if the plan has out-of-network outpatient mental health benefits, which most PPO and POS plans do and most HMO and EPO plans don't. Even then, the plan usually applies a separate OON deductible first and pays a percentage of its own allowed amount, not of the therapist's fee.

How much will I get back for out-of-network therapy?

After the OON deductible is met: the plan's coinsurance share of its allowed amount for the code. With a $110 allowance and 40% coinsurance, that's $66 back on a $180 session. Before the deductible is met, usually nothing.

What is a superbill for therapy?

A detailed receipt with the provider's NPI, tax ID and license, the client's details, ICD-10 diagnosis codes, and each session's date, CPT code, place of service, fee and payment, signed and dated. The client sends it to their plan with the plan's claim form to be reimbursed.

Does the out-of-network deductible count toward the in-network deductible?

It depends on the plan. Some count spending toward both; many keep them separate. Ask on the call and write the answer down.

What is courtesy billing?

The out-of-network provider submits the claim to the plan for the client instead of handing them a superbill. The client usually still pays at the session, and the plan may send its payment to the client.

Do I need a Good Faith Estimate for out-of-network clients?

You need one for clients who are uninsured or who aren't having a claim submitted to their plan. Whether a client who files their own superbill counts isn't spelled out; many practices give those clients an estimate too.

Does the No Surprises Act protect out-of-network therapy clients?

Its balance-billing protections cover emergencies and out-of-network providers at in-network hospitals and certain other facilities, not a client who chooses an out-of-network therapist for planned sessions. Self-pay clients do get the Good Faith Estimate and its dispute process.

Sources

1. 45 CFR §149.610, Good faith estimates for uninsured (or self-pay) individuals; CMS, Good faith estimate FAQs. ecfr.gov · cms.gov
2. CMS, No Surprises: consumer protections. cms.gov
3. CMS, "The Mental Health Parity and Addiction Equity Act (MHPAEA)." cms.gov
4. CMS, Uniform Glossary of Coverage and Medical Terms (allowed amount). cms.gov
5. HealthCare.gov, "Balance billing" and plan types. healthcare.gov · healthcare.gov
6. Texas Department of Insurance, "Fully insured vs. self-insured," "Texas protects consumers from surprise medical bills" and "Get help with an insurance complaint." tdi.texas.gov · tdi.texas.gov · tdi.texas.gov

The examples are made up. This guide is general information, not legal or billing advice. Cima isn't a law firm or an accounting firm. Plan terms, laws and payer policies differ and change; confirm with each plan and its documents.