Out-of-network, explained in three phone questions.
How out-of-network therapy reimbursement works: what a superbill is, the three questions to ask your plan, what CPT 90837 means, and your real cost.
By Dr. Corina Lopez, PhD · ·4 min read Draft — awaiting review
“Do you take my insurance?” is the first question on most first calls, and my answer — I am out-of-network for everything except Lyra Health — often ends the conversation before the useful part. So here is the useful part.
What out-of-network means
In-network therapists have a contract with your insurer; you pay a copay and they bill the rest. Out-of-network therapists have no contract; you pay the full fee at the session, and your plan may pay you back a portion afterward. Whether it does, and how much, depends on your specific plan — not on me.
Many PPO plans have out-of-network mental health benefits. Most HMO plans do not. You cannot tell from the card; you have to ask.
What a superbill is
After each session I give you a superbill: an itemized receipt with my license and tax information, the date, the service code, and the fee. You submit it to your insurer (most have an app or a form). If your plan has out-of-network benefits, they send you a check for their share once you have met your deductible.
The three questions
Call the member services number on your card and ask:
- “Do I have out-of-network benefits for outpatient mental health?” If no, stop here — you would pay the full fee with no reimbursement, and you can decide with that knowledge.
- “What is my out-of-network deductible, and how much of it have I met this year?” Reimbursement starts only after the deductible. If it is $3,000 and you have met none of it, your first several sessions will not be reimbursed.
- “What percentage do you reimburse for CPT code 90837, and what is your allowed amount for it?” 90837 is the code for a standard 53+ minute psychotherapy session. Plans reimburse a percentage — often 50 to 80% — of their allowed amount, which may be lower than my fee.
Doing the math
Say my fee is $235, your plan’s allowed amount for 90837 is $200, they reimburse 70%, and your deductible is met. You pay $235 at the session; they send you $140; your real cost is $95. If your deductible is not met, your real cost is $235 until it is.
Write the answers down with the date and the representative’s name. Plans misquote; the record helps.
Fees, the Lyra arrangement, and payment are on contact & fees, and the questions page covers the rest. If the numbers do not work, say so on the first call — I would rather tell you plainly what is possible than have you guess.
This is a field note about billing, not financial or legal advice. Plans vary; your insurer’s answer is the one that counts.