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  • Amanda Earle, MA, LAC, LPC

In-Network & In the Know: How to Determine Insurance Coverage

While pursuing my Master’s degree in Counseling, I operated a small business offering administrative assistance to therapists in (solo and group) private practice. One of the most beneficial and eye-opening tasks included helping clients determine their insurance coverage, benefits, and eligibility.


Laws at Each Level


Since 2008, various laws at both the federal and state levels have been enacted to promote "parity", or equal insurance coverage among mental health, substance use, and other medical services. The National Alliance on Mental Illness (NAMI) provides a brief yet comprehensive summary of why and how these laws affect certain types of plans. CLICK HERE to learn more from the NAMI website.


Determining YOUR Coverage


As NAMI emphasizes, “Comprehensive parity requires equal coverage, not necessarily ‘good’ coverage.” Therefore, I strongly encourage all prospective and current clients to contact your specific plan to determine your specific coverage for mental health and substance use care prior to starting services. With a better understanding of your benefits, you can estimate the cost you will pay per session and whether using insurance will be beneficial.


Step 1:


Call the Behavioral Health phone number listed on the back of your insurance card. If there is no Behavioral Health line, you can call the general Member services number and ask to be connected to representative in Behavioral Health.


Once connected to a rep, say you are calling to determine coverage and benefits for “outpatient IN-NETWORK mental health and/or substance use services in an office setting.”


Step 2 for Cigna, United Healthcare, United UMR & Anthem Blue Cross Blue Shield plans:


Ask the following questions and record all answers...


(1) Do I have a PPO (Preferred Provider Organization) or HMO (Healthcare Maintenance Organization) plan?

(2) What is the co-pay or co-insurance amount I will be charged per session*?

(3) What is my In-Network deductible amount, if any? 

- How much of this deductible has been met so far?

- Does this deductible cross-accrue with other medical expenses?

- For PPO plans... Until this deductible is met, how much in addition to my co-pay will I be expected to cover per session?

- Once my deductible is met, what can I expect to pay per session?

(4) When do my benefits renew? (They may say "Calendar year" or give a date)

(5) Is CPT code 90837 or a 60-minute psychotherapy session covered?

(6) Do I need any pre-authorizations for this code to be billed?


* Does this cost per session differ for Video Teletherapy sessions?


Step 2 for Kaiser plans:


Ask the following questions and record all answers...


(1) What is the co-pay or co-insurance amount I can expect to pay per therapy session*?

(2) What is my In-Network deductible amount? 

- How much of this deductible has been met so far?

- Does this deductible cross-accrue with other medical expenses?

- Once my deductible is met, what can I expect to pay per session?

(3) When do my benefits renew? (They may say "Calendar year" or give a date)

(4) Does the CPT code 90837 or a 60-minute psychotherapy session qualify for coverage?

(5) Please provide me with a referral number to the SonderMind Provider Network. (This is necessary to bill the first appointment).


* Does this cost per session differ for Video Teletherapy sessions?

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