How To Ask My Insurance About Out-Of-Network Coverage

Also, see our page on Why Pivotal Counseling Isn’t “In-Network”

The Basics

Before we talk about how to ask, you need to know some basic language. Anytime insurance receives a claim, they look for two things.

1. A diagnosis code
   Insurance companies operate off of “medical necessity.” That means they only pay for things they think you absolutely need, not just things you want. A diagnosis code is the sequence of numbers that tells them what you are having treated.

2. A CPT code
   The CPT code is the sequence of numbers that tells the insurance what procedure the clinician is doing to treat the diagnosis. For example, there are different CPT codes for when a doctor removes a wart as opposed to when they remove a skin tag.

The combination of those things will determine if they pay the claim. They may cover a diagnosis but not a particular CPT code. They may cover a CPT code but not to treat certain diagnoses. So, here’s how to ask about reimbursement.

How to ask about Out-of-Network coverage for individual services

If you are coming in to counseling by yourself, this is the right section.

Once you reach a customer service agent, let them know you have questions about out of network coverage. Ask them the following questions.

1. Do you reimburse for CPT code 90834? This is the CPT code for basic individual counseling sessions.

2. Do you reimburse for diagnosis code F43.20? This is the diagnosis code for a general adjustment disorder. We cannot diagnose you without doing an assessment. At the same time, most clients who come in would qualify for this so it is a safe one to ask about. If they will reimburse for this, they will typically reimburse for most common mental health diagnoses.

How to ask about out of network coverage for Relational/COUPLES/MARRIAGE COUNSELING?

If you call and ask your insurance just that question, they’ll typically say yes. But that likely doesn’t mean what you think it does. They’re likely talking about situations where you may sit in on a session to support your partner as they are treated for an individual issue (like a bipolar disorder, anxiety, depression, etc.). It would be insurance fraud to file this type of claim for reimbursement when in reality you are both in session together as equal participants and working on relational issues, not an individual issue. However, there are some insurance companies who recently have shown a willingness to reimburse for actual relational/couples/marriage counseling.

To find out if yours is one of them, call the number on the back of your card, ask for benefits information and then specifically ask these two questions.

1. “Do you reimburse for procedure code 90847?” This code indicates that there are two of you in the counseling office at the same time.

2. “Do you reimburse for diagnosis code Z63.0?” This code more accurately reflects what is happening and what will be the focus of counseling, i.e., “Relationship Distress with Spouse or Intimate Partner.”