How to Check Your Out-of-Network Mental Health Benefits: A Call Script

To check your out-of-network mental health benefits, call the member services number on your insurance card and ask about six things: whether you have out-of-network mental health coverage at all, your out-of-network deductible, your coinsurance, the allowed amount for the specific service codes, your out-of-pocket maximum, and any pre-authorization rules. Write down every answer, the representative's name, the date and a call reference number.

The script below turns those questions into words you can read aloud, then explains how to interpret each answer. It starts from the four questions Dr. Lewis's practice suggests asking your insurer and adds the details that most often change the final number. This is general information, not tax or legal advice.

Before you call: what to have in front of you

Representatives answer the question you ask, not the one you meant. A little preparation keeps the call short and the answers specific.

• Your member ID card, and the ID of the policyholder if the plan is through a spouse or parent.
• The type of clinician you plan to see: a psychiatrist (MD), a psychiatric nurse practitioner, or a psychotherapist such as a psychologist or licensed clinical social worker. Some plans treat these differently.
• The service codes listed in the next section, so you can ask about each one by number.
• Where you will be during visits (in the office, or at home in another state for telehealth).
• The fill-in table at the end of this article, or a notebook.

Check your plan type first

Before you dial, look at the plan name on your card or in your benefits portal. The plan type often answers the first question on the script before you ask it.

Plan names can be misleading, so confirm on the call. It also helps to have the plan's Summary of Benefits and Coverage in front of you. Insurance companies and job-based health plans must provide this plain-language summary, and you can ask your insurer or group health plan for a copy at any time. It usually lists the out-of-network deductible and coinsurance, which lets you use the call for the details the summary leaves out, such as allowed amounts by code.

The call script, word for word

Read each line as written. If the representative gives a general answer, ask the follow-up in brackets.

1. "I'm checking my out-of-network benefits for outpatient mental health care. Do I have out-of-network benefits for mental health services?" [Is that true for both psychiatry and psychotherapy?]
2. "Do I have a deductible for out-of-network mental health services? How much is it, and how much have I met so far this plan year?" [Is it separate from my in-network deductible?]
3. "What is the reimbursement rate for out-of-network mental health services once the deductible is met?" [Is that a percentage of the allowed amount or of the billed charge?]
4. "What is the approved visit cost, or allowed amount, for these service codes?" Then read the codes one at a time.
5. "What is my out-of-network out-of-pocket maximum, and do my out-of-network payments count toward it?"
6. "Do any of these services need pre-authorization or a referral when the provider is out of network?"
7. "Are telehealth visits reimbursed the same way as in-person visits? Does it matter which state I am in during the visit?"
8. "When does my plan year start and end?"
9. "Is my plan fully insured, or is it self-funded by my employer?"
10. "How do I submit an out-of-network claim, which form or portal do you use, and what is the filing deadline?"
11. "May I have a call reference number for today's conversation?"

If the representative cannot find the allowed amount for a code, ask whether the plan uses a published fee schedule or a percentage of a reference rate, and whether a written benefits summary can be sent to you.

Which service codes to ask about

Insurers price each visit by its procedure code, so the allowed amount for a first evaluation can differ from a follow-up or a therapy hour. These are the codes most commonly used in outpatient psychiatry. Ask your clinician's office which ones apply to the visits you expect.

Psychotherapy codes are time-based. Medicare billing guidance assigns 16 to 37 minutes to 90832 and 90833, 38 to 52 minutes to 90834 and 90836, and 53 minutes or more to 90837 and 90838. A prescriber visit billed as 99214 plus 90833, for example, will have two allowed amounts that are added together, so ask about both codes.

Plans also distinguish new from established patients. In Medicare's definition, a new patient is someone who has not received professional services from that clinician, or another clinician of the same specialty in the same group, within the previous 3 years. Ask whether your plan prices new-patient visits differently.

How to read the answers

Deductible

Until you meet the out-of-network deductible, the plan usually reimburses nothing, although the claims you submit count toward it. The detail people miss is that many plans keep a separate out-of-network deductible. Having met the in-network one does not mean the out-of-network one is met. The article on what out-of-network psychiatry really costs walks through the arithmetic with a worked example.

Coinsurance and the allowed amount

Reimbursement is a percentage of the plan's approved or allowed amount, not of the fee you paid. Dr. Lewis's practice describes the usual range as around 50 to 80 percent of the insurer's approved visit cost, and notes that the approved amount may or may not be as much as the actual cost of the visit. The gap between the fee and the allowed amount stays with you, and on many plans it does not count toward the out-of-pocket maximum. Ask that question directly.

Out-of-pocket maximum

Some plans cap out-of-network spending for the year; others have no out-of-network cap at all. If there is one, ask whether it includes the deductible and coinsurance only, or also amounts above the allowed amount.

Pre-authorization and telehealth

Routine outpatient visits often need no pre-authorization, but some plans require it for certain services. If the answer is yes, ask who submits it and how long approval lasts. For telehealth, confirm that out-of-network virtual visits are reimbursed and whether the plan cares where you are located at the time.

A worked example: turning the answers into a per-visit estimate

Once you have the numbers, the arithmetic takes four steps. The figures below are for illustration only; use your own plan's answers.

1. Start with the allowed amount for the code, not the clinician's fee. Say the plan's allowed amount for a follow-up visit is a fixed figure you will call A.
2. Check the deductible. If the out-of-network deductible is not yet met, the plan usually pays nothing on that visit, although the claim you submit counts toward the deductible.
3. Apply the coinsurance. Once the deductible is met, a plan that reimburses 70 percent pays 0.7 times A, a rate within the range the practice describes as usual: around 50 to 80 percent of the approved visit cost.
4. Subtract from what you paid. Your net cost is the fee minus the reimbursement. If the fee is higher than A, the difference is yours, and on many plans it does not count toward the out-of-pocket maximum.

Two adjustments catch people out. A prescriber visit that includes psychotherapy is priced as two codes added together, an E/M code plus an add-on code, so get an allowed amount for each. And a first visit may be priced differently from follow-ups, because plans distinguish new from established patients. Allowed amount, UCR and balance explained shows why the allowed amount is often lower than the fee, and in-network vs out-of-network psychiatry compares total yearly costs, not just per-visit ones.

Fully insured or self-funded: why it matters

Who regulates your plan decides which consumer protections apply. Private employer plans that self-insure are generally not subject to state health insurance laws, according to the U.S. Department of Labor. Fully insured plans bought in New York are regulated by the state.

That difference is practical. In New York, if a state-regulated insurer cannot locate an in-network provider for you, it must approve a referral to an out-of-network provider who meets certain conditions, and your cost sharing is the same as in network. For policies bought or renewed on or after July 1, 2025, the state's standard for a first outpatient mental health appointment is 10 business days. The New York Department of Financial Services states that these protections do not apply to self-funded employer coverage. Its mental health coverage page explains how to ask for that referral.

If you are not sure which kind of plan you have, ask the representative, then check with your employer's benefits office.

Medicare, Medicaid and other public coverage

The script above is written for commercial insurance. Public programs work differently, and the questions change.

• With Original Medicare, the key question is less about out-of-network benefits than about the clinician's Medicare status. Medicare will not pay for services from a provider who has opted out of Medicare, except in emergencies, and you may be asked to sign a private contract and pay the provider directly. Medicare suggests contacting your State Health Insurance Assistance Program (SHIP) before signing one. A non-participating provider is different: that clinician can charge more than the Medicare-approved amount, but generally no more than 15% above it. Ask the clinician's office which category applies. Medicare and out-of-network psychiatrists covers the details.
• Medicaid and Medicaid Managed Care plans raise their own questions. If you have Medicaid and are considering a private-pay clinician, read Medicaid and private-pay psychiatry in New York first.

Dr. Lewis's practice is out of network with all plans, including Medicare and Medicaid, and the same is true of all of its practitioners.

A fill-in table for your answers

Copy this table and fill in one row per question. Note the date and reference number at the top.

With the deductible, coinsurance and allowed amounts in hand, you can estimate your cost per visit in a few minutes. The step-by-step guide to superbills and out-of-network claims covers what happens after the visit.

If a claim is later paid differently: parity and appeals

Your call notes matter most when a claim is paid differently from what you were told. Two sets of rules help.

The first is federal mental health parity. According to the U.S. Department of Labor, the Mental Health Parity and Addiction Equity Act means that financial requirements such as copays and deductibles for mental health benefits need to be similar to those for medical care, and that visit limits, prior authorization and proof of medical necessity must be comparable. If your plan treats mental health visits more restrictively than comparable medical visits, your rights under mental health parity explains how to raise it.

The second is the claims and appeals process. For employer group health plans covered by federal claims rules, the plan generally has to decide a claim for services you have already received within 30 days, and it must give you at least 180 days after a denial notice to file an appeal. Keep the denial letter, your call log with reference numbers and the superbill together. How to appeal a denied mental health claim walks through the letter and the timeline.

Notes for specific insurers

The questions are the same for every plan, but each large insurer has its own portals, forms and habits. Dr. Lewis's practice can facilitate submitting the out-of-network claim for you on BCBS, Aetna or Cigna plans. These guides cover what to expect from each insurer:

• Aetna out-of-network benefits for psychiatry
• Cigna out-of-network benefits for psychiatry
• Blue Cross Blue Shield out-of-network benefits
• UnitedHealthcare and Oxford out-of-network benefits

If you are worried about what an insurer or employer learns when you file, what your insurer and employer see when you file a mental health claim explains what a claim contains.

Common mistakes on benefits calls

• Asking "Is psychiatry covered?" and accepting "yes." That often describes in-network coverage. Say "out of network" in every question.
• Asking for a percentage without the base. Seventy percent of the allowed amount and seventy percent of the fee are very different numbers.
• Forgetting the second code. A combined medication and therapy visit has two allowed amounts.
• Assuming the deductible you met in network also covers out-of-network claims.
• Not asking about the filing deadline, then sending superbills months later in a batch.
• Skipping the reference number. Without it, a disputed answer is your word against the plan's.
• Ignoring the network adequacy route. In New York, a state-regulated plan that cannot locate an in-network provider for you must approve a referral at in-network cost sharing; New York's network adequacy rule explains how to ask.

After the call: keeping the answers useful

A benefits call is only worth the time if the answers are still findable when a claim comes back. A few habits help.

• Ask for written confirmation. Some insurers will send a benefits summary by mail or post it in the member portal after a call; ask whether yours will.
• Keep a simple claims log. For each visit, note the date, the codes on the superbill, the date you submitted it, and what the plan paid. Patterns, such as one code always paid at a lower rate, show up quickly.
• Recheck when anything changes. A new plan year, a new job, a switch from a fully insured plan to a self-funded one, or a move to another state can change every answer on the sheet.
• If you have two plans, ask both which one is primary. When you are covered by your own plan and a spouse's or parent's, the order in which the plans pay affects how you submit claims, so ask each plan how it coordinates with the other.

Superbills from Dr. Lewis's practice are available in the patient portal after each session, which makes it easier to submit claims promptly rather than in a batch at the end of the year. The full submission process is covered in superbills and out-of-network claims.

When the answers point to a different first step

If you have no out-of-network benefits, or the allowed amounts are low and the deductible is high, out-of-network care may cost close to its full price for most of the year. That does not rule it out, but it changes the decision. The decision framework for out-of-pocket psychiatry sets out when in-network care is the better first move. If you are paying without insurance, you are also entitled to a written estimate before care, explained in good faith estimates for self-pay psychiatry. A health savings account or flexible spending account can also change the math; see using an HSA or FSA for psychiatry.

How Dr. Lewis's practice fits in

Dr. Lewis is an out-of-network provider with all insurance plans, including Medicare and Medicaid, as are all of the practice's clinicians, and payment is due at the time of service. The practice provides a superbill you can submit for possible out-of-network reimbursement, and for BCBS, Aetna or Cigna plans it can facilitate submitting the claim for you. Current fees are listed on the insurance and payment page. If your call shows you need care that is in network with your plan, ask the team on the discovery call about options; the call also covers questions about insurance. More background on choosing care is in the guide to choosing psychiatric care.

Frequently asked questions

Can I check out-of-network benefits online instead of calling?

Many insurers show deductibles and coinsurance in the member portal, but allowed amounts for specific codes are often not listed there. A call is usually the only way to get those figures and a reference number.

What if two representatives give me different answers?

Write down both answers with names, dates and reference numbers, then ask for a written benefits summary or a supervisor. If a claim is later paid differently, those notes support an appeal.

Do I need my diagnosis to check benefits?

Usually not. Outpatient mental health benefits usually do not depend on the diagnosis, although some plans exclude certain services, and the claim itself will include a diagnosis code from your clinician.

Does my plan pay a psychiatric nurse practitioner the same as a psychiatrist?

It depends on the plan. Some insurers set different allowed amounts by license type, so mention the clinician's credential when you ask about each code.

Should I recheck my benefits every year?

Yes. Deductibles reset at the start of each plan year, and coinsurance, allowed amounts and covered services can change when an employer renews or switches plans.

What is a Summary of Benefits and Coverage, and how do I get one?

It is a plain-language summary of a plan's benefits and costs that insurers and job-based plans must provide. You can ask your insurer or group health plan for a copy at any time. It is a good place to find the out-of-network deductible before you call.

I have an HMO. Is there any way to get out-of-network mental health care covered?

HMOs generally do not cover out-of-network care except in emergencies. Ask whether the plan makes exceptions when no suitable in-network clinician is available; New York has a specific rule for state-regulated plans that cannot locate an in-network provider for you.

How long do I have to appeal if an out-of-network claim is denied?

For employer group health plans under federal claims rules, you must be given at least 180 days after the denial notice to appeal. Check your denial letter for the exact deadline and the address for appeals.

Sources

1. Medicare NCCI Policy Manual, Chapter XI: Medicine (Revision Date 1/1/2026). Centers for Medicare & Medicaid Services, 2026. cms.gov
2. Evaluation and Management Services (MLN006764), May 2026. CMS Medicare Learning Network, 2026. cms.gov
3. Billing and Coding: Psychiatric Diagnostic Evaluation and Psychotherapy Services (A57520). CMS Medicare Coverage Database, 2026. cms.gov
4. Technical Release No. 2014-01: Guidance on State Regulation of Stop-Loss Insurance. U.S. Department of Labor, Employee Benefits Security Administration, 2014. dol.gov
5. Mental Health and Substance Use Disorder Information. New York State Department of Financial Services, 2025. dfs.ny.gov
6. Health insurance plan & network types: HMOs, PPOs, and more. HealthCare.gov (CMS), 2026. healthcare.gov
7. Summary of Benefits and Coverage. HealthCare.gov (CMS), 2026. healthcare.gov
8. Does your provider accept Medicare as full payment?. Medicare.gov (CMS), 2026. medicare.gov
9. Mental Health and Substance Use Disorder Parity. U.S. Department of Labor, 2026. dol.gov
10. 29 CFR 2560.503-1: Claims procedure. Electronic Code of Federal Regulations (U.S. Department of Labor), 2026. ecfr.gov
11. Out-of-pocket maximum/limit. HealthCare.gov (CMS), 2026. healthcare.gov

Educational information, not medical, tax or legal advice. Decisions about diagnosis, medication and treatment belong with a clinician who knows your history.