Using Blue Cross Blue Shield Out-of-Network Benefits for Psychiatry

Blue Cross Blue Shield out-of-network mental health coverage depends on which Blue company issued your plan and which plan your employer or you chose. "BCBS" is not one insurer: the Blue Cross Blue Shield Association describes itself as an association of independent, locally operated Blue Cross and Blue Shield companies. If your plan includes out-of-network benefits, you can usually pay an out-of-network psychiatrist directly and be reimbursed for part of each visit after your out-of-network deductible, based on the plan's allowed amount rather than the fee.

This guide shows how to identify your Blue company, why the national BlueCard program does not turn an out-of-network psychiatrist into an in-network one, how Blue plans in New York, New Jersey and California differ, and how to file a claim. It is general information, not tax or legal advice; your plan documents are the final word.

Which Blue company is yours

Your ID card names your "home plan", the Blue company that holds your coverage. That company sets your benefits, decides your claims and answers your questions, even when you receive care in another state. Several states have more than one Blue company, each covering its own territory.

If you work for a company headquartered elsewhere, your home plan may be a Blue company in another state even though you live in New York. That is common, and it does not change your out-of-network benefits. It does change which company you call and where you send claims.

Why BlueCard does not make a provider in network

Many people assume a Blue card works everywhere. It does, but only with providers that participate with a Blue company. The association describes BlueCard as linking participating health care providers and the independent Blue companies through a single electronic network for claims processing and reimbursement. BlueCard PPO extends PPO-level benefits to members traveling or living outside their plan's area when they use a provider designated as a PPO provider.

A psychiatrist who does not participate with any Blue company sits outside that system entirely. Seeing that psychiatrist uses your home plan's out-of-network benefits, wherever either of you is located. Two practical consequences follow:

• A Blue plan whose network excludes the clinician pays only what its out-of-network terms allow, and nothing if it has no out-of-network coverage.
• Your claim goes to your home plan, not to the Blue company where the psychiatrist practices, unless your home plan tells you otherwise.

If you live in New Jersey or California and are considering telehealth with a New York practice, the same logic applies. Your home plan's out-of-network rules decide reimbursement. Dr. Lewis, for example, sees telehealth patients only when they are physically located in a state where she holds an active medical license.

Questions to ask your Blue plan before the first visit

The four questions on the practice's insurance page are the core: whether you have out-of-network benefits for mental health services, whether there is an out-of-network deductible, the reimbursement rate, and the approved visit cost. For a Blue plan, add the questions that come from its structure.

A fuller script, including the service codes to ask about, is in the guide to checking out-of-network benefits.

How Blue plans set the allowed amount

Each Blue company writes its own out-of-network payment rules into its plan documents, and those rules can differ between plans issued by the same company. Methods used by insurers include a percentage of Medicare rates, a percentile of charges in a benchmarking database, or a company fee schedule, and you should not assume which one your Blue plan uses. Your certificate or plan booklet names the method; member services can tell you the figure for a specific procedure code.

Reimbursement is then a percentage of that allowed amount. The practice notes that reimbursement is usually around 50-80% of the insurer's "approved visit cost" or "customary amount", and 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. The explainer on allowed amounts and UCR walks through the arithmetic.

New York's rules, and their limits

New York requires insurers that issue comprehensive group policies covering out-of-network services to offer at least one option that covers 80% of the "usual and customary cost" of each out-of-network service after the deductible. The law defines that cost as the 80th percentile of charges for the service by providers of the same or similar specialty in the area, drawn from a nonprofit benchmarking database. That requires an option to be offered; it does not mean your employer chose it.

The rule also does not reach every Blue plan. New York's Department of Financial Services explains that employer or union coverage that is self-funded is not subject to New York law, and that your ID card will say "self-funded" or will not say "fully insured" if your coverage is self-funded. Many large employers that use a Blue company self-fund, so check before relying on state rules.

Federal employees: FEP options differ sharply

If you are covered through the Federal Employee Program, your option matters more than your state. Under FEP Blue Basic, benefits are not available for services from Non-preferred providers, except in certain situations such as emergency care. Under FEP Blue Standard, care from Non-preferred providers is covered at a different cost share, and you generally pay the difference between the plan's payment and the billed amount in addition to your coinsurance.

In practice, a federal employee on Basic who wants to see an out-of-network psychiatrist would be paying entirely out of pocket for routine visits, while a member on Standard can file for partial reimbursement. Check the current year's FEP brochure, because benefits are set each year.

Filing a claim with your Blue plan

Out-of-network providers often do not bill your plan directly. Anthem tells members that their provider typically submits the claim, but that in some cases when they visit a doctor outside their plan they may have to do it themselves, using forms from its Forms Library. Its checklist is a good one for any Blue plan: make sure the claim form includes all required information, especially procedure codes from the doctor's office, file promptly and within the time limit, and include any required preapproval.

1. Download the superbill from the practice after each visit, and check it lists the provider's NPI and tax ID, the date, the procedure and diagnosis codes, and the amount paid.
2. Find your home plan's member claim form or online submission route. Horizon, Excellus, Highmark, Anthem and Blue Shield of California each use their own forms and member websites.
3. Answer the questions about other coverage. A blank coordination-of-benefits question is a common cause of delay.
4. Submit to the home plan named on your card and keep the date and any confirmation number.
5. Watch for the explanation of benefits and check it against your expected allowed amount.

The general steps, and what a complete superbill contains, are in superbills and out-of-network claims, step by step.

Decision times and appeals

For employer-sponsored plans covered by the federal claims regulation, the plan must decide a claim for care already received within a reasonable time and no later than 30 days after receiving it, with one possible extension of up to 15 days. If a claim is denied, you have at least 180 days from the notice to appeal. See how to appeal a denied mental health claim, and if the plan treats mental health care more strictly than medical care, your mental health parity rights.

Three typical situations

These hypothetical examples show how the same psychiatrist can mean very different reimbursement depending on the plan.

• A Brooklyn resident with a fully insured Anthem PPO through a New York employer. New York insurance law applies, the plan's certificate states the out-of-network allowed-amount method, and the member can ask whether the employer bought the 80% usual-and-customary option described above.
• A New Jersey resident whose employer, headquartered in another state, self-funds a plan administered by that state's Blue company. Claims go to that out-of-state home plan, its own plan document sets the allowed amount, and New York's insurance rules do not apply.
• A federal employee on FEP Blue Basic. Routine outpatient visits with a Non-preferred psychiatrist are not covered, so reimbursement is not available for them however the claim is filed.

In each case, the right first call is to the member services number on the card, with the questions from the table above.

Common snags with Blue out-of-network claims

When in-network care is the better first step

If your plan has no out-of-network coverage, as with FEP Blue Basic for routine visits, or the out-of-network deductible is high relative to the care you need, an in-network clinician may be the sensible start. New York residents in fully insured plans can also ask about the state's network adequacy rule, covered in getting out-of-network care at in-network cost. The cost comparison is set out in in-network vs out-of-network psychiatry.

Many patients pay for psychiatric care using a health savings account or a flexible spending account; eligibility rules vary between plans and change from year to year, so confirm what yours covers with your plan administrator. See using an HSA or FSA for psychiatry. If your household also has Cigna coverage, the Cigna out-of-network guide covers that insurer.

How Dr. Lewis's practice handles Blue plans

Dr. Lewis is an out-of-network provider with all insurance plans, as are all of the practice's practitioners, 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 plans (as for Aetna and Cigna) it can facilitate submitting the out-of-network claim for you; superbills are available in the patient portal after each session. Dr. Lewis sees patients in person in Brooklyn and by telehealth for patients physically located in a state where she holds an active medical license, and the team confirms eligibility for your state before the first visit; there are pages for New York and New Jersey. Fees are on the insurance and payment page. If you need care that is in network with your plan, ask the team on the discovery call about options. More on paying for care is in the Choosing Psychiatric Care guide.

Frequently asked questions

My card says Anthem but I live in New Jersey. Which company handles my claim?

The company named on your card, your home plan, decides the claim. Send out-of-network claims where that company tells you to, not to the Blue company where you live or where the psychiatrist practices.

Does BlueCard cover out-of-network psychiatrists in other states?

BlueCard is built around providers that participate with a Blue company. A psychiatrist who participates with no Blue plan is out of network everywhere, so your home plan's out-of-network benefits apply.

Is Empire the same as Anthem in New York?

Anthem Blue Cross Blue Shield is the Blue company the association lists for much of New York, and its New York site still uses the empireblue.com address. Older cards and letters may say Empire.

Can I get reimbursed for therapy and psychiatry on the same Blue plan?

Usually both fall under outpatient mental health benefits, but each provider's services are billed separately. Check whether your plan applies the same deductible and coinsurance to both.

I'm a federal employee on FEP Blue Basic. Is there any way to be reimbursed?

For routine outpatient visits with a Non-preferred provider, FEP Blue Basic generally pays nothing. Ask FEP about exceptions, consider an in-network option, or review whether FEP Blue Standard suits you at the next open season.

What if my reimbursement is much lower than the percentage I was quoted?

The percentage applies to the allowed amount, not the fee. Ask the plan for the allowed amount for each code and how it was set. If you believe the claim was processed wrongly, you can appeal.

Sources

1. Local Blue Cross and Blue Shield Companies and Licensees. Blue Cross Blue Shield Association, 2026. bcbs.com
2. Glossary (BlueCard; BlueCard PPO). Blue Cross Blue Shield Association, 2026. bcbs.com
3. How to Submit, Track and Access Anthem Claims. Anthem Blue Cross Blue Shield, 2026. anthem.com
4. FEP Blue Basic. Blue Cross and Blue Shield Federal Employee Program, 2026. fepblue.org
5. FEP Blue Standard. Blue Cross and Blue Shield Federal Employee Program, 2026. fepblue.org
6. Surprise Medical Bills. New York State Department of Financial Services, 2026. dfs.ny.gov
7. New York Insurance Law Section 3241: Network coverage. New York State Senate, 2026. nysenate.gov
8. 29 CFR 2560.503-1, Claims procedure. Electronic Code of Federal Regulations, 2026. ecfr.gov

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