Reflections Mental Health Services

By Alphonso Gaita, LCSW, Reflections Mental Health Services. Telehealth across New York State.

If the therapist you clicked with isn’t in your insurance network, don’t give up on working with them. A lot of plans include out-of-network therapy benefits, and you can use a document called a “superbill” to get part of what you paid back after the fact.

The catch is that almost nobody explains the process well. So here’s how it actually works in New York.

What is out-of-network coverage?

If you have an HMO, you usually have no out-of-network coverage, so only in-network providers get reimbursed. If you have a PPO or POS plan, you probably do have out-of-network benefits, which means your insurer pays back a share of what you spend on providers outside their network.

Out-of-network coverage usually comes with its own separate deductible (often higher) and its own coinsurance percentage (often 50 to 70%, versus 80 to 90% in-network).

What is a superbill?

A superbill is an itemized receipt your therapist hands you after each session (or once a month). It includes:

• Your name and date of birth
• Therapist’s name, credentials, license number, NPI (national provider identifier), and tax ID
• Practice address
• Date(s) of service
• CPT codes (the medical billing codes for the services rendered, usually 90791 for intake, 90834 for a 45-min session, 90837 for a 60-min session)
• ICD-10 diagnosis code (a clinical diagnosis required for insurance claims)
• Amount you paid

You then send the superbill to your insurance company through their online portal, by mail, or by fax. They process it and reimburse you based on your out-of-network benefits.

How to actually submit a superbill

1. Get the superbill from your therapist (most hand them over automatically; some make you ask).
2. Log into your insurance member portal and look for “Submit a claim” or “Out-of-network claim.”
3. Upload the superbill as a PDF, along with proof of payment (a credit card receipt or bank statement).
4. Wait 4 to 8 weeks. Insurance companies are slow. They’ll send a check or a direct deposit for the reimbursable portion.
5. Track everything. Keep a folder. If a claim gets denied, you can usually appeal.

What you’ll actually get reimbursed

This varies a lot. Here’s a typical example:

• Session rate: $150
• Insurer’s “allowed amount” for that CPT code: $120 (insurance sets its own rate, called UCR, for Usual, Customary, and Reasonable)
• Out-of-network deductible: $1,000 (you pay this much before reimbursement kicks in)
• Coinsurance after deductible: 60%
• Once the deductible is met, you’d get back: $120 × 60% = $72 per session

So on a $150 session, once you’ve met the deductible, your real out-of-pocket cost lands around $78.

When out-of-network is worth it

• When you’ve found a therapist who’s the right fit, since clinical match matters more than a network list
• When you have a PPO with reasonable out-of-network coverage
• When the in-network options all have months-long waitlists (a common NY problem)
• When your need is specialized (EMDR, ERP for OCD, eating disorder treatment) and in-network options are thin

What to ask your insurance about out-of-network

1. Do I have out-of-network mental-health benefits?
2. What’s my out-of-network deductible, and how much have I met this year?
3. What’s my coinsurance percentage after the deductible?
4. What’s the allowed amount (UCR) for CPT codes 90834 and 90837?
5. How do I submit a claim, and how long does processing usually take?

We’ll provide your superbill automatically

At Reflections, we’re in-network with Aetna, Blue Cross Blue Shield, Highmark, Carelon, and Cigna. For every other insurer, we give you a superbill after each session so you can submit for out-of-network reimbursement. Full insurance details here, or make an appointment and we’ll verify your specific benefits before your first session.

References

• American Medical Association. (2024). CPT Code Set: Psychotherapy Services.
• Centers for Medicare & Medicaid Services. (2024). Mental Health Parity and Addiction Equity Act.
• New York State Department of Financial Services. (2024). Out-of-Network Coverage Requirements.
• Kaiser Family Foundation. (2024). Out-of-Network Use of Mental Health Services.