Insurance + Billing FAQs

How does billing work?

Payment is due at the time of service, so your card is charged for the full amount of the session on the day of the appointment. The billing system will then automatically generate superbills which has the billing information an insurance company needs to submit reimbursement. The billing system emails superbills once per month on the first of the month for the sessions in the month prior, which can be forwarded directly to insurance for direct reimbursement.

What are your rates?

Our fees range from $190-275 per session (45-minutes). Longer sessions are prorated at the 45-minute rate. Contact our office to discuss current options and find a good fit. We offer a limited number of sliding scale appointments based on need and financial hardship. Feel free to inquire about availability.

If you provide fees and codes to insurance, they will let you know how much reimbursement you can expect, so you can then calculate the ultimate out-of-pocket cost to you.

What are the billing codes for sessions?

For an initial 3 hour intake, here are codes that will be listed (NOTE: add “-95” to the first code listed if it is a telehealth appointment):

90791 (initial assessment)

+99354 (extended session, 30-60 mins)

+99355 (for each additional 45 mins, so there are two +99355s for a 3 hour intake)

+99355

For 90-min follow up sessions:

90837 (follow up sessions of 45 mins in length);

+99354 (this code is added so follow up sessions are 90 mins total)

For 45-min follow up sessions:

90834

What are some questions I can ask my insurance provider to determine out-of-pocket costs?

1. What is my deductible is and how close am I to meeting it?

2. What is my coinsurance (the amount I would be responsible to pay, which is typically between 20-50%)?

3. What is the maximum allowable amount is for a 90834 CPT code (which is the code for a standard psychotherapy appointment)?

This is the amount your insurance will allow to be billed for your appointment based on the practice address. If the full session fee is $250, but the maximum allowable amount is $100, you would only get reimbursed a percentage based on $100 per appointment.

If your coinsurance is 0% it would mean they would cover all of the $100, but leave the rest for you to pay. So then the total cost to you per appointment would be $150. It is possible that they will allow the full session rate, but you'll have to confirm this with them.

Either way, payment in full is due at the time of service (we accept credit cards), and your insurance will pay you on the back end once they process your claim. You may also want to ask them how long it will take for them to process your claim and pay you.

Is it possible to get out-of-network coverage at in-network rates (Network Gap Exemption)?

Yes, it’s possible through a Network Gap Exemption. Read on for more information or contact our office to discuss the process of applying with your insurance.

A Network Gap Exemption (NGE) is a mechanism by which private insurance is mandated to cover out-of-network (OON) care when there's a demonstrated deficiency or 'gap' in the insurer's network for that specific type of specialist. This 'gap' typically implies that the insurance company lacks an adequate number of in-network providers with the required expertise or specialization. By requesting an exemption, individuals can receive in-network coverage levels for their OON psychotherapist/mental health specialist. Essentially, NGE’s call out the insurer's non-compliance with legal mandates to maintain a comprehensive network, compelling them to cover necessary mental health care.

NGE’s are supported by a robust legal framework in California, based in three areas: timeliness requirements (SB 221 states that you’re generally entitled to mental health care within 10 business days and within 15 miles or 30 minutes of your home), network adequacy requirements (insurance networks are required to cover specialist care), and mental health parity laws (SB 855 describes, among other things, how insurance companies must provide mental health care at the same level they cover medical care, meaning your psychotherapy copay cannot be higher than your normal medical copay).

Most relevant is this language from the California Code of Regulation (CCR) 2240.1 (e):

“(e) Networks must provide access to medically appropriate care from a qualified provider. If medically appropriate care cannot be provided within the network, the insurer shall arrange for the required care with available and accessible providers outside the network, with the patient responsible for paying only cost-sharing in an amount equal to the cost-sharing they would have paid for provision of that or a similar service in-network. In addition to in-network copayments and coinsurance, in-network cost sharing includes applicability of the in-network deductible and accrual of cost sharing to the in-network out-of-pocket maximum.”

Eligibility for an Network Gap Exemption

To be eligible for a NGE, you must have a mental health condition that meets medical necessity (any diagnosable mental health condition), and need treatment from a provider who’s training or specialization is not available in-network, or who is not available within timeliness/geographic requirements (10 business days for non-urgent mental health appointments, and 30 minutes or 15 miles from patients location).

In this case, I am trained in an evidenced-based specialty, ISTDP (Intensive Short-Term Dynamic Psychotherapy), and it forms the backbone of what I offer as a therapist. This is a specialty which is highly unlikely to have in-network specialists, thus creating eligibility for an NGE.

Requesting an NGE

1) Make sure you document all aspects of your process (dates of calls, name of representatives you speak to, information you are provided) as it may help prove helpful if you need to appeal a rejection or file a complaint.

If you have a PPO, skip to step 3.

2) If you have an HMO, contact your primary care doctor, and ask them to write a referral for ISTDP (intensive short term dynamic psychotherapy). You can explain to your doctor that this has been helping you overcome the psychological and emotional roots of your current struggles, and the referral is needed to request insurance reimbursement. Try and get a print out or PDF (some kind of copy) of the referral with the phrase 'ISTDP' written on it.

3) Call your insurance and say you’d like to request a network gap exemption (also sometimes called a provider deficiency request, or out-of-network override), because you’ve identified a deficiency in their network, and you need medically necessary specialty mental health care that is not available in-network.

4) To complete the request, you'll need to provide information about this treatment and your condition.

Your Diagnosis:

My information: Name,, License number, NPI , TaxID address Phone number

CPT codes: It's best to give them two codes, 90834 (45 minute sessions), and 90837 (60 minute sessions). While we usually use code 90834, asking for coverage for both codes allows greater flexibility for your treatment if we ever have reason to do an extended session.

You'll also need to provide your rationale for requesting the exemption. It is best to describe your needs, and the network gap: "This approach (ISTDP) has been effective for my condition, and I have been unable to find a provider with this training within the network".

What to do in Case of Rejection

If your insurance company rejects your request, ask for a detailed explanation of the reason for their rejection. This reason will determine how you appeal the decision - you'll want to base your appeal on the relevant California laws (SB 855, SB 221, and SB 858 which states that insurance companies can be fined up to 200k per infraction if they continually ignore these laws).

Keep in mind that insurance companies do not publicize this mechanism, and often try to avoid providing the coverage they are legally mandated to cover. You may need to push and fight to get them to comply with the law. Remember, asking for this coverage is not asking for special treatment, it's asking for insurance companies to follow California laws related to mental health coverage.

If appealing to your insurance company does not yield the desired response, the next step is to escalate and file a complaint with the Insurance Commissioner of California, which has the authority to overrule any decision by your insurance company and force compliance.

Additionally, a proven method for eliciting quicker and more effective responses from a challenging insurance company is to enlist the assistance of your state assembly member. Representing your interests, they have staff members dedicated solely to helping constituents navigate state-related issues, including those involving non-compliant insurance companies.

What do I tell my insurance to request a Network Gap Exemption?

Sample Letter (copied below too): https://docs.google.com/document/d/1M-1f8gC9rphrAQ_ot5AbmQZBB286nT1lrgfT2uCYywo/edit?usp=sharing

For more information and support, visit www.insurancemage.com.

[Your Full Name]

[Your Address]

[City, State, Zip Code]

[Email Address]

[Phone Number]

[Member ID]

[Date]

[Insurance Company Name]

[Insurance Company Address]

[City, State, Zip Code]

Subject: Request for Coverage of Out-of-Network ISTDP Specialist as In-Network Due to Network Gap

Dear [Insurance Company Name],

I am writing to request coverage for my out-of-network ISTDP specialist, [THERAPIST NAME], at in-network benefit levels, due to a network deficiency for this type of specialty within your provider network. I have been unable to find the necessary specialty care within your network, necessitating this request.

Having suffered from [DIAGNOSIS] for [LENGTH OF TIME], I have found previous treatments insufficient in addressing my condition, and require specialty care to treat my mental health condition. ISTDP is an evidence-based treatment with a substantial body of research demonstrating its cost effectiveness and efficiency, and I have found it to be uniquely effective for me. My attempts to locate an in-network psychotherapist with this specialization have been unsuccessful, indicating a gap in your network's provision of necessary mental health services.

Therefore, I am formally requesting a network gap exemption (also known as a provider deficiency request, out-of-network override, or out-of-network exemption) for coverage of my ISTDP behavioral health treatment with [THERAPIST NAME].

Given that legal frameworks are often updated, here are a few of the most recent California laws regarding insurance networks/network deficiency laws, as well as mental health parity requirements and timeliness requirements in California. The California Code of Regulation (CCR) 2240.1 (e) outlines that: “Networks must provide access to medically appropriate care from a qualified provider. If medically appropriate care cannot be provided within the network, the insurer shall arrange for the required care with available and accessible providers outside the network, with the patient responsible for paying only cost-sharing in an amount equal to the cost-sharing they would have paid for provision of that or a similar service in-network.” Additionally, SB 855, states that “insurance companies [are required] to either provide or authorize appropriate mental health care within 15 business days.” [IF HMO PLAN, ADD THIS NEXT PART, DELETE IF PPO PLAN]: Additionally, SB 221 clarifies this by stating that “a referral to a specialist by a primary care provider or another specialist shall be subject to the relevant time-elapsed standard.” My referral for specialist ISTDP treatment from DOCTORS NAME was provided on DATE OF REFERRAL, and is attached below. I anticipate your response to this time-sensitive request.

Warm regards,