Questions to Ask Your Health Insurance Provider About Your Benefits

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Health insurance can be confusing and frustrating.  These suggested

questions should help to clarify your insurance situation but can't

anticipate all the possibilities.  Ask your insurance company

anything you feel is important.

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1. Does my policy have ‘out of network benefits’?

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2. Is there a deductible?  If so, how much?

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3. How many sessions will my insurance policy cover?  Is that in a calendar year (starting in January)?

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4. How much does my insurance company pay?  100%?  80%?  Other?

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5. What does my insurance company deem as a ‘reasonable and customary’ fee upon which they will reimburse?  For example: If my therapist charges $130.00 how much of that amount does my insurance company deem as a ‘reasonable and customary fee’ and is this amount what my insurance company will base their reimbursement amount on?

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6. What is the best way to submit an insurance claim form?

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a. What do I need to do?  Do I need to complete a form or can my therapist provide a receipt?  (See question b.)

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b. What does my therapist need to do?  In order to be reimbursed can she provide me with a receipt with the date(s) of service, diagnosis, CPT code(s), her license, Tax ID and NPI numbers that I can then submit?  Can I submit online or do I need to use snail mail?

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c. 90834 is the procedure code for individual therapy.  Does my insurance cover 90791 — the procedure code for diagnostic evaluation/assessment sessions?  How many assessment sessions am I allowed?

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7. Is my Therapist, Henryetta Bergstresser, LCSW, in your system as an out-of-network provider? Her National Provider # (NPI) is 183 144 2532.  If not, does she need to provide you with any paperwork in order for my insurance claims to be reimbursed?

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8. How long does it take for a claim to be processed?

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9. What is the procedure if a claim is not responded to in a timely fashion?

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10. IF you have ONLY IN NETWORK benefits:

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a. How many sessions am I allowed?

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b. What do you pay my therapist?

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c. Do I have a co-pay to my therapist? How much?

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d. Do you have a list of ‘in-network’ providers who specialize in the kind of therapy I am seeking? Can you email me a list of ‘in-network’ providers?