HOW INSURANCE WORKS

Most of our therapists are Out-of-Network providers. This means that they are not in-network or credentialed with any insurance companies. We will let you know about each clinician during intake.

If your insurance plan includes out-of-network benefits, your insurance provider will typically reimburse a portion of the session costs once you've met your deductible.

When receiving care from an out-of-network provider, you will generally be required to pay the full cost of services upfront until your deductible is met. The cost of therapy sessions varies depending on time and type with the range being $175.00 - $350.00 (we have limited sliding scale sessions available please inquire at the time of intake). Afterward, you can submit a claim to your insurance company for reimbursement. The insurer will review the claim, determine the eligible reimbursement based on your out-of-network coverage, and issue the appropriate payment.

Alternatively, if you're seeing an in-network provider, the process is simple: schedule your appointment, attend your session, pay your copay, and you're all set!

A few steps to make this process easier!

1. COMPLETE YOUR PAPERWORK ON SIMPLE PRACTICE (REQUIRED)

Before you begin therapy, you’ll receive an email from Simple Practice our electronic health record platform. The subject of the email will be “Client Portal” and will be sent from your therapist @simplepractice.com. Your client portal will have all of the intake paperwork that needs to be completed before your first session. You cannot be seen without these forms signed - by law. You will also have ongoing access to billing paperwork and the ability to pay or update payment methods through this portal so please make your sign-in something you will remember!

If you’re having trouble accessing Simple Practice, please reach out to info@pleasantvillewellnessgroup.com for assistance. 

2. LOOK UP AND CONFIRM YOUR OUT-OF-NETWORK BENEFITS

The decision to come to therapy means that you’ve made an important investment in your emotional health and wellbeing. Congratulations!

Our therapy rates vary by therapist and the length of sessions, and insurance use. At PWG, we strongly believe that cost shouldn’t get in the way of receiving quality services.

Are you unsure if you’re eligible for insurance reimbursement? Here’s some helpful info because we know that dealing with insurance companies can be a confusing and frustrating experience.

You should first and foremost call the 800 number on the back of your insurance card, speaking to a representative and having them confirm your out of network benefits, the amount of your deductible and expected reimbursement will be helpful for you to estimate cost.

When you speak to someone or use an online tool the codes to inquire about will typically be one of the following:
90837 - Individual therapy hour 53 minutes
90834 - Individual therapy session of 45 minutes
90847- Family Therapy

If you need more clarification please be sure to ask!

Remember to confirm the estimated reimbursement amount with your insurance company as they have the most up-to-date information about your benefits. Additionally, if you are going to have telehealth sessions,  it is important to confirm you are eligible for telehealth services.

Questions to ask your insurance representative:

  • “Does my plan include out-of-network benefits for mental health care? Specifically, for outpatient psychotherapy?” “Does it also include tele-health visits?”

  • “Do I have a deductible for out-of-network mental health services? If yes, what is the remaining amount I will have to pay before my health plan starts to reimburse me for fees that I pay out-of-pocket?”

  • “What is the maximum amount my plan will reimburse for mental health service code 90837 with a Psychotherapist?” If the rep does not provide a clear answer, ask: “What is the maximum allowed amount for mental health service code 90837 with a psychotherapist, and what percentage of the maximum allowed amount will my plan pay?” (This percentage of the maximum allowed amount is the amount you would receive as reimbursement.)

  • Superbill and/or Courtesy Claims submission eligibility: Once you confirm your plan provides out-of-network coverage our team will let you know if you are eligible for superbills and/or our courtesy claims submission program.

    *Please see the list below of plans that are not supported by our courtesy claims submission program. This list is subject to change.

    • 1199 SEIU

    • Blue Cross Blue Shield (all plans)

    • Healthfirst

    • Affinity Health

    • Humana

    • Aither

      Kaiser Permanente

      Allied

      All Medicare/Medicaid plans

    • BenefitAdministrative systems

    • MultiPlan

    • CDPHP

      Partners Healthcare MA

      Compsych (Comcast Plans via BCBS)

      PHCS Specific Services, Network PPO

      EmblemTricare

    • Fidelis Am Better

    • Tufts

3. Learn how to get reimbursed. 

WHAT IS A SUPERBILL?

A superbill is a detailed statement itemized that is used in medical billing. It is a document that your mental health provider gives to patients after a session, outlining the services rendered and the associated costs.

The primary purpose of a superbill is to facilitate the reimbursement process between patients and their insurance companies. It contains all the necessary information that insurers require to process claims and reimburse patients for covered medical expenses.

WHAT INFORMATION IS INCLUDED ON A SUPERBILL?

  • Patient Information: Patient name, date of birth, contact details, insurance information, and any relevant patient identification.

  • Provider Information: Therapists name, practice address, contact details, and any sorrnecessary provider identification numbers.

  • Date(s) of Service: The date(s) on which the medical service was provided.

  • CPT (Current Procedural Terminology) Codes: These are standardized codes that represent medical procedures and services. Each service provided during the appointment is assigned a specific CPT code. 

  • Diagnosis Code (ICD-10): Diagnosis codes that correspond to the patient’s medical condition. These codes explain why the services were performed.

  • Description of Services: A brief description of the medical services or procedures performed during the appointment.

  • Place of service (POS): The code that is related to in-person or virtual visit. 11 is the POS code for in-person (an appointment takes place with the client in the therapist’s office). 10 is the POS for telehealth visits. 

  • Units: The quantity of each service provided. For instance, if a patient received two vaccinations, there would be two units listed for that specific service.

  • Fee or Charge: The cost associated with each service rendered, along with the total charges for the appointment.

How does this differ from the weekly invoice?

Great question!
Your weekly invoice is a bill for the services rendered that week this does not include the necessary codes and diagnosis that insurance companies require to facilitate reimbursement. Superbills are sent out monthly this typically can be easily submitted via your insurances online portal.

WHAT IS COURTESY CLAIMS SUBMISSION?

Courtesy claims submission is when a healthcare provider submits out-of-network insurance claims on behalf of the client. If a client sees a provider outside their insurance network, the provider may submit the claim to the insurance company for processing, even if they do not have a contract with that insurer. This service is offered as a courtesy to help clients with the claims process.

How Courtesy Claims submission works:

  1. Each session is paid in full at the time of service.

  2. Our billing team submits your claims within 1 week of the date of service.

  3. Once your deductible has been met and the reimbursements will be sent to the provider your cost per session may be adjusted. This will be highly individual depending on the reimbursement rate. Typically checking your out of network benefits, your deductible the allowed amount and the percentage covered will give you and us an estimated forecast for what the reimbursement will be and what your cost per session will be at that point.

** It is important to note that not all insurance plans support courtesy claims submission, and the willingness to accept such claims can vary between insurers. At the time of registration, our team will determine whether or not a client’s insurance plan is eligible for courtesy claims submission. If we are unable to support a client’s plan, our team will provide you with a monthly superbill. 

4. SUBMIT YOUR CLAIMS 

If you are receiving superbills you will receive an email from Simple Practice on the 5th of every month for the month prior. This email will provide a secure link for you to download your superbill. 

Submitting a superbill involves sending the document to your insurance company for reimbursement or keeping it for your records. 

HOW TO SUBMIT A SUPERBILL TO YOUR INSURANCE:

  1. Review: Double-check the accuracy of the information on the superbill, including service dates, service descriptions, codes, and costs.

  2. Contact Your Insurance: If you’re planning to seek reimbursement from your insurance company, contact them to inquire about their specific submission process, required forms, and any additional documentation they may need.

  3. Submit the Superbill: Depending on your insurance company’s requirements, you may need to mail, fax, upload electronically, or submit the superbill through an online portal. Some insurers might also require you to fill out a claim form along with the superbill.

  4. Keep a Copy: Make sure to keep a copy of the submitted superbill, claim form (if applicable), and any other related documents for your records.

  5. Follow Up: If you don’t receive reimbursement or any response from your insurance company within a reasonable timeframe, follow up with them to inquire about the status of your claim.

Remember that the specific process can vary based on your insurance company’s policies and the nature of the medical services. Always communicate directly with your insurance company to ensure you follow the correct procedure for submitting a superbill. 

5. REMEMBER TO KEEP US INFORMED

 If your insurance or credit card information changes or expires, please make sure to update your information by emailing billing@pleasantvillewellnessgroup.com or calling

914-538-2438.