INSURANCE BENEFITS

Before starting treatment, it is highly recommended that you call your insurance provider to understand your Out-of-Network (OON) coverage. This ensures you have a clear picture of your expected reimbursement.

1. Preparation: What You’ll Need Before the Call

Have the following information ready to go before you dial the number on the back of your insurance card:

• Your Insurance Card: You will need your Member ID and Group Number.
• Provider Information: If they ask for Dr. Hu’s credentials, she is a Child Psychiatrist (Medical Doctor) and the practice is Remède Therapy.
• Pen and Paper: To document the representative’s name, the date of the call, and your Reference Number for the conversation.

2. The Call: Questions to Ask

Call the “Member Services” or “Mental Health/Behavioral Health” number. Once connected to a representative, ask the following:

• The Basics: “Do I have out-of-network benefits for outpatient mental health?”
• The Deductible: “What is my out-of-network deductible? Is it separate from my in-network deductible? How much of it have I met this year?”
• The Reimbursement Rate: “Once my deductible is met, what percentage of the allowed amount do you cover for psychiatric services? (Typically, patients see 0–60% reimbursement).”
• The Limit: “Is there a limit on the number of sessions covered per calendar year?”
• Prior Authorization: “Do I need prior authorization or a referral from my primary care doctor before seeing Dr. Hu?”

3. Confirming Procedural Coverage (CPT Codes)

The representative will ask for specific CPT (Procedural) codes to tell you exactly how much they pay for each type of visit. Ask specifically about these:

• 90792: Initial Psychiatric Evaluation
• 90837: 60-minute Psychotherapy
• 99213 / 99214: Medication Management
• 90836 / 90838: Psychotherapy “Add-on” (used when medication and therapy happen in one visit)

4. Submitting Your Claim

Finally, ask: “How do I submit a Superbill for my claim? Can I upload it through your member portal, or must I mail it?”

Remède Tip: When you receive your Superbill (SB), it will already contain all the CPT codes, Diagnostic (ICD-10) codes, and Dr. Hu’s Tax ID/NPI numbers that the insurance company requires for your reimbursement.

Insurance terminology can feel like a different language. Here are the most common “jargons” you will encounter when discussing your out-of-network benefits:

1. Allowed Amount

Insurance companies do not reimburse based on our actual fee; they reimburse based on what they decide a service should cost.

• The Reality: If our fee is $450, but your insurance “allows” only $250, they will pay their percentage (e.g., 60%) of that $250. You are responsible for the remaining balance. This is often called the “Fair Market Value” or “Customary Fee.”

2. Out-of-Network Deductible

Most plans have two separate “buckets” for deductibles: In-Network and Out-of-Network.

• The Reality: You must reach your Out-of-Network Deductible before your insurance will send you a reimbursement check for Dr. Hu’s services. Payments made to in-network doctors (like your PCP) usually do not count toward this specific bucket.

3. Prior Authorization

Some plans require “permission” before you see a specialist or start a specific treatment (like an Intensive program).

• The Reality: If your plan requires Prior Authorization and you do not obtain it before your session, the insurance company will likely deny your claim entirely, even if the service was medically necessary.

4. Single Case Agreement (SCA)

An SCA is a one-time contract where the insurance company agrees to pay an out-of-network provider at in-network rates.

• The Reality: This is rare and usually only granted if the insurance company cannot provide an in-network doctor with the same level of specialization (e.g., specific expertise in ARFID or ERP). This must be negotiated by the patient with their insurance manager.

5. CPT vs. ICD-10 Codes

Think of these as the “What” and the “Why” of your visit.

• CPT (Procedural Code): The “What”—e.g., 90837 for a 60-minute therapy session.
• ICD-10 (Diagnostic Code): The “Why”—e.g., F41.1 for Generalized Anxiety Disorder.
• The Reality: Your Superbill (SB) must have both. If one is missing, the insurance computer will automatically reject the claim.

6. Co-Insurance

Unlike a “Co-pay” (a flat $20 or $30 fee), Co-insurance is a percentage.

• The Reality: If your co-insurance is 40%, the insurance company pays 60% of their “allowed amount,” and you cover the rest.

7. Superbill

A Superbill (SB) is essentially an “itemized receipt” for medical services that contains specific clinical information required by insurance companies. Because Remède is an out-of-network provider, you pay the practice directly at the time of service, and the Superbill is the document you then submit to your insurance company to request reimbursement.

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Where do I find these codes? To make it easy, Remède includes all the necessary CPT codes, ICD-10 codes, and Provider Tax IDs on your monthly Superbill (SB). You can download these at any time from the.