Calling your Insurance for Benefits and Pre-authorization
To determine whether your insurance covers psychological or counseling services, you need to call your insurance provider and request the information. (Coverage details also may be available on your insurer’s web site).
In the event that you have to call your insurer, make sure you have your insurance identification card, a pen or pencil, and a printout of this page. Do not feel shy about requesting this information; as the customer, you have a right to this information.
Your insurance provider’s phone number is usually toll-free, and is located on the back of your insurance card. Your insurer may require you to be pre-authorized to receive mental health benefits, and direct you to a managed health care company whose job is to “manage” your use of my services.
When interacting with your insurance provider’s representatives, state that you are calling to find out what coverage you have for services provided by an out-of-network provider who is a licensed psychologist.The representative will ask for your name, date of birth, policy holder, policy holder identification number, and group number.
The insurance representative may ask for specific information to determine whether I qualify as an out-of-network provider. My identification and credentials are as follows:
Paul Cantz, PsyD, ABPP. Licensed Psychologist in the State of Illinois License # 071008080. Licensed Psychologist in the State of New York # 026325
My National Provider Identification (NPI) 1730485772
Remind them that I am not in their panel and do not work under their fee schedule.
The representative will probably ask what the diagnosis is. Tell the representative that the diagnosis is ___________________________________ (I will give it to you on your superbill or tell you directly). If you do not yet have a diagnoses ask the representative if there are any diagnoses given in counseling situations that are not covered.
After you answer all of the representative’s questions, ask “To whom am I speaking?”
Write down the representative’s name__________________________.
Then ask “In the future, what is the best phone number to call with future inquiries about mental health benefits?”
___________________________________________
Next the representative will ask what procedures are going to be performed. If the representative does not ask , tell the representative that you have questions about the coverage for a number of procedures and that you have the codes for these procedures.
_____________________________________________________________________________________________________
Provided below is a procedures checklist that may apply to you (depending on what services you will receive from me), as well as codes (CPT, or Clinical Procedure Terminology). ________________________________________________________________________
Procedure 1: Intake / Diagnostic Interviews
CPT code 90791
- Insurance coverage provided: Yes ___ No ____.
- Rate charged by Dr. Cantz: $______ per hour (Same than psychotherapy fee)
- Insurer reimbursement: ______.
- Is there a maximum dollar amount or maximum number of interviews allowed for this service? (typically there are 2 to 4 intake interviews) ___________________________________________________________________________________________________________________
Procedure 2: 45 minutes Individual and/or Family Member
CPT code 90834
Individual - Insurance coverage provided: Yes ___ No ____.
- Rate charged by Dr. Cantz: $_______ per hour
- Insurer reimbursement: ______
- Is there a limit on the number of sessions I can have in any one day? Yes ___ No ____... -Or in any one week? Yes ___ No ____.
- Is there a maximum dollar amount for this service? ________.
- Is there a yearly maximum? _____________.
- Is there a lifetime maximum? ____________________.-
Procedure 3: 60 minutes Individual and/or Family Member
CPT code 90837
Individual - Insurance coverage provided: Yes ___ No ____.
- Rate charged by Dr. Cantz: $_______ per hour
- Insurer reimbursement: ______
- Is there a limit on the number of sessions I can have in any one day? Yes ___ No ____... -Or in any one week? Yes ___ No ____.
- Is there a maximum dollar amount for this service? ________.
- Is there a yearly maximum? _____________.
- Is there a lifetime maximum? ____________________.-
Couples (if applicable)
Some insurance companies will not cover couples counseling. If they do:
- Insurance coverage provided: Yes ___ No ____.
- Rate charged by Dr. Cantz : $______ per hour
- Insurer reimbursement: ______
- Is there a limit on the number of sessions in any one week? ___
- Is there a maximum dollar amount for this service? ________.
- Is there a yearly maximum? _____________.
- Is there a lifetime maximum? ____________________.
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(If applicable) Procedure 4: Psychological Testing
CPT code 96101
- Insurance coverage provided: Yes ___ No ____.
- Rate charged by Dr. Cantz: $ 200 per hour
- Insurer reimbursement: ______
- Is there a limit on the number of sessions in any one day? ___. In any one week? ___
- Is there a maximum dollar amount for this service? ________.
- Is there a yearly maximum? _____________.
- Is there a lifetime maximum? ____________________.
___________________________________________________________________________________________________________________
Now ask the representative, for any of the above CPT codes you inquired about:
Are there any other restrictions or limitations we have not talked about? ___________________________________________________________
Will Dr. Cantz, as an out-of-network provider, be expected to fill out any additional forms such as description of the problems that brought me to therapy including symptoms, past history of symptoms, prognosis for change, etc? Yes ____ No ____.
Will Dr. Cantz be asked to have a telephone case review on your file with an insurance representative? Yes ___ No ___.
What deductible must be satisfied?________________________________.
How much of my deductible is already satisfied? ____________(if you have had recent procedures and the bill has not been processed, the computer will not have this information).
At this point, if you have decided to proceed and use your insurance benefits, you may be assigned an
Authorization Number. Write it down:______________________________
Once again ask for your representative’s name:__________________________.
After ending the conversation, record the date:__________ and time ____________ of phone call.
This should provide you with most of the information that you need to know about how much you will be reimbursed by your insurance company for your treatment.
The information in this page is intended to guide you in your choice of psychotherapist. This information may or may not apply to you or your insurance carrier. Dr. Cantz cannot guarantee that your insurance will reimburse any costs incurred during your fee for service treatment with him.
The content on this website is for general information and educational purposes only, and is not intended to substitute professional services. Visiting this website or contacting Dr. Cantz by e-mail or phone does not constitute or establish a therapeutic or professional relationship.