Private Pay (Out of Network Benefits)

Out-of-Network (OON) benefits mean that your healthcare provider, such as your LCSW or SLP, doesn't have a contract with your insurance company. This means you pay the provider's full fee upfront for each session. To receive a refund, your provider will provide you with a detailed receipt, known as a Superbill. The Superbill is your special invoice that contains all the codes (like the diagnosis and procedure codes) your insurance company needs to process the claim. You, the client, are responsible for submitting this Superbill to your insurer. Before you get any money back, you must first pay your OON deductible (a set amount, like $2,000) entirely out-of-pocket.

Once your deductible is met, your insurance will start sending you a refund based on your percentage of reimbursement (co-insurance), typically between 50% to 80%. They calculate this percentage against their "Allowed Amount" (their pre-determined fair price for the service), not necessarily the provider's full fee. For example, if your plan covers 70% and your therapist charges $150, you might receive 70% of the allowed amount (say, $105) back, which is $71.50. Your actual cost for that session would then be the initial $150 you paid minus the $84 refund, making the session $66. Always call your insurance company directly to verify your specific deductible and reimbursement percentage before starting services.

Payment

We use Ivy Pay to process all session fees. This secure payment system is built specifically for licensed healthcare professionals like your LCSW or SLP, ensuring your financial data is handled with strict HIPAA-compliant confidentiality. After you securely input your credit card, debit, HSA, or FSA card information via a text link we send you, payment is processed automatically right after your session, making the financial transaction seamless. The key benefit for you is the instant Superbill generation: Ivy Pay allows you to access and generate your detailed Superbill immediately after payment is processed, which enables you to submit your out-of-network claim to your insurance company right away, significantly speeding up the process of meeting your deductible and receiving your reimbursement much faster than waiting for a monthly statement.

How to Check Your Benefits (The Action Plan)

  1. Find the Number: Call the Member Services phone number on the back of your insurance card.

  2. Ask the Magic Questions:

    • "Do I have Out-of-Network benefits for Outpatient Mental Health (LCSW) or Speech Therapy (SLP)?

    • "What is my OON Deductible, and have I met any of it?"

    • "Once the deductible is met, what is my Co-insurance percentage?"

    • "What is the Allowed Amount they use to calculate reimbursement for a therapy code like 90837 (or a speech code like 92507)?

  3. Start Submitting: Once you begin sessions, pay the provider, obtain the Superbill, and submit it immediately to your insurance company to start receiving your reimbursement!