What does Out-of-Network (OON) mean?
An In-Network provider has a direct contract with an insurance company to accept a specific negotiated rate. An Out-of-Network provider does not have a contract with that specific insurance company.
However, most PPO and POS insurance plans include a provision that allows members to see a provider outside of their network. In these cases, the insurance company will often reimburse you for a significant portion of the session cost once you have met your deductible.
How does the payment process work?
The process for Out-of-Network care follows these four steps:
Payment at Time of Service: You pay the full session fee to CNY Mental Health Therapy at the time of your appointment.
Receive a Superbill: At the end of each month (or upon request), we provide you with a specialized invoice called a Superbill.
Submit to Insurance: You can opt to have us submit the Superbill on your behalf to your insurance company or you can mail or upload the Superbill to your insurance company’s member portal on your own.
Receive Reimbursement: The insurance company processes the claim and mails a check directly to you for the portion they cover.
How much will I actually be reimbursed?
Reimbursement rates vary wildly depending on your specific plan. Generally, insurance companies cover between 50% and 80% of the allowable amount for a therapy session after your out-of-network deductible has been met.
What is a Superbill?
A Superbill is a detailed receipt that contains all the clinical information an insurance company requires to process a claim. This includes:
Provider Information: Name, provider credentials, NPI number, and Tax ID.
Clinical Information: A diagnosis code (ICD-10) and a procedure code (CPT code).
Transaction Details: Date of service and the total amount you paid.
Important Note About Using Your Insurance
Requesting a superbill means a diagnosis must be recorded. Since insurance companies will not reimburse without a medical necessity code, the primary benefit of no diagnosis in private pay is lost once a superbill is submitted to an insurer.
Why choose OON instead of finding an In-Network provider?
Many clients choose to use their OON benefits for several reasons:
Specialized Care: You may want to work with a therapist who specializes in a specific modality such as couples therapy, EMDR, or DDP, which may not be available in-network.
Fit and Connection: Research shows that the relationship between therapist and client is the biggest predictor of success. OON allows you to choose the best fit for you rather than just who is on a list.
Availability: In-network providers often have long waitlists. OON can provide faster access to care.
What questions should I ask my insurance company?
We recommend calling the member services number on the back of your insurance card and asking:
"Does my plan provide reimbursement for out-of-network outpatient mental health?"
"What is my out-of-network deductible, and has it been met for the year?"
"What is the reimbursement rate for CPT code 90837 (53+ minute individual therapy)?"
"How do I submit a Superbill for reimbursement?"
Comparison of Coverage Types
| Feature | In-Network | Out-of-Network (OON) |
| Payment | You pay a small copay/coinsurance. | You pay the full fee; Insurance mails you a check. |
| Provider Choice | Restricted to a specific list. | Total freedom to choose your therapist. |
| Paperwork | Handled by the provider. | You submit the Superbill to your insurer. |
| Deductible | Usually a lower deductible. | Often a separate, higher deductible. |
