Using Out-of-Network Benefits: How Superbills and Reimbursement Actually Work

By Leila Hariri, MD Double board-certified in adult and child & adolescent psychiatry 10 min read

If you are considering an out-of-network psychiatrist, the honest headline is this: you will pay the full fee at the time of service, and you may or may not get a meaningful portion of it back. Whether you do depends almost entirely on details of your plan that you can determine in about fifteen minutes on the phone — before you commit to anything.

Most people don’t make that call, and then feel blindsided. This is the guide to making it.

What a superbill is

A superbill is an itemized receipt containing everything your insurance company needs to process an out-of-network claim. It is not a bill you owe — you have already paid. It is documentation you submit to your insurer to request reimbursement.

A complete superbill includes:

• The practice name, address, phone, and NPI (National Provider Identifier)
• The provider’s tax identification number
• Your name, date of birth, and address
• Each date of service
• CPT codes describing what was done
• ICD-10 diagnosis codes
• The charge for each service and confirmation that you paid

The CPT codes you are most likely to see in psychiatry:

• 90792 — psychiatric diagnostic evaluation with medical services (the initial appointment with a physician)
• 90791 — psychiatric diagnostic evaluation without medical services
• 99213, 99214, 99215 — established-patient office visits of increasing complexity, typical for medication management follow-ups
• 90833, 90836, 90838 — psychotherapy add-on codes billed alongside a medication visit when therapy occupied part of the appointment

The four questions to ask your insurer

Call the member services number on the back of your card. Ask for the behavioral health or mental health benefits department. Then ask, in this order:

1. “Do I have out-of-network outpatient mental health benefits?” If the answer is no, stop — nothing else matters, and you now know that an out-of-network practice will cost you full price indefinitely.
2. “What is my out-of-network deductible, and how much of it have I met this calendar year?” Note that the out-of-network deductible is usually separate from and larger than your in-network deductible. A $5,000 out-of-network deductible means you are paying full price until you have spent $5,000.
3. “After the deductible is met, what percentage of the allowed amount do you reimburse?” Commonly 50–80%.
4. “What is the allowed amount for CPT codes 90792 and 99215 in ZIP code [your ZIP]?” This is the question nearly everyone omits, and it determines your actual reimbursement more than anything else.

Also worth asking: whether pre-authorization is required, what the deadline for claim submission is, and whether claims can be submitted through the member portal. Write down the representative’s name, the date, and a reference number for the call.

The concept that surprises everyone: allowed amount

Your insurer does not reimburse a percentage of what you paid. It reimburses a percentage of what it has decided the service is worth — the “allowed amount,” sometimes called the usual, customary, and reasonable rate.

Worked example. Suppose your initial evaluation costs $600, your plan reimburses 70% after deductible, and your insurer’s allowed amount for CPT 90792 is $300.

• You might reasonably expect 70% of $600 = $420.
• You will actually receive 70% of the $300 allowed amount = $210.
• Your true out-of-pocket cost is $390, not $180.

Neither figure is wrong or hidden — but only one of them is the number you can plan around. This single arithmetic step is why so many patients feel misled by a system that technically disclosed everything.

Which plans reimburse, and which don’t

• PPO — usually includes out-of-network benefits. This is the plan type where superbills routinely produce real money back.
• POS — often includes out-of-network benefits, sometimes requiring a referral.
• HMO and EPO — typically no out-of-network coverage except for emergencies. A superbill will generally produce nothing.
• Medi-Cal — does not reimburse out-of-network private practice.
• Medicare — requires care. Psychiatrists may formally “opt out” of Medicare and see patients under a private contract; when a physician has opted out, neither you nor the physician can bill Medicare, and a superbill will not be reimbursed. If you have Medicare, ask directly whether the psychiatrist is enrolled, non-participating, or opted out — the three statuses have entirely different consequences for you.

Federal mental health parity law (MHPAEA) requires that plans covering mental health treat those benefits comparably to medical benefits. It does not require a plan to offer out-of-network coverage at all.

How to actually submit a claim

1. Collect your superbills. Most practices issue them monthly. Ask how yours are delivered.
2. Get the right form. Search your insurer’s site for “out-of-network claim form” or “member reimbursement form.” Many plans now accept uploads through the member portal, which is faster and creates a record.
3. Complete the member section carefully. Mismatched subscriber ID or date of birth is the most common cause of a rejected claim.
4. Attach the superbill and proof of payment if requested.
5. Submit within the deadline. Many plans require submission within 90 to 365 days of service. Do not let superbills accumulate for a year.
6. Keep copies of everything, including submission confirmations.
7. Track the EOB. The Explanation of Benefits shows what was allowed, applied to deductible, and reimbursed. Reconcile it against what you expected.

Reimbursement typically arrives in two to six weeks, paid to you rather than to the practice.

If your claim is denied

Denials are frequently clerical rather than substantive. Read the EOB for the specific reason code, then:

• Fix and resubmit if it is a data error — wrong ID, missing NPI, illegible form.
• Request the missing item if the denial cites incomplete documentation. The office can usually supply a corrected superbill promptly.
• File a formal appeal if the denial is substantive, such as “not medically necessary.” You have a legal right to appeal, and the EOB must explain how. A brief letter of medical necessity from your psychiatrist is often sufficient.
• Escalate if needed. California residents can request an Independent Medical Review through the Department of Managed Health Care, or file a complaint with the California Department of Insurance depending on plan type. Both are free, and plans frequently reverse denials once an external review is requested.

HSA, FSA, and the tax angle

Psychiatric care is a qualified medical expense, so HSA and FSA funds may generally be used — effectively a 20–40% discount depending on your marginal tax rate, and available regardless of network status. This is the most reliably valuable and most consistently overlooked mechanism for reducing out-of-pocket cost.

Separately, unreimbursed medical expenses exceeding 7.5% of adjusted gross income may be deductible if you itemize. Confirm specifics with a tax professional.

Doing the arithmetic honestly

Before your first appointment, you can calculate your genuine annual cost. Estimate the number of appointments — a common first year is one initial evaluation plus six to ten follow-ups — multiply by the fees, subtract expected reimbursement based on the allowed amounts you obtained by phone, and apply your HSA tax advantage.

The resulting figure is either manageable or it isn’t. If it isn’t, that is worth knowing now, and it is worth saying out loud when you call a practice. A good office will refer you to in-network psychiatrists, academic clinics, or training programs where excellent care is available at substantially lower cost. Being unable to afford a private practice is a budget constraint, not a reason to go without psychiatric care.

For this practice’s specific fees and policies, see the fees and insurance page.