Understanding Out-of-Network Care
How Out-of-Network Care Works — and Understanding the Reimbursement Process
Many patients are familiar with using insurance for medical visits, but fewer understand how out-of-network care works or how reimbursement works. This guide provides information on how to navigate reimbursement if you choose to work with an out-of-network provider.
You should begin by contacting your insurance to get details.
1. What Does “Out-of-Network” Mean?
When a clinician is out-of-network, it means they do not have a contract with your insurance company. You pay the session fee at the time of your visit, and then—if your plan offers out-of-network coverage—you may receive reimbursement directly from your insurance company.
Some insurance plans reimburse a significant portion of the visit; others reimburse little or none. It depends entirely on the specifics of your plan.
Out-of-network care can offer important benefits, including:
More time per appointment
More individualized care, without insurance-driven limits
Specialized services (such as reproductive psychiatry) not always available in-network
This model allows for care to be thoughtful, collaborative, and tailored to your needs.
2. What Is a Superbill?
A superbill is a detailed medical receipt designed specifically for insurance reimbursement. It includes:
Diagnosis code (ICD-10)
Procedure codes for your visit (CPT)
Date and length of session
Provider information
Fees paid
Confirmation that you paid out of pocket
A superbill does not guarantee reimbursement—but it gives your insurance company all the information required to review your claim.
3. How to Submit a Superbill (Step-by-Step)
There is a process to follow:
Step 1. Pay for Your Visit
Payment is made at the time of service using a credit card, HSA, or FSA card.
Step 2. Request a Superbill
You can request it through the patient portal after your appointment.
(You only need a superbill if you are planning to submit to insurance.)
Step 3. Upload the Superbill to Your Insurance Company
Most insurance companies allow online submissions through your member portal.
Some may require a brief claim form as well.
Step 4. Wait for Insurance Review
Insurers evaluate:
Whether your plan includes out-of-network benefits
Whether your deductible has been met
Whether the visit is eligible under the policy
What percentage they will reimburse
Step 5. Receive Reimbursement
If approved, reimbursement is sent directly to you—not to the clinician.
4. What Determines Your Reimbursement Amount?
Several factors influence how much you may receive:
1. Your Out-of-Network Deductible
Some deductibles are low; others are several thousand dollars. You must meet this amount before reimbursement begins.
2. Allowed Amount
Insurance companies decide how much they consider a “reasonable” fee for a service. They reimburse a percentage of that amount, not necessarily the actual session fee.
3. Reimbursement Rate
Common reimbursement rates range from 40% to 80%, depending on your plan.
4. Visit Type
Different CPT codes have different allowed amounts.
To check your benefits, call your insurance company and ask:
Do I have out-of-network mental health benefits for telepsychiatry?
What is my out-of-network deductible?
What percentage of the allowed amount is reimbursed?
Where do I submit superbills?
5. Can I Use My HSA or FSA?
Most patients can use:
Health Savings Accounts (HSA)
Flexible Spending Accounts (FSA)
to pay for psychiatric visits even if the clinician is out-of-network. This allows you to use tax-advantaged funds for your care.
6. Why Some Patients Prefer Out-of-Network Care
Out-of-network care often means:
Appointments are longer and more thorough
Treatment plans are individualized rather than insurance-driven
Care is flexible, responsive, and built around your goals
7. If You Have Questions
Insurance reimbursement can feel confusing. If you’re unsure about:
Whether your insurance covers out-of-network care
How to submit a superbill
What your potential reimbursement might be
You should contact your insurance company directly for additional information.
