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Whether you are a client or a professional, navigating insurance can feel like learning a new language. With so many terms, it’s hard to feel confident when helping a client dissect their coverage for services at the start of therapy. Let’s take a look at some of the common terms in insurance when providing mental health services to clients in private practice.
1. Provider: Professional person providing services
2. Member: Person with insurance seeking services
3. Claims: Billing documentation to request payment for services rendered
4. CMS 1500 Form: The form used when submitting paper claims, including Medicaid and Medicare
5. EOB/Explanation of Benefits: Break down of benefits and rates of reimbursement to a member per their insurance plan
6. Copay: the amount a member owes the provider at the time of service
7. Deductible: The amount a member must pay out of pocket before services are covered fully by insurance.
For example, a $5000 family deductible means the family must pay $5000 for services within one year before insurance will pay for any additional costs at 100%. This usually covers both medical and mental health services if those are included in the member’s plan.
A high deductible results in the member paying for mental health therapy out of pocket until the deductible is met, which creates the most confusion for clients, especially if they know they have a $0 copay and now have to pay $150-$250 per session out of pocket.
8. Superbill: Documentation given from the provider to the member to submit to insurance after member pays for the service out of pocket, for member’s to submit for possible partial reimbursement by insurance.
9. INN/In Network: Provider is credentialed with the member’s insurance panel
10. OON/Out of Network: Provider is not credentialed with the insurance panel but member may have OON benefits that cover some of the costs.
11. Credentialing: Starting the process of getting on an insurance panel
12. Provider service center/representative: Call center for provider’s questions
13. Insurance Opt Out Form: a document a client can sign indicating they don’t want to use their insurance (not allowed with Medicaid in Colorado) and have elected to be a private pay client. Check out our example in our online store.
Each client’s insurance coverage will outline different expectations and coverage for services. Ensuring they have mental health benefits is a first step for each client when exploring access to therapy, followed by identifying their copay and/or deductible. This effort can reduce financial barriers to therapy and eliminate surprises, which causes stress for both client and professional when insurance comes back with a different outcome than expected. Although insurance can feel frustrating, it allows greater access to care for folks who are seeking mental health support, and with some additional understanding of the terms, we can feel more confident navigating this system in our practices.
Disclaimer: Khara Croswaite Brindle is not an insurance representative. The definitions above are provided from her experience as an insurance-based private practice owner in Colorado since 2016 and do not replace a formal review of each insurance contract as a credentialed provider running your own independent business.