How to Get Reimbursed for Adult ADHD and Autism Assessments in Pennsylvania
Finding the right evaluator is an important and sometimes challenging process—especially when navigating the financial side of things. If you’ve found an evaluator you would like to work with, but they’re not “in” your insurance network, you might be wondering: Can I still see them and get reimbursed? The answer might be yes—if you have out-of-network benefits.
Here’s a breakdown of what out-of-network benefits are, how to find out if you have them, and how they can work for you.
What Are Out-of-Network Benefits?
Out-of-network (OON) benefits are part of many insurance plans that allow you to see providers who don’t directly work with your insurance company—and still get some reimbursement for the cost.
Instead of paying just a small copay like you might for an in-network provider, you pay the full fee upfront. Then, you submit a claim to your insurance company, and they reimburse you. The amount that they reimburse you depends upon your specific plan, so it will either be a partial reimbursement, like 70%, or fully reimburse you.
How Do I Know If I Have Out-of-Network Benefits?
Contact your insurance provider, and ask the representative the following questions. Be sure to write down the answers!
“Do I have out-of-network benefits?”
“What is the deductible amount I must meet before cost-sharing occurs?”
“What is the amount of the deductible paid so far, for this plan year?”
“Once my deductible is met, what is my cost-sharing responsibility, if any?”
“What are the ‘allowed amounts’ for the following service codes aka CPT codes:
90791
90837Double check which codes your evaluator uses before contacting your health plan to maximize your reimbursement!
“So for example, once my deductible has been met, given the allowed amount for a 90837 is X, I can expect reimbursement from you in the amount of Y for each session?”
“How many units of 90791 are eligible for reimbursement at the start of care with a new service provider? One or two?”
“How many units of 90837 are eligible for reimbursement on the same calendar day? One or two?”
“Is there a difference in allowed amount if the service occurs in-person versus telehealth?”
“What steps do I take to submit a superbill to you to request reimbursement?”
“Will I receive reimbursement from you via check, or do you offer direct deposit?”
(If they offer direct deposit and you’d prefer it:
“Can you walk me through how to set up direct deposit?”)“What is your name and the reference number for this call?”
How Do I Use My Out-of-Network Benefits?
If you do have OON coverage, here’s what the process usually looks like:
You pay your provider directly at the time of service.
Your provider sends you a “superbill”—a paid medical invoice that includes all the information your insurance company needs to process an out-of-network claim such as diagnosis code, CPT code, dates of service, provider info, etc.
You submit the superbill to your insurance company, either by mail or through their online portal.
Your insurance processes the claim. If you’ve met your deductible, they’ll send you reimbursement—usually as a check in the mail or via direct deposit, depending on what you’ve set up.
Some clients use third party services like Mentaya to streamline this process, and decrease the administrative burden.
How Do Out-of-Network Benefits Help Me?
Out-of-network benefits:
Expand your options. You’re not limited to a short list of in-network providers—you can choose someone who’s a better fit for your identity, your goals, or your specific therapeutic needs.
Offer flexibility. You may be able to access more specialized services, including longer sessions or advanced modalities, which are often not covered in-network.
Offset your costs. Even partial reimbursement (such as 60%–90%) can make services more affordable.
Need Help Figuring It Out?
If you're considering working with a provider who is out-of-network, don’t be afraid to ask for support. Many providers offer guidance on how to check your benefits or offer documentation to make the process easier.
Understanding your benefits can be empowering—and can open the door to services that truly meets your needs.
If you’re seeking an Adult ADHD and Autism Diagnostic Assessment in Pennsylvania, you are welcome to explore our website and use our benefits calculator to check your out-of-network benefits!
