Maximizing Your Out-of-Network Therapy Benefits in Pennsylvania: A Step-by-Step Guide
OON, OOP, Deductible, oh my!
Choosing an out-of-network (OON) mental health provider can open the door to more personalized, specialized care that truly aligns with your needs and goals for therapy. While in-network options may be limited, OON providers often offer greater expertise in specific therapeutic approaches, more flexible scheduling, affirming service options, and a stronger focus on individualized treatment.
By effectively using your OON benefits, you can access high-quality care while getting reimbursed for a portion of your costs—helping you invest in your well-being without unnecessary financial strain.
In this guide, we’ll walk you through common health care terms, and the steps to maximize your OON benefits so that you can make stress-free, informed decisions about your mental health care in Pennsylvania.
Common Health Care Terms
Allowed Amount- This is the maximum payment the plan will pay for a covered health care service. May also be called “eligible expense,” “payment allowance,” or “negotiated rate.”
Balance Billing – When an out-of-network provider bills you for the balance remaining on the bill that your plan doesn’t cover. This amount is the difference between the actual billed amount and the insurance allowed amount. For example, if the provider’s charge is $200 and the allowed amount is $110, the out-of-network provider will bill you directly for the remaining $90. Note: because an in-network provider has a contract with your insurance company to provide services for plan members for certain costs, they are not permitted to balance bill.
Cost Sharing – Your share of costs for services that a plan covers that you must pay out of your own pocket; sometimes called “out-of-pocket costs”. Some examples of cost sharing are copayments, deductibles, and coinsurance.
Deductible – An amount you could owe during a coverage period for covered health care services before your plan begins to pay. An overall deductible applies to all or almost all covered items and services. A plan with an overall deductible may also have separate deductibles that apply to specific services or groups of services. A plan may also have only separate deductibles. For example, if your deductible is $1,000, your plan won’t pay anything until you’ve met your $1,000 deductible for covered health care services subject to the deductible.
Coinsurance – Your share of the costs of a covered health care service, calculated as a percent. You owe the coinsurance percentage plus any deductibles you owe. For example, say your health insurance plan’s allowed amount for an office visit is $100 and your coinsurance is 20%. Scenario A: If you’ve paid your deductible, then you owe 20% of $100, which is $20. So your health plan will reimburse you $80 for that visit. Scenario B: If you haven’t paid your deductible yet, then you owe the full allowed amount, which is $100, and you will not receive reimbursement until your deductible has been met.
Now you’re ready to maximize your out-of-network benefits!
Step 1: Verify Your OON Benefits
Call your insurance provider or check your benefits online to confirm:
“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 CPT codes:
90791
90837
90834
“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 treatment?
1 or 2?
How many units of 90837 are eligible for reimbursement on the same calendar day?
1 or 2?
How many units of 90834 are eligible for reimbursement on the same calendar day?
1 or 2?
Is there a difference in allowed amount if the session 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 this, ask them how to set that up
“What is your name and the reference number for this call?”
Step 2: Choose an OON Therapist Who Fits Your Needs
Look for a therapist whose approach aligns with your goals. Many OON providers specialize in specific modalities, such as Brainspotting, EMDR, or Somatic Experiencing, offering a level of expertise that in-network providers may not.
Step 3: Pay for Your Sessions Upfront
OON providers typically require payment at the time of service. You’ll receive a superbill, an itemized medical receipt containing the necessary details and codes to request insurance reimbursement.
Step 4: Submit Your Superbills for Reimbursement
Submit superbills to your insurance provider based on their preferred method (online portal, fax, or mail). Keep track of submission deadlines and follow up if needed.
Step 5: Monitor Your Reimbursements
Once approved, your insurance company will send reimbursement checks or direct deposits. Keep a record of payments and track how much of your deductible has been met.
Step 6: Consider a Reimbursement Service like Mentaya
If handling claims feels overwhelming, consider using a service like Mentaya to simplify the process. Mentaya is designed specifically for therapy reimbursement, allowing you to quickly check your out-of-network benefits, automate claim submissions, and track reimbursements—all in one place. By using Mentaya, you can reduce the hassle of paperwork and get reimbursed faster, making it easier to focus on your mental health care. You can test out Hautz Counseling’s Benefits Calculator here.
Step 7: Use an HSA or FSA to Manage Costs
If you have a Health Savings Account (HSA) or Flexible Spending Account (FSA), you can use these pre-tax funds to pay for sessions, further reducing out-of-pocket costs.
Looking for a therapist?
By following these steps, you can make the most of your OON benefits while receiving the high-quality care that best supports your mental health journey.
If you’re looking for a therapist, you are welcome to explore Hautz Counseling’s speciality mental health services here.
