Billing basics
How to check out-of-network benefits (script for parents)
Before a family commits to private-pay therapy, a ten-minute call to their insurer answers whether they will get money back. Give them this script.
The call: who and what
Parents call the member services number on the back of the insurance card and ask for out-of-network benefits for outpatient therapy services. Have the child's member ID, the provider's NPI, and the likely CPT codes ready (your practice can supply these).
Step 1
Confirm OON benefits exist
“Does my plan include out-of-network benefits for outpatient [speech / occupational / physical / behavioral] therapy?” HMO and EPO plans often have none — better to know now.
Step 2
Ask about the OON deductible
“What is my out-of-network deductible, and how much of it have I met this year?” Reimbursement starts only after the deductible is met.
Step 3
Ask about coinsurance and allowed amounts
“After the deductible, what percentage do you reimburse, and is it based on billed charges or an allowed amount?” Plans often pay 50–80% of an internal ‘allowed amount’ that can be lower than the therapist's fee.
Step 4
Check visit limits and diagnosis rules
“Are there visit limits per year for these CPT codes? Do you require preauthorization or exclude any diagnoses?” Some plans exclude developmental diagnoses — ask directly.
Step 5
Confirm the claim process
“How do I submit claims — is there a member reimbursement form? What is the timely filing deadline?” Write down the answers and a reference number for the call.
What the answers mean
- High OON deductible + low usage → little reimbursement early in the year; families should still submit every superbill so charges count toward the deductible
- ‘Allowed amount’ far below the fee → reimbursement percentage applies to the lower number; set expectations
- No OON benefits at all → superbills still matter for HSA/FSA substantiation and taxes
FAQ
What CPT codes should parents mention on the call?
The codes the practice actually bills — for example 92507 for speech treatment, 97530 for OT treatment, 97110/97112 for PT, or 97153 for ABA. The practice should provide these before the call.
What is a gap exception?
If no in-network provider offers the needed specialty nearby, families can request a network gap exception so out-of-network care is processed at in-network rates. It requires a request before starting care in most plans.
More practice guides
Educational content only — not billing, legal, or tax advice. Verify payer policies and regulations for your state and situation.