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Regarding Insurance Benefits

I am an out-of-network provider for all insurance plans.  This means that I do not file a claim against your insurance, but you can file on your own behalf.  I can help you navigate through this process.  It is actually very easy.  The field of mental health is more and more going towards this model for good reason.  Here are several reasons I do not participate as an in-network provider. 

Confidentiality
When your insurance pays out towards your care they have access to personal information regarding your treatment.  These may include, but are not limited to, your current symptoms, issues you are discussing, my subjective diagnosis of your case, your prognosis, and any other information that they may need to evaluate your case.

Authorizations and Over-diagnosis
It takes a great deal of time for me to communicate with your insurance provider.  Authorization is the process by which the company approves your ongoing care from any practitioner.  While physical health is a bit more easily determined, mental health benefits are up to the discretion of the case manager who reviews your information at the insurance company.

In order to provide services to those in need many practitioners over diagnose a patient in order to provide, from the best motive, the care the practitioner believes is best. 

When the insurance company is eliminated I get to devote more time to your case rather than waiting on the phone for an hour to authorize your visits, your diagnosis is kept confidential for only you and for me, and I do not have to hire an additional staff person which would escalate my rates.

Payments
Your insurance company is more interested in keeping you happy than keeping me happy.  Therefore the process of getting paid is completely different.  Given this situation it is not in my best interest to participate in this way.  However, I want you to get benefit from your insurance. 

I will provide you a receipt which can be forwarded to your carrier with an additional form for processing.  You will then receive a check for the portion of my fee that is paid by your plan.  This amount will vary from around 40% up to 70% depending on your specific plan.  Any additional information to your carrier will be by your authorization only.  Just contact me for any assistance with this process.
 

Instructions for Submitting an Out-of-Network Claim 

Call the customer service number for Mental Health and Substance Abuse Claims (NOT Medical Claims) and get information on where to send the information for processing and what they need to be included with the fee receipt we provided for you.  Generally you will have to give them your member number and group number.  Clarify what they need so that it does not delay the processing of your claim.  Any questions can be cleared up at this step.  This is a very common procedure for the insurance company and will be easy once you know where and how to send this in to your carrier.

Note that if you do not route your claim correctly through the Mental Health and Substance Abuse channel then you will have to correct this to get your claim covered.

I have provided everything on the fee receipt that is required of our office.  Most insurance companies have already dealt with my office and have it on file.  If a company does not have us on file then I can provide any additional information to them to expedite the processing of your claim.  Please let me know as soon as possible if you need my assistance. 

If clinical information is to be shared with your insurance provider, outside of the fee receipt, I will ask for a release of information from you.  Please alert me to fill out a release of information form so that this can be on file should there be future questions.

Many of my patients use this coverage to pay for a portion of their therapy costs and it is my experience that these claims are paid quickly and as appropriately billed given your condition and the procedures performed.

If you have questions please do not hesitate to contact the office.

Copyright © 2009. Beau A. Nelson, MA, LCSW Counseling and Psychotherapy. All rights reserved.