Navigating Mental Health and Substance Use Disorder Insurance

By Adonta Lee, A.A.

Finding out weeks, even months after your Mental Health (MH) or Substance Use Disorder (SUD) appointment, that you have an outstanding balance because your insurance company is not in-network with your provider or that you have a deductible, can be a financial hardship. Knowing what your particular insurance plan covers ahead of time can alleviate the unknown, claim denials, and balances that leave you, the policy holder, responsible for the payment. To know this, a simple phone call you to your insurance company will tell you what to expect and perhaps save unnecessary frustration.

By calling the member number on the back of your insurance card, you’ll be able to speak to a representative that will give you your specific plan coverage and benefit details.  Although it is rare since the implementation of the Mental Health Parity and Addiction Equity Act and also the Affordable Care Act, there are some instances when an insurance plan has no MH or SUD benefits. If your plan fell into this category, it could leave you responsible for paying out of pocket so it is important to know your benefits up front.  When you call you will need to have basic information including the insureds’ name, date of birth, address, subscriber ID number, etc., to get the process started. The benefits that you should be prepared to write down are in-network, out-patient MH and SUD benefits. This will consist of deductible amount and the accumulation of, copay, co-insurance, and out of pocket amount, and if there are any visit limits or authorizations required. You will want to know the same for out of network providers as well.  This may or may not come in handy, but to know is better than not knowing. When using out of network benefits, you should confirm with your provider if he/she will agree to those benefits. Out of network benefits usually consist of a higher deductible and co-insurance.

One tricky secret to insurance companies is that sometimes, they may send (“carve out”) your MH and SUD benefits to another company. Since that company would manage those benefits, paying for all or part of the MH and SUD service, it is vital to make sure your provider is in network with that company, if they are in fact sent to another company. This is tricky because if you don’t ask they won’t tell. Thus, the importance of calling and finding out everything you can before your appointment.

After you have had your MH or SUD appointment, your claim will be filed to your insurance company. Once received, the claim will be reviewed then processed according to what your plan covers and that specific provider’s contracted agreement. If you have a deductible, you will have to meet that amount in order for your copay to go into effect. After you meet your deductible, your copay or co-insurance will depend on how much the insurance company pays according to the provider’s contracted agreement, leaving the remainder of the copay due by the patient or parent/guardian. Once you reach your out of pocket maximum, the accumulation of copay, co-insurance, and deductible, but not your monthly premiums, your sessions will be covered at 100%.

For every appointment or session, the policy holder should receive an EOB (explanation of benefits) from the insurance company; your provider will as well. The EOB provides the financial details of a date of service. It might include, but is not limited to information like: date of service, billed amount, allowed amount, session code, session type, amount paid to provider, patient responsibility, and denial reason.

A claim could be denied for various reasons such as: typos, insufficient secondary insurance information, non-covered services, lapse of coverage, etc.  If a claim date of service is denied, however, if it was billed correctly by your provider to the insurance company, you the policy holder can reprocess that claim. Members can reprocess a claim date of service by calling the number on the back of the card, providing the same basic information as the verification, and speaking to a claims representative, informing them of the situation. However, if in fact, there is a discrepancy, and the claim was filed incorrectly, either the policy holder will need to rectify the issue or the provider’s office will need to send a corrected claim. Reference numbers are available for every call to the insurance company, providing proof of what transpired during the phone call.

Insurance can be tricky, so calling ahead of the appointment and finding out what your MH and SUD benefits are, can be beneficial and reassuring, allowing you to focus on the appointment itself! We will help you navigate your benefits when you are seen by one of the professionals at Behavioral Healthcare Associates, LLC. Please give us a call for your mental health and substance use disorder needs at 

919-292-1464 or look us up on our website