Guide for Using OON Benefits

Please note that clinicians at Sequence Services are out-of-network providers for all insurance carriers. You will get a statement (also called a “super bill”) for all services rendered, which you can submit to your insurance company for reimbursement. If your insurance includes out-of-network benefits, it may reimburse a portion of the fees. Use the guide below to find out your benefits from your insurance company.

PAYMENT

Please note that payment in full is required at the completion of each visit. Sequence Services accepts credit cards and debit cards.

GETTING YOUR OUT-OF-NETWORK BENEFITS INFORMATION

If you elect to seek reimbursement from your insurance company, it is your responsibility to contact your insurance plan to establish if you have out-of-network benefits, what you will be reimbursed if you do, and how to submit your claim(s) directly to your insurance plan.

Before you call, plan to have 15-30 minutes to complete the call. Have your insurance card, and the name, date of birth, address, phone number, and possibly social security number of the primary subscriber if it’s not you. Also, have a pen and paper/notepad.

Questions to ask:

1. Do I have mental or behavioral health coverage with out-of-network benefits?
2. What are the requirements to use the out-of-network benefits?
3. Is a prior authorization required?
4. Is a referral required from my primary care physician?
5. What is my out-of-network deductible, if any?
   1. How much of my out-of-network deductible has been met?
   2. What is the start date of the year for my out-of-network policy?

In addition, ask the representative if your policy covers these services (use the service codes provided below). How much is the insurance company’s “allowable fee,” and what percentage of that fee do they cover?

• Diagnostic Interview - Code 90791
• Individual Psychotherapy - Code 90837 (50-60 min) or 90834 (45 min) or 90832 ( <30 min)
• Family Therapy (primary client+) - Code 90847 or 90846
• Group Therapy-Code 90853

Other questions to ask:

• Is there a limit to the number of therapy session covered in my plan?
  • What is the session limit?
  • How many sessions do I have left?
• How can I access the required out-of-network claim form?

At the end of the call, make sure to have:

• Date/time you called
• Representative’s name
• Reference number for the call

Sequence Services will provide you with a statement (receipt) reflecting all the relevant codes and information, including charges, payments made by you, ICD-10 diagnostic codes, service codes, and your clinician’s Federal ID number. Occasionally certain forms of treatment, or a large number of sessions, require a prior authorization. If this is the case, Sequence may need to provide information about your diagnosis, history, and treatment plan to your insurance company. Once this information is provided, it will be subject to the privacy policies of the insurance provider.

COLLECTING REIMBURSEMENT

Generally, to collect directly from your health insurer, you need to do the following:

• Keep your receipts
• File for reimbursement – Complete the claim form provided by your insurance company, attach the superbill provided by Sequence to this form, and send these documents to your insurance company.
• On your claim form, leave the box regarding “assignment of benefits” COMPLETELY BLANK. This will ensure reimbursement is sent to you and not to Sequence.
• Always retain a copy of the claim form and superbill that you sent to the insurance company.