Medical Insurance FAQ

Insurance is confusing and complicated! To help you get the most out of your benefits, we’ve created a list of terms and provided answers to the most frequently asked questions about medical insurance. See below for answers to our most common questions regarding the use of mental health and behavioral health benefits from your health insurance provider.

Terms to know

INN (In-network) - If your provider is “in-network” with your insurance company, it means that both your provider and insurance company have signed a contract stating that they will pay the provider and decided on an “allowed amount” that the insurance company is willing to pay the provider.
OON (Out-of-network) - If your provider is out-of-network with your insurance plan, your provider does not have a contract with your health insurance plan provider. Some insurance plans offer out of network benefits, and may reimburse the client for out-of-network visits.
Deductible - is the amount of money that you need to pay out of pocket before your insurance begins to provide coverage.
Example: If you have a deductible of $1000, you are responsible to pay for the full rate for each visit until you have reached the $1000 limit. Once the deductible is reached, you are only responsible for your co-insurance or copayment amount.
Co-Insurance: is a percentage of the total amount due for your visit that you are responsible for paying.
Example: If you have a 20% co-insurance, you are responsible for 20% of the total amount for your visit. If your provider charges $100 per visit, you will need to pay $20 per visit. Your insurance company is responsible for 80% of the visit cost.
Out of pocket max/limit: This is the maximum amount you are required to pay for all of your health visits. After the deductible and co-insurance payments reach the out of pocket limit, your insurance company will likely pay for your visits in full.
Example: You have been paying a $50 co-pay per visit until you have reached your out of pocket maximum of $2000. Now your insurance company is paying for your visits in full and you owe $0 per visit.
Co-Pay: This is the amount that you owe per visit as decided by your insurance company.
Example: Your insurance company let the provider know that you have a $10 co-pay per visit. This means you will need to pay the provider $10 per visit, and the insurance company will pick up the remainder of the cost.
Premium: This is the fee you pay monthly/bi-weekly (usually out of your paycheck through your employer) to keep your insurance coverage active.
Example: Your employer takes $100 out of each paycheck to cover your insurance premium cost.
Claim: This is what the provider/front office sends to your insurance company to let them know what service was performed, when, and how much is due.
Example: Once your visit was complete, your provider sent a claim electronically to your insurance company letting them know $100 was due for the visit. The insurance company either approves and sends payment for the visit, or denies the claim/does not send payment.
HMO: Stands for “Health Maintenance Organization” and is a type of health insurance plan that usually limits coverage to care from doctors who work for or contract with the HMO. It generally won't cover out-of-network care.
PPO: Stands for “Preferred Provider Organization” and tend to have higher monthly premiums in exchange for the flexibility to use providers both in and out of network without a referral.

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How do I get a summary of my benefits?
How do I know if the services offered by Chicago Counseling are covered?
What is my co-pay going to be?

When you enroll in our client portal and fill out your new client documentation, there will be a place to enter your insurance benefits. You will need your insurance card nearby during this process so you can locate your Member ID and Group # (see below for instructions on how to locate those numbers). Once all of your documentation has been completed, our front office team will verify your insurance plan with your insurance carrier. Your insurance carrier will report to use how much they will cover for visits with our providers. This can vary due to the specific plan, and contract you have with your insurance carrier. This amount also changes per service and per office/provider (see above to learn about in-network providers vs out of network providers). Our front office team will inform you of the cost per visit via a client portal message before your first visit occurs (usually within 24 hours after you finish your new client documentation).

If you are looking for a general summary of all your benefits (not just for our specific office), you can contact your insurance company by calling the member services phone number on the back of your card.

What does it mean when my insurance company denies a claim?

There could be many reasons why your insurance company denied your claim. The most common reasons include: non-payment of your premium, employment change (plan termination), the service is not covered under your plan, or a mistake on behalf of your insurance company.

The best way to resolve a denied claim is to call your insurance carrier (at the member services number on the back of your insurance card) and ask them why the claim has been denied. There have been many occasions where the claim was denied by mistake, and payment was later received from the insurance carrier.

When a claim is denied, the remaining billable amount for the service is your responsibility as the client. If payment is received from your insurance carrier in the future, the front office will credit your account and a refund can be issued by request.

When an insurance claim is denied, our front office always double checks the claim for any mistakes on our end and will resubmit the claim if any mistakes are found.

How does out-of-network coverage work?

See the definition of out-of-network coverage above. As a courtesy, our office will submit out of network claims on behalf of our clients. Some plans offer out-of-network coverage, and may reimburse you for your visits.

Payment can’t be guaranteed because we do not have a contract with your out-of-network carrier. You can ask your insurance company about your out-of-network coverage by calling the member services number on the back of your insurance card.

How will I get reimbursed from my out-of-network insurance company?

All checks from your out-of-network insurance carrier should be sent directly to you as the insured client. Any checks sent to Chicago Counseling will be marked as VOID and a letter will be sent to the carrier requesting that payment is sent to the client instead.

What does my insurance mean by “Medical Necessity”?

Insurance companies operate on a “medical necessity” requirement. Unfortunately, this is a universal insurance concept that can complicate care. Insurance companies require that the named insured must:

• Attend a Diagnostic Intake session

• Qualify for a mental health disorder diagnosis

• Attend sessions for the purpose of treating that diagnosis

• Give permission for insurance companies to obtain any created medical records

Due to the medical model used by insurance companies, we are not able to bill your insurance for parent coaching services, life coaching services, or couples counseling where the focus is on the relationship not on an individual’s clinical treatment

Please be wary of counseling, psychotherapy, and psychological services that do not disclose this information to you. If you are using your health insurance, a diagnosis has been made and placed on your medical record. A practice billing for inappropriate services can result in costly clawbacks and unexpected bills in the hundreds and sometimes thousands. It is our goal to make this as transparent and clear as possible

Will my insurance cover my psychiatrist or other provider (psych testing, psychiatry, ADHD Coach, etc)?

With every insurance company, coverage varies for each office and provider. You will want to ask this new provider if they are in-network with your insurance company first (learn about in-network vs out-of-network above). Then, you can ask the new provider/office to provide you with a quote, or you can call your insurance carrier by calling the member services number on the back of your card and ask them to provide you with a quote for that specific provider/service. Although we try our best to refer our clients to an in-network provider (or most affordable option), Chicago Counseling has no way of knowing what your cost will be for an outside office/provider.

How do I find my member ID and Group #?

Please refer to the image below to help you locate your member ID and Group #.

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