Introduction:
I hear a lot of people (legitimately) complain about the cost of psychotherapy. However, there is a subset of these folks that have great insurance that allows them to be either partially or fully reimbursed for sessions outside their network. Because the paperwork can be a deterrent to seeking therapy, and because it can simply be confusing, I decided to create an informational post about how to submit paperwork for out-of-network claims with a focus on psychotherapy. By the end of this post, you should have the information you need to bill your insurance company for your psychotherapy. Any feedback or questions would be of great help to make this the most user-friendly and informative content on the topic out there. Be sure to read or skim all the way to the end for the additional resources.
Getting Started:
As a first step, the name and address of your insurance’s claims department must be printed or typed into the upper right hand corner of the CMS-1500. The example below is the address for medicare/medicaid claims. Links to forms with major insurance companies’ addresses pre-printed on the form can be found at the bottom of the Links & Resources page.
Field 1:
Though not technically mandatory, checking the box of the relevant public/private insurance types is helpful in getting a claim processed quickly. If you are unsure which box to tick, leave this field blank. However, in most cases “Group Health Plan” is the relevant category.
Field 1a:
This is a required field. Patient’s ID number (in case of a child, child’s unique ID number is entered here); the patient’s name also goes in field 4. Guardian/Guarantor’s name is no longer used. In the case of children, the child’s information/ID number should be entered.
Shown below, your Policy ID number can be found on your insurance card.
Fields 2-5:
These fields must be completed for the claim to be processed. Simply enter your name and address in the relevant fields. Phone number is the only field in this cluster that may be left blank.
Field 6 (seen above):
Check “Self;” every individual covered by the insurance plan should have his/her own unique ID number–even if the patient is a spouse or child of the primary policy holder.
Field 10:
This field is required and simply requires responses to three “yes” or “no” questions. No is usually the answer to all three, especially when it comes to psychotherapy. In some cases, such as an adjustment disorder diagnosis as well as PTSD and other acute stress disorders, it may be relevant to answer “yes” on one or more of these. However, unless there is a special need to indicate that a diagnosis is related to employment, a car accident, or other life stressor, answering “No” to all three questions will typically suffice.
Field 11:
In this set of fields, only 11d requires an answer. You will answer “No” unless you are covered by multiple insurance plans.
Field 12 (HIPPA release) & 13 (Authorization to pay provider):
The typical scenario in psychotherapy when Out-of-Network Benefits are involved is that the patient pays up front and submits a claim for (partial) reimbursement. If this description fits your arrangement with your therapist, then you need not sign either line 12 or 13. If signed, the check and explanation of benefits goes to your therapist. When it is not signed, those items will be sent to you.
N.B.:
- For providers submitting claims on behalf of their patients, you may have patients sign an authorization form at the beginning of treatment and write “signature on file” in both fields.
- Date of signature must be within one calendar year of the date(s) of service for which you seek reimbursement.
Field 19:
Not mandatory. This field is used when re-submitting a rejected claim. Use this line to indicate what was corrected for resubmission. You may write something like: “Correcting lack of provider NPI number” to alert the reviewer of the changes you made.
Field 20:
This is a required field that is almost always simple to deal with. For psychotherapy, this will always be “No”. In rare cases, psychiatrists may bill for outside labs for the purpose of monitoring medications. Otherwise, just check “No”.
Field 21:
All claims for services rendered should include a formal diagnostic code which should appear on an invoice provided by your therapist. There may be several diagnoses listed, but most therapists are conservative with diagnoses and will likely only bill for one. The format of the diagnostic code follows the ICD-10 (An international book containing medical diagnoses and their billing codes) format which takes the following form: F##.# or F##.##. For example, Major Depressive Disorder, Recurring, Moderate = “F33.1”
N.B.:
- The primary diagnosis goes in field A
- Only diagnoses overseen by the provider should be included (in most cases the primary diagnosis is sufficient). That is, a psychotherapist would not include medical diagnoses that have nothing to do with mental health and for which the services are not relevant.
Field 24:
This field contains 6 Rows and 11 columns; all but three columns must be completed for the claim to be processed.
Each row represents a billable encounter. For weekly psychotherapy, one form is sufficient for monthly reimbursement. For more frequent sessions (e.g., 2 times per week) you must complete multiple forms per month.
A. For date of service, from and to dates will be the same for individual psychotherapy (dates are different only for inpatient hospitalizations)
B. Place of service is a numeric code arbitrarily assigned to a type of setting. Office/Clinic is nearly always the setting of psychotherapy. “11” is the code to use in the case of seeing a psychotherapist in private practice or in an outpatient clinic setting. Exceptions could include “03” for school or “12” for home-based psychotherapy. Other setting codes are listed below:
C. Not Mandatory
D. CPT/HCPCS. The standard form for submitting claims (i.e., the form I am currently explaining) is sometimes referred to by insurance folks as a “hicpic” form (i.e. HCPCS form). HCPCS stands for “Healthcare Common Procedure Coding System”, while CPT stands for “Current Procedural Terminology.” Put simply, every visit with a healthcare provider is assigned a numeric label according to what the provider does with/for you. For psychotherapy, you are most likely to see the code “90834” for individual psychotherapy, 45-minutes in duration. When meeting with a psychologist, other possible codes are:
90791 – Diagnostic Interview (no medical services)
90792 – Diagnostic Interview (prescribers/with medical services)
90832 – Individual Psychotherapy (30 minutes)
90837 – Individual Psychotherapy (60 minutes)
90847 – Family Psychotherapy (Patient Present)
90853 – Group Psychotherapy
96101 – Psychological Testing (hourly)
96118 – Neuropsychological Testing (hourly)
The appropriate service code(s) should be included and appropriately itemized on any invoice you receive from your therapist. Modifiers are sometimes relevant, but will be provided to you when necessary. In most cases, the modifier portion of column D should be left blank.
E. Diagnosis pointer refers back to field 21. When there is only a primary diagnosis in Field 21, “1” will be entered into column E. In short, you will enter either 1,2,3, or 4 (or some combination of these numbers) to indicate which diagnosis/diagnoses is the one your therapist is treating. Using a number saves the trouble of squeezing long diagnostic codes into small boxes.
F. Charges – Enter the total cost for a particular encounter or set of encounters listed on your statement. If you are being billed for one session of individual psychotherapy (45 minutes), or “90834”, then this charge would be the provider’s hourly rate (45 minutes is typically considered to be an hour to psychotherapists). If it contains three sessions of the same service, simply sum the three rows of charges to get a total.
G. Days/Units – For most psychotherapy encounters, this will simply be “1”. The exception here would be psychological/neuropsychologcial testing, where multiple hourly units may be billed for one encounter. For example, “96101” is the CPT code for 1 hour of psychological testing.
Psychologists will often devote between 2-4 hours per session of testing. If you spent 4 hours with a psychologist for testing, and the provider’s fee is $100 per hour, then Charges (column F) would be $400 and Days/Units (Column G) would be “4”.
N.B.
In reality, testing consists of more units/charges than what you spend face to face with the provider. Testing requires a great deal of labor outside of face-to-face encounters. So don’t be alarmed if your invoice contains more “units” of 1 hour increments than the face-to-face time. Of course, you should ask for an explanation if the number seems curiously high.
H. Not Mandatory
I. Not Mandatory
J. NPI number: The provider of the services for which you seek reimbursement will have a distinct number that should be included in this column. For more information about NPI’s and the function they serve, click here. This number should be provided on any invoice and can be obtained directly from your provider when absent on an invoice. When not included on an invoice, NPI’s are public information and can thus be found by searching online here.
N.B.:
In rare cases where multiple NPI’s are linked to the same row in field 24, separate forms need to be filled out for each NPI number. If you received services from one provider, you can ignore this and need not confuse yourself unnecessarily.
Field 25:
This is a required field where you must enter either the Tax ID/Employer Identification Number (EIN) or Social Security Number (SSN) of your provider. While your provider, if in private practice and operating as a sole proprietor, can use their SSN here, they are unlikely to do so. Most providers/organizations have an EIN that should be included on the invoice you receive.
N.B.:
In most cases, Tax I.D. numbers are privately held and are not available to the public. This means your doctor/therapist needs to give it to you–typically written on the invoice. The exception is if the therapist is providing the service as a representative of a publically-traded company, in which case you can also find the EIN by searching here.
Field 26:
This is a code–letters, numbers, or some combination of the two–that is assigned by your provider. While I have had claims processed without this information, strictly speaking, this field should be populated. You may ask your provider for this, check your invoice for a relevant value. Hospitals will assign medical record numbers, which may be entered here. For private practitioners, Date of Birth (D.O.B.) is a value used to match records with the patient. If you cannot find a relevant value when completing a claim for services from a private practitioner, I suggest simply entering an 8-digit date of birth “code” (e.g., if you were born on October 7th, 1970, you could write “10071970” or “19701007.” You could also make something else up. The point is, fill this in, but don’t stress about it.
Field 27:
Not Mandatory
Field 28:
This is a mandatory field. Simply sum all of the charges in Field 24, column F, from rows 1-6.
N.B.
This is also a good place to reiterate that for twice-weekly, thrice-weekly, etc. psychotherapy and more frequent encounters, one form is not sufficient for a one-month billing cycle. A second or third form may be needed, each one treated as its own entity when summing charges. I like to keep a template on file with basic information already entered (e.g., fields 1-5) to make completing multiple forms more efficient.
Field 29:
You are required here to enter the amount paid. So as not to fuss over this I recommend the following basic system:
- If your provider is an in-network provider and collects a co-pay from you, enter the sum of co-pays that you have given to your therapist.
- If your provider is receiving Out-of-Network Benefit checks (i.e., you are signing lines 12 & 13), I suggest simply entering “$0.00” here.
- In the most common scenario, where you are paying your therapist’s full fee out of pocket, of course you will sum the charges from each encounter for which you have paid.
Field 30:
For “Balance Due,” you are required to subtract the number entered in Field 29 from the number entered in Field 28 (i.e., Total Charges – Amount Paid = Field 30).
Field 31:
Enter name and credentials of the provider, as well as the date of completing claim. A signature from the provider is not necessary.
Field 32:
Not Mandatory
Field 33:
In this field, you are required to enter your therapist’s name, address, phone number, and NPI number (Field 33a). For private practitioner providers, this will be your psychotherapist’s info. For clinics and/or group practices/mental health collectives, the organization may have its own distinct information, NPI number. This is the field that tells the insurance companies where the reimbursement and explanation of benefits will be sent. Determine whether this will go to a private practice office, to a clinic administrator, or some other location.
Conclusion:
The CMS-1500 looks daunting in the beginning, but can be straightforward to complete with a little guidance. What’s great is that once you’ve successfully done it once, you can repeat as many times as needed. Be sure to check out the additional links and resources at the end of this post.
If you would like clarification on any of the above explanations, or have other questions/comments about submitting out-of-network claims, reach out to me here. I will either reply with further clarification or answer your question in a new post. If you found this article helpful, subscribe below and you will never miss a new post or resource published here. Cheers!
Resources:
Fillable, Blank CMS 1500 Form (can be used to submit claims for nearly all insurance companies).
Required Fields Checklist to help track whether you have neglected any mandatory fields
Sample Completed Claim Form that (mostly) coincides with the information presented here
Video providing similar information on how to complete the CMS 1500 can be found here.
Other Insurance-Related Links:
NAMI: Understanding Health Insurance
Empire/Anthem/BCBS Insurance Claim Form
GHI/Emblem Insurance Claim Form