KNOW YOUR BENEFITS
Giving the gift of an evaluation or therapy to your child can be a life changing experience that may help your child or teen thrive to the best of their abilities in every aspect of their lives. An evaluation requires a significant investment of time and finances, therefore it is important to understand the resources that are available to you. Prior to coming to your initial diagnostic interview, you should be familiar with your insurance plan benefits by calling your insurance company directly. Use the insurance questions outlined below when talking with your insurance company to help you to fully understand your benefits and avoid any surprises. By following this guide, you will help facilitate a smooth evaluation and/or therapy process for your child or teen.
EVALUATION SERVICES and FEES:
Clinicians at 360 accept a down payment of $2,800.00 for evaluations with any remaining balance due at the feedback session (when testing results and recommendations are discussed.) Please note that testing costs vary and may be more or less depending on the scope of the evaluation, presenting concerns, time spent reviewing records, and the age of your child. A “superbill” will be provided at the feedback session, which will include all appropriate diagnostic and billing codes for direct submission by the patient family to their insurance company, and potential direct partial reimbursement by the insurance company to the patient family depending on specific plan benefits. Please be aware that many insurance companies require pre-authorization prior to testing. If this is the case, you will need to bring a hard copy of the pre-authorization form with the submission fax number to the diagnostic interview. Most pre-authorizations decisions are made within one week, and the outcome (granting or denial of coverage) is between you and your insurance company. 360 and its sole practitioners do not participate in appeal of decisions or any other negotiations with insurance companies.
A payment of $225.00 in full will be required at time of service for each 52 minute therapy session. We also offer 45 minute therapy sessions for patients whose insurance companies reimburse shorter sessions. 45-minute therapy sessions are billed at $215.00. Each practitioner will provide a “superbill” with appropriate diagnostic and billing codes to facilitate potential direct reimbursement to the patient family by their insurance company. It is critical that you work with your insurance company directly to understand potential reimbursement and pre-authorization requirements as 360 does not provide direct billing services, and we do not work directly with insurance companies other than submission of pre-authorization requests when required. It will be important to call your insurance company and to know your benefits prior to the diagnostic interview, as some insurance companies require pre-authorization for services.
OREGON HEALTH PLAN/MEDICARE/MEDICAID:
We do not accept OHP, Medicaid or Medicare patients, and we cannot accept cash payments from these patient families except under certain circumstances for evaluations only per OHP, Medicaid, and/or Medicare guidelines. These evaluations will be approved/denied on a case by case basis by each practitioner. 360 Pediatric Psychology, PC, and the sole practitioners will not file claims for Medicare or Medicaid and you will not be eligible to independently file claims for the services that we provide, ANY BENEFITS THAT YOU WOULD NORMALLY RECEIVE THROUGH THESE PLANS WILL BE FORFEITED IN THE EVENT THAT YOUR CASE IS APPROVED FOR CASH PAYMENT.
While many patients are successful in seeking reimbursement for a portion of the fees, reimbursement is considered a matter between you and your insurance company. We accept credit cards or checks. If a credit is due to the patient family, it will be made at the time of the feedback session. You may also use funds from your health savings or flex account to pay for services. If insurance does not cover psychological services, then you may be eligible to deduct the cost of services on your tax return as a health-related expense. (Please consult your accountant or tax return adviser for specific guidelines).
Determining your out-of-network mental health coverage
Call your insurance carrier by calling the number on the back of your card listed for mental health. Check your coverage carefully and find answers to the following questions:
- Do I have “out-of-network” mental health benefits?
- IS PRE-AUTHORIZATION REQUIRED, & IF SO, WILL YOU PLEASE EMAIL ME THE PRE-AUTHORIZATION FORM?
- If pre-authorization is required, what is the fax number for submission of my request? Is there a name or department to which the fax should be directed?
- Is there a deductible that must be met first and how much is my deductible?
- What is the coverage amount for evaluation and therapy sessions? (Usually the insurance company reimburses a percentage of what it has deemed “usual and customary”). Typical CPT codes (updated as of July 8th, 2019) used would include:
- 90791: Psychiatric diagnostic interview
- 90837: Psychotherapy, 52 minutes with patient and/or family member
- 90834: Psychotherapy, 45 minutes with patient and/or family member
- 96136: Psychological Testing (including Neurodevelopmental or psychoeducational testing), 1st 30 minutes by licensed psychologist.
- 96137: Remainder of Psychological Testing hours, billed in 30 minute increments.
- 96132 & 96133: Neuropsychological Testing (for medical health problems such as chronic medical illness/concussions/epilepsy) for neuropsychological testing services by licensed psychologist
- 96130 & 96131: Psychological Evaluation Services (including test selection, test results interpretation, report writing and feedback.
- How many therapy sessions does my plan cover?
- Is referral required from my primary care physician?
- What is the process for getting directly reimbursed for out of network services?
- For therapy related to medical concerns, ask whether the insurance company covers Health and Behavior Codes, which may be filed under the medical portion of your insurance.
Depending on your plan, there may be out-of-network benefits that are comparable to in-network benefits.
Our professional fees vary according to the service provided and are based on standard regional psychotherapy and assessment rates. All payments are due at the time of service, which we will request to take via credit card, HSA card or check.
Please note that we will provide “superbills” with all appropriate diagnostic and billing codes for direct submission by patient families to their insurance companies. 360 Pediatric Psychology and its sole practitioners do not provide direct billing services to out-of-network insurance companies. For evaluations, we ask patient families to pay a deposit of $2,800 (down payment) at the diagnostic interview, and any remaining balance or credit is due at the feedback session with hourly rates set at $225.00 per hour after the initial intake/diagnostic interview (which is charged at $295.00 for up to 90 minutes). Therapy payments are due in full at the time of service. We bill $295 for the initial diagnostic interview and $225.00 per 52 minute therapy session thereafter.
- The initial appointment (30-90 minute clinical diagnostic interview) is billed at a flat rate of $295. This includes diagnostic formulation, review of records, and written documentation of the visit prior to the start of testing or therapy.
- We work in collaboration with a network of providers to provide support therapy to facilitate therapy services.
- Assessment or testing sessions are billed at a base rate of $225.00 per hour, billed in 30 minute increments with additional hours billed outside of session for scoring, interpretation, diagnostic formulation, report writing and feedback. Evaluations require psychologists to spend significant time both inside and outside of sessions with test selection, record requests and review, test administration, consulting, scoring, interpreting, and writing up results in a comprehensive report. The feedback session is scheduled within the next week to explain the evaluation results to families. A comprehensive report is delivered to the family as well as the child’s pediatrician (with parental consent) at the time of feedback as time allows. The patient family is responsible for delivering a copy of the report directly to the school. We offer short (10 minutes or less) consultations at no charge with other significant care providers in your child’s life. If the parent chooses to schedule a school meeting, an hourly rate of $225.00 including preparation time, drive time (to and from the meeting) and meeting time will be charged to the parents. This service is not covered by insurance, and patient families are responsible for the cost of the entire school visit at the time of service.
- No Shows and Cancellations 360 and its sole practitioners strive to accommodate our families in a reasonable amount of time. *Without 24-hours notice cancellation for therapy sessions, you will be subject to a full rate charge of $225 for a 52-minute missed appointment fee. If you miss an evaluation appointment, you will be charged the full rate of however many hours were scheduled for your appointment that day.* Many times evaluation appointments are 3-4 hours in length. Late Charges due to frequent tardiness or late cancellations may be assessed at the clinician’s discretion.
- Phone calls to patients or school staff, physicians, etc., lasting longer than 10 minutes will incur charges prorated in 5-minute increments at the base rate for therapy sessions (i.e., $225 for 50 minutes).* There is no charge for brief contacts lasting less than 10 minutes or calls related to scheduling or therapy homework purposes (e.g., pre-arranged check-in calls, clarification of therapy assignments). A clinician may bill for after-hours emergency services at the full clinical rate, regardless of method of communication.
*Please note these charges are rarely reimbursed by insurance.
For families seeking reimbursement from their insurance carrier, we can provide a “superbill” that families may submit to their insurance company. While we are considered “out-of-network” providers, families may receive partial reimbursement based on their plan’s mental health benefits. Your insurance will be responsible for potential direct partial reimbursement to you based on your out-of-network benefits, and reconciliation of your child’s account is made at the final feedback session with any outstanding payment or credit due at that time. Returned checks or charges will incur an additional $35.00 fee, and ongoing unpaid balances may incur interest and/or collections charges.
NOTE: It is critical that you contact your insurance company using the phone number on your member card to understand your estimated benefits based on your individual plan. Please visit our “Using Insurance” tab under “Financial Policies” on our website to obtain a useful list of questions for your insurance company. Please be aware that some insurance companies require pre-authorization prior to testing or treatment, you are responsible for requesting the pre-authorization forms and getting them to your clinician at least one to two weeks prior to your first appointment.
Note for children & teens of divorced/separated parents: The parent who brings the child or teen is responsible for payment as specified above at the time of service. If the child attends a session without a parent, payment will need to be sent with the child (via check or cash) or a credit card kept on file. In the case of separated or divorced parents where one parent is court-ordered to pay for services, a copy of this document (in its entirety) is required before this information can be used. Also in cases of separation/divorce where both parents have legal custody, both parents are required to sign the Separated/Divorced Parents Consent, or for the non-present parent to provide written consent or written confirmation of knowledge of treatment or assessment being provided to their child or teen.
You might ask… Why would I go to a provider out-of-network with my insurance, when I can go to an in-network provider?
- 360 Pediatric Psychology and its sole practitioners strive to provide a comprehensive, personalized experience to each family in which every aspect of the child’s life is taken into consideration. Our clinicians reach out to medical care providers, teachers, coaches and parents to provide 360-degree assessment and treatment for your child. We offer a fast, concierge approach without the additional fees, as we understand diagnosis and treatment can be overwhelming to families.
- Some problems or concerns may not be covered by your insurance. Learning disorder evaluations are often not covered by insurance.
- Your insurance company’s preferred provider might not be your preferred provider. Insurance companies are increasingly dictating the tests provided and restricting the number of hours/sessions allowed, which in the case of assessments, can render more of a screening approach to the evaluation and an abbreviated final report which may or may not give a complete picture of your child’s strengths and challenges, or answer your questions in full.
- Additionally, many providers have long wait lists; 360 strives to schedule our patients in a timely manner and to complete evaluation services within a 1-to-2 week timeframe with full participation of parents, educators and caregivers.
- Your out-of-pocket costs might be similar to in-network costs, and the end product (extent of evaluation) may be abbreviated in comparison to a self-pay evaluation with direct reimbursement. You should work with your insurance company’s customer service department to help determine if this is the case with your estimated benefits.
- Paying out of pocket is the most confidential way to have your child assessed, diagnosed and treated.
- 360 Pediatric Psychology goes above and beyond to provide the most comprehensive diagnosis and recommendations possible for your child using state-of-the art testing tools.