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. 

 

IN-NETWORK EVALUATION AND THERAPY SERVICES: 

Until October 15, 2019, we are credentialed and in-network with Blue Cross/Blue Shield of Oregon (BCBS of other states is billed through BCBS of Oregon) and PacificSource insurance plans. We will directly bill your insurance company. Any remaining balance will be the responsibility of the family and is due at the time of service. Starting January 1, 2020, a down payment of $2,500.00 for evaluations with balance due at the feedback session (testing is capped at $3,000.00, the initial diagnostic interview is a flat fee of $250.00, and the feedback session is $175.00 per hour, billed in 15 minute increments).  Additionally, $175.00 payment in full for each 50 minute therapy session will be required at time of service. A "superbill" will be provided at time of service to the family with all appropriate billing and diagnostic codes to facilitate potential direct reimbursement by your insurance company. 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.

 

As of August 1, 2019, 360 and its sole practitioners will no longer provide direct billing services for out-of-network insurance companies.

 

OUT-OF-NETWORK EVALUATION SERVICES FEES: 

For evaluations, a $2,500 down payment will be required at the initial diagnostic interview session with any remaining balance or credit due at time of feedback (when testing results and recommendations are made). Evaluation fees include a flat $250.00 diagnostic interview fee, testing fees at $175.00 per hour (billed in 30 minute increments), and a feedback session fee of $175.00 (billed in 15 minute increments after the first hour). Most evaluations total approximately $3,000.00, but can vary depending on the referral question and complexity of each child's case, their age, and history. 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. 

 

OUT-OF-NETWORK THERAPY FEES:

A payment of $175.00 in full will be required at time of service for each 50 minute therapy session. 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 no longer provides direct billing services, and we do not work directly with insurance companies other than submission of pre-authorization requests when required. 

 

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. 

MAKING PAYMENTS: 

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, and we provide a 5% discount to those who pay by check with full payment at the time of the diagnostic interview. 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, 50 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.