In today’s insurance environment, clients and their families have an increased responsibility for working with their insurance carriers, specifically with regard to their mental health coverage (also referred to as behavioral health coverage). The following is designed to help you understand CRG’s billing and insurance procedures while at the same time providing information that will assist you in understanding your individual insurance plan.
Most services at CRG are considered mental health services. Insurance coverage for mental health services is often different than coverage for medical services; therefore, we recommend you contact your insurance carrier to verify your mental health benefits prior to coming to our office.
When checking your benefits, it is important to note that most of CRG’s clinicians are participating providers with the Sagamore Provider Health only. If your insurance carrier provides mental health coverage through Sagamore, you are considered in network and should receive the in-network benefits for covered services outlined in your policy. CRG will collect copayments, deductibles and coinsurance amounts at the time of service and will file the charge balances with your insurance carrier. Any unpaid amounts will then be billed to you for payment.
If your mental health coverage is not through Sagamore, you are considered out of network. We expect full payment at the time of service from our out-of-network families; then we will submit claims to your insurance carrier as a courtesy to you and your family. If you have out-of-network benefits, you should receive reimbursement for services directly from your insurance carrier.
Insurance carriers sometimes have specific requirements that must be satisfied before benefits are administered (such as prior authorization for services). It is important for you to determine what steps need to be taken to ensure you satisfy your carrier’s requirements. CRG is happy to assist you with meeting policy requirements; however, payment for services is ultimately the responsibility of the financially responsible party, not your insurance company.
Checking Your Benefits
We recognize that the current insurance environment is complex, especially when it comes to mental health. We hope that the following points will assist you when checking on your plan’s coverage:
- The Sagamore Provider Health Network is in network. All other provider networks are out of network.
- CRG’s speech/language and educational services are out of network, even with Sagamore.
- Please note that some insurance plans have separate mental health coverage through another carrier or network. If this is the case with your plan, the name and contact information for your mental health carrier should be included in your policy handbook and on the back of your insurance card.
- Some plans only cover services with particular types of providers (for example, your plan may cover services with a psychologist but not with a social worker). It is important to inquire which types of providers are covered under your plan. CRG’s staff or our website can provide you with the credentials of the provider(s) you are scheduled to see.
- Additionally, some plans only cover particular types of services (for example, they cover individual therapy but not family therapy). It is important to ask your insurance company if the service(s) you are scheduled to receive are included in your plan.
- It is also important to find out if your insurance policy has any diagnosis exclusions (for example, your plan may cover treatment for depression but not treatment for ADHD). We recommend you ask if there are any psychological conditions that are not covered by your policy.
- Some policies only cover services up to the point of diagnosis (e.g., they will cover psychological testing but not treatment for certain conditions). We recommend you ask if this is the case with your plan so you know what to expect once claims are filed for your services.
- CRG tries to accommodate families’ schedules as much as possible by allowing patients to coordinate medication management and therapy appointments on the same day. However, please keep in mind that while this can be more convenient for families, some insurance companies will not cover two appointments for a patient within the same day.
- Some of our clinicians schedule phone appointments for patients who are unable to travel to the office on a routine basis. Insurance plans often do not cover telephone services at the same rates as office visits, if they cover them at all. Before scheduling phone services, we recommend you verify your coverage.
Pre-Authorization for Services
You are responsible for checking if prior authorization must be in place prior to your first appointment. Lack of obtaining required pre-authorization results in immediate denial for payment by insurance companies. To assist with obtaining a prior authorization:
- The initial visit with any one of CRG’s providers is considered an “Initial Diagnostic Interview.” If requested by your insurance company, the procedure code for the visit is 90791.
- Be prepared to give the provider’s name and licensure (e.g., Ph.D., M.D., LCSW) as well as the date of the scheduled appointment.
- Please take into consideration the turnaround time for your insurance company to complete a prior authorization once they receive all the necessary information.
- It is important to follow up with your insurance company to verify the authorization is in place prior to services as it can be extremely difficult or impossible to obtain authorization after services have occurred.
- If you or a member of your family receives additional treatment at CRG, we recommend you again check with your insurance company to determine if pre-authorization is required. For instance, ask what steps need to be taken to obtain authorization for ongoing services such as therapy or medication management.
- Often, insurance carriers require providers to send in forms indicating clients’ treatment progress and recommendations for ongoing services. CRG will assist with this process but it is your responsibility to ensure authorizations are current. We ask that you provide us with the appropriate forms in advance of the deadline to allow timely submission back to your insurance carrier.
We hope this information helps you in obtaining quick and accurate reimbursement from your insurance company. We have experienced that educating our families on what to expect both clinically and financially helps with decision-making in treatment and enables our clients to focus on what is most important – leading happy, healthy lives.
The following worksheet has been created as a tool to aid you when checking with your insurance carrier on your plan’s benefits. If you have any questions, please do not hesitate to contact CRG’s billing department at (317) 575-9111, Option #156.