How to Estimate the Amount of Reimbursement

Every insurance plan reimburses at different rates. Please note that ketamine for mental health is not currently covered by any insurance plans in Arizona. However, you may receive reimbursement for the office visit.

To find out what your plan might reimburse you for our services, follow these steps:

Step 1: Call the Number on Your Insurance Card

Look at the back of your insurance card. Call the member services or customer service number.

You can say:

“Hi, I’d like to ask about my out-of-network mental health benefits.”

Step 2: Tell Them What Type of Provider You’re Seeing

Let them know you’re seeing a psychiatric nurse practitioner (sometimes they’ll ask if it’s a medical doctor or a therapist).

You can say:

“I’m seeing a psychiatric nurse practitioner for medication management and psychotherapy.”

Step 3: Give Them the CPT Codes

CPT codes are the billing codes we use to describe your appointments. Ask them what they will reimburse for these out-of-network codes:

• 99203, 99204, 99205 for the initial intake appointment

• 99213, 99214, or 99215 for follow-up appointments with evaluation and management

• 90833 – Psychotherapy (add-on code with medical evaluation & management for 25-minute sessions)

• 90836 – Psychotherapy (add-on code with medical evaluation & management for 50-minute sessions)

• 90837 – Psychotherapy alone (50-minute sessions)

• 90838 – Psychotherapy (add-on code with medical evaluation & management for >50-minute sessions)

*** Most sessions will be a combination of these codes, for example: 99214 + 90833

You can ask:

“What is my reimbursement rate for these CPT codes if I see an out-of-network provider?”

They may also ask for the place of service, which is usually:

• 02 – Telehealth

• 11 – Office visit

They may ask for our Zip Code: 85716

Step 4: Ask About Deductibles and Coinsurance

Ask:

“Do I have an out-of-network deductible? If so, how much of it have I met?”

“After I meet my deductible, what percentage of the cost will be reimbursed?”

Example: They might say, “After you meet your $1,000 out-of-network deductible, we reimburse 60% of the allowed amount.”

Important: Don’t forget that your deductible resets January 1st every year.

Step 5: Ask About Out of Pocket Maximum

This is the amount of money that you pay out of pocket in total before your insurance starts reimbursing you 100% of all out of network costs.

For example you might have a deductible that's $1000 (which you meet at some point during the year). After that, insurance might reimburse you 80% of the allowed amount until your total out of pocket maximum is reached, for instance $4000. After that, your insurance would pay 100% of the covered costs.

Of note, anything above the allowed amount per session will not be factored into these insurance calculations. For example, if the allowed amount from your insurance company is $125 for the billing code 99213 and we bill $200 for 99213; then you would be responsible for the difference of $75 per session, which will not be included in the insurance calculations.

Step 6: Ask What Documents You Need to Submit

Ask:

“Can I submit a Superbill to get reimbursed? What information needs to be on it?”

***Wily Wellness includes everything needed on your Superbill (CPT codes, diagnosis codes, our NPI numbers, etc.)

Step 7: Write Everything Down

Take notes! Write down:

• The date and time you called

• The name of the person you spoke with

• What they said about your benefits

This helps if you ever need to follow up later.

Get the Superbill(s)

After your appointment (or monthly/quarterly), request a Superbill from Wily Wellness. Our admin staff will generate it for you, and you will be able to download it from the patient portal.