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Filing Out-of-Pocket Costs: A Quick Guide for Patients

Health Care Bills: How to file claims and out-of-pocket costs to your health insurance.

This post is intended to help our patients seek reimbursement or receive benefits for out-of-pocket costs associated with an appointment at our office. While this will help lead you in the right direction, each insurance company and each plan has their own individualized process, and this is not a guarantee of payment. Please keep in mind that this process is not always quick and can take 2-3 months for an insurance company to process the claims submitted.

Why would I need to submit a claim or proof of out of pocket costs to the insurance company myself?

  1. You have an out-of-state insurance that we cannot submit to (ie. out of state Medicaid, where our Medicaid NPI # will not allow us to submit)

  2. You have an out-of-network insurance company and may not have out of network benefits but you want the costs to go towards your out-of-pocket max benefits.

  3. You have in-state insurance that we cannot submit to, as we are not credentialed with them (ie Medicare or Tricare).

  4. Your insurance company has continually denied the claim being submitted by the health care provider

  5. You have used all of your mental or behavioral health benefits (or have no mental health coverage) for the year, but you want payments to go towards your out-of-pocket max. (ie you already had an assessment but are looking to get a second opinion)

  6. You have new insurance and are looking for them to backdate your appointment costs and seek reimbursement.

What do I need in order to submit a health insurance claim form?

  1. All of your general insurance information. This includes insurance name and plan name, member name, member ID, group number, and policy holder information.

  2. The claim form may ask if you have coinsurance or dual coverage (primary, secondary, tertiary insurance)

  3. An itemized receipt from your healthcare provider (in this case it would be CAAC). This receipt will include the healthcare provider’s name, the company name, the company header (usually a logo attached), the date of service (DOS), the patient’s name and date of birth, CPT codes and units (these are the service codes and the time associated with them), diagnosis codes (ie F.88.0 for other psychological disorders or F.84.0 for autism spectrum disorder), billed amounts, and amounts paid.

  4. The insurance company may ask for test and parent/teacher rating form names (you may ask your provider for these).

  5. The reason for the appointment or testing. You may ask for the appointment note from the provider if this helps.

How do I submit to my insurance?

  1. Go online to your health insurance company’s portal or call them and obtain multiple copies of all the forms you need to fill out, including the claim form.

  2. Ask your healthcare provider (us) for all of the documentation stated above.

  3. Fill out all of the paperwork to the best of your knowledge.

  4. Make copies of everything you filled out and obtained copies of. You may need to resubmit if it gets lost or if you also need to submit to a secondary insurance as well.

  5. Send everything off to your insurance company. This can usually be done in a couple of ways. Majority of insurance companies allow you to do this through their online member portal. Others may allow you to mail it in, but be aware that this may take longer to process. Check with your insurance company to determine the best option for you and for your plan.

Other things to consider:

  • Claims may take a couple of months to process

  • You will likely need to make calls and check in on the status of your claim often

  • Your first attempt may get denied, but check what your insurance company’s policies and procedures are on for appeals.

*Please check in with us if you have additional questions about this process!

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