Important Health Insurance Information

I am currently in network and accept the following health insurance plans:

  • Blue Cross Blue Shield
  • Cigna & Evernorth
  • MVP Healthcare
  • VT Medicaid

There are many more plans in Vermont that I am not an in-network provider with. I can provide a superbill and out of network claim, but cannot guarantee insurance company claims will be paid for out of network services.

Clients paying with cash, or out of pocket with health insurance plans that have high deductibles or copays, will be required to provide a valid payment method to be kept on file along with a signed authorization for automatic payments. I will process payment for each session’s deductible or copay after the session. I will file a claim with your insurance company for therapy through an online client account portal. I will send you receipts, EOB copies, and account statements electronically. You will receive a receipt for payment electronically from my secure merchant account payment processor.

Your receipts and statements can be used to file for HSA and FSA reimbursement. In the event that there is insufficent funds in your payment method, an invoice will be sent, and payment of your outstanding balance is due before the next scheduled appointment unless other arrangements are made.

Some HSA and FSA cards cannot be accepted at this time due to the processing procedure they follow for transactions. I don’t recommend clients make payments directly to the insurance company through their patient portal for my charges (copays and deductibles). The insurance company patient portal process takes much longer, it involves several unnecessary steps that are inconvenient and confusing.

You  have a right to request a good faith estimate of the cost of my services, as guaranteed by the “No Surprises Act.”

Talk to your Insurance Provider

Health insurance plans are different from one company to another. Before the first session, call your insurance company or talk to your human resources department. You will be responsible for the fees if your insurance company does not reimburse me.

Ask your insurance provider these questions:

  • Does my plan cover outpatient mental health care services?
  • Does my plan cover telehealth services over video or telephone?
  • Do I have a deductible I am responsible for paying?
  • How much is my deductible and how much have I met?
  • Do I have a co-pay or co-insurance I am responsible for paying?
  • How much is the co-pay or co-insurance amount?
  • Does therapy require prior authorization?
  • Does it need a referral from your primary care provider?
  • How many sessions will my insurance plan cover?

Payment Types:

I accept American Express; Mastercard; Visa, and some HSA/FSA cards through my client account portal (Therapy Notes LLC).

Requirements and Criteria for Mental Health Services

These were requirements and criteria from one major insurance company in 2008. These may be different from one company to another, and may have changed since 2008. They are meant to provide the rationale for the approaches I use in sessions, assessments, outcome measures, and the process of formulating a plan, implementing it, and adhering to it as much as possible. If the requirements and criteria are not met, your insurance company may not pay the benefits.

1. Services Must Be Medically or Therapeutically Necessary.

Therapeutic necessity is defined as services consistent with the diagnosis and impairment which are non-experimemntal in nature and can be reliably predicted to positively affect the patient’s condition. (Evidence Based and Empirically Supported)

2. The intensity of treatment must be consistent with the acuity and severity of the patient’s current level of impairment and/or dysfunction.

3. There must be documentation of reasonable progress consistent with the intensity of treatment and the severity of the disorder.

4. There should always be documented, specific evidence of a diagnosable mental disorder (based on the current Diagnostic Stastistical Manual of Mental Disorders).

5. The treatment plan includes specific, objective, behavioral goals for discharge.

6. Justification to continue treatment includes “persistence of significant symptoms and impairment or dysfunction resultant from mental illness which required continued treatment including impaired social, familial, occupational functioning or evidence of symptoms which reflects potential dangers to self, others, and/or property.

7. Insufficient behavioral and/or dysfunctional evidence is present to support the current diagnosis.

8. Lack of therapeutic appropriateness and/or lack of therapeutic progress and evidence of therapeutic gains and setbacks are required documentation procedures.

* Noncovered services include: services without a definite treatment plan; services without corresponding documentation; medically unneccessary services; and services without a diagnosable mental disorder. 

This summary of third party documentation procedures indicates specific requirements that are designed to document the efficacy of therapy in such areas as validation of diagnosis, functional impairments, symptoms, treatment, client cooperation, and providing behavioral evidence of gains and setbacks in treatment.