How to Verify Your Insurance Benefits
Verifying your mental health benefits before your first appointment helps you understand your costs and avoid surprises. This 15-minute phone call can save you hundreds of dollars in unexpected bills.
Insurance information provided over the phone is not a guarantee of coverage, but it gives you the best available estimate of what you'll pay. This guide walks you through exactly what to ask and how to interpret the answers.
Why Verification Matters
A few minutes now prevents billing surprises later
Understand Your True Costs
A therapy session typically costs $150–180. Your actual out-of-pocket cost depends on your deductible status, copay amount, and coinsurance percentage. Without verification, you might expect a $30 copay but actually owe the full $150 because your deductible isn't met.
Confirm Network Status
Provider directories can have errors or be outdated. A provider may be in-network for medical services but out-of-network for mental health if your plan uses a behavioral health carve-out. Direct verification catches these issues before you receive a surprise bill.
Identify Authorization Requirements
Some plans require prior authorization for therapy. Starting treatment without required authorization can result in denied claims. Verification tells you if you need approval before your first session.
Create Documentation
If there's ever a billing dispute, having documentation of what you were told—with a call reference number—gives you leverage to appeal. Without this, it becomes your word against the insurance company's records.
Before Your First Appointment
Follow these steps to verify your coverage
Gather Your Information
Find your current insurance card and have it in front of you. Note your Member ID, Group Number, and the Member Services phone number (usually on the back). If your card shows a separate number for "Behavioral Health," use that number instead—your mental health benefits may be managed by a different company like Optum, Magellan, or Carelon.
Prepare Before Calling
Have pen and paper ready to document everything. Write down the date and time before you dial. Know the exact name and address of the provider you plan to see. If possible, have the provider's NPI (National Provider Identifier) number—you can ask our office for this.
Call Member Services
Call the number on your card and say: "I'd like to verify my benefits for outpatient mental health therapy with an in-network provider." Be prepared for possible transfers—if they mention a behavioral health administrator, write down that company's name and number.
Ask the Essential Questions
Use our detailed question list below. For each answer, write down exactly what the representative says. If an answer is unclear or uses unfamiliar terms, ask them to explain. Don't hesitate to ask them to repeat information.
Get Documentation
Before hanging up, ask: "Can I please have the call reference number for this conversation?" Also get the representative's name and ID number. This documentation is critical if there are ever billing disputes later.
Verify and Cross-Reference
After the call, log into your insurance member portal to verify what you were told. Cross-reference with your Summary of Benefits and Coverage (SBC) document. If anything conflicts, call back and reference your previous call number.
Watch for Behavioral Health Carve-Outs
Many insurance plans use a separate company to manage mental health benefits. Look at your card carefully:
- If there's a separate phone number labeled "Behavioral Health," call that number
- Common behavioral health administrators include Optum, Magellan, Carelon (formerly Beacon), and Lyra
- Your medical network and mental health network may be completely different
Questions to Ask Your Insurance
Use these exact questions and document every answer
When you call, you can start with this script: "I'd like to understand my benefits for outpatient mental health therapy. Can you tell me my deductible, my copay or coinsurance per visit, and whether I have any visit limits?"
Then ask these specific questions to get complete information:
About Network Status
Ask:
"Is Complete Health Wellness Group at [ADDRESS] in-network for my specific plan for outpatient mental health services?"
Good answer: "Yes, that provider is in-network for your plan." Make sure they confirm the specific address—some practices have multiple locations with different network status.
Concerning answer: "I show they're out-of-network" or "I don't see them in our system." Ask about out-of-network benefits, or call our office to double-check—directory errors are common.
Red flag: "You'll need to call your behavioral health company for that." This means you have a carve-out and need to call a different number.
About Your Deductible
Ask:
"What is my annual deductible for outpatient mental health services, and how much have I met so far this year?"
Good answer: "Your deductible is $1,500 and you've met $800 so far." This means you owe $700 more before your copay/coinsurance kicks in. At $150 per session, that's about 5 sessions at full price.
Best answer: "Mental health visits have a $0 deductible" or "Your deductible is met." You'll only pay your copay from the first session.
Concerning answer: "You have a $3,000 deductible and haven't met any of it." This is common with high-deductible health plans (HDHPs). You'll pay full price ($150–180) for your first 17–20 sessions before insurance kicks in.
About Your Copay
Ask:
"What is my copay for an outpatient therapy visit with an in-network licensed clinical professional counselor (LCPC) or licensed clinical social worker (LCSW)?"
Good answer: "Your copay is $30 per visit." This is a fixed, predictable amount you'll pay each session (after meeting your deductible, if applicable).
Alternative answer: "You don't have a copay—you have coinsurance." This means you pay a percentage rather than a flat amount. Ask the next question about coinsurance.
Concerning answer: "Your copay is different for different provider types." Ask specifically about LCPCs and LCSWs, as these are our clinicians' license types.
About Coinsurance
Ask:
"After I meet my deductible, what is my coinsurance percentage for outpatient mental health visits? And what is the allowed amount for a therapy session?"
Good answer: "You pay 20% coinsurance after deductible. The allowed amount for CPT 90837 is $150." This means you'll pay $30 per session (20% of $150) and insurance pays $120.
Calculate it: If they give you a percentage and allowed amount, multiply them. 20% × $150 = $30. 30% × $150 = $45. This is your cost per session after deductible.
Concerning answer: "I can't tell you the allowed amount." Ask if you can get this from your member portal, or ask for the "UCR rate" or "usual and customary rate" for your area.
About Your Out-of-Pocket Maximum
Ask:
"What is my out-of-pocket maximum, and how much have I paid toward it this year?"
Good answer: "Your out-of-pocket max is $4,000 and you've paid $2,500 so far." Once you hit $4,000 total in deductible + copays + coinsurance, insurance pays 100% for the rest of the year.
Why it matters: If you're close to your out-of-pocket max (from other medical care), you may soon pay nothing for therapy sessions. Only in-network, covered services count toward this limit.
About Session Limits
Ask:
"Does my plan have a limit on the number of outpatient mental health sessions covered per year? Is that a hard cap, or is it subject to medical necessity review?"
Best answer: "No, there's no limit on covered sessions." Federal mental health parity laws prohibit limits that are more restrictive than medical benefits. Most modern plans have no hard session caps.
Concerning answer: "You have 20 visits per year." Ask: "Is that a hard cap, or can additional sessions be approved with medical necessity documentation?" Also ask what happens if you need more than 20 sessions.
Authorization answer: "Coverage is unlimited with ongoing authorization." Ask how often authorization is required and how many sessions are typically approved at once.
About Prior Authorization
Ask:
"Does my plan require prior authorization for outpatient therapy sessions? If yes, what's the process and timeline?"
Best answer: "No prior authorization is required for standard outpatient therapy." Most plans don't require prior auth for routine weekly therapy sessions.
If authorization is required: Ask: "How many sessions are typically approved at once?" "How long does approval take?" "What happens if I start therapy before authorization is approved?" Let us know—we may need to submit documentation.
Note: Prior authorization is more commonly required for intensive outpatient programs (IOP), psychological testing, or high-frequency visits (more than weekly).
About Telehealth Coverage
Ask:
"Are telehealth/video therapy sessions covered under my plan at the same rate as in-person visits? Are audio-only (phone) sessions also covered?"
Best answer: "Yes, telehealth is covered at the same copay as in-person, including audio-only." Maryland law requires payment parity for telehealth services.
Concerning answer: "Telehealth has a different copay" or "We only cover video, not phone sessions." Some plans have different cost-sharing for telehealth. Get the specific amounts.
Maryland-specific: The Preserve Telehealth Access Act of 2025 makes audio-only coverage permanent and requires payment parity with in-person visits.
About Out-of-Network Benefits (If Applicable)
Ask (if provider is out-of-network or you want to know your options):
"Do I have out-of-network benefits for mental health? What is the out-of-network deductible and coinsurance? Do you reimburse based on a usual and customary rate?"
Good answer: "Yes, you have out-of-network benefits. Your OON deductible is $1,000 and coinsurance is 50%." You can see any provider and submit superbills for partial reimbursement.
Watch out for: Separate out-of-network deductibles (often higher than in-network), lower reimbursement rates based on "UCR" amounts, and balance billing (you pay the difference between provider charges and what insurance allows).
Documentation Template
Write down all of this information during your call:
Date/Time: _______________
Insurance Company: _______________
Rep Name: _______________ Rep ID: _______________
Call Reference #: _______________
In-Network Confirmed: Yes / No
Deductible: $_______ Met: $_______
Copay: $_______ OR Coinsurance: _______%
Out-of-Pocket Max: $_______ Met: $_______
Session Limits: _______________
Prior Auth Required: Yes / No
Telehealth Covered: Yes / No
Always Get the Call Reference Number
This is the most important documentation you'll get
Critical: Get the Call Reference Number
Before ending any call with your insurance, always ask: "Can I please have the call reference number for this conversation?"
Also ask for the representative's name and employee ID number. Write down the date and time of the call.
This reference number creates a record that the insurance company can access. If there's ever a dispute about what you were told—like being told a provider is in-network but later receiving an out-of-network bill—this documentation is essential for appeals.
Why This Number Matters
- The reference number lets any representative pull up the notes from your original call
- If you were given incorrect information, this creates an audit trail
- Our billing team can reference this number when following up on claims issues
- It strengthens appeals if a claim is denied contrary to what you were told
If They Say They Don't Have Reference Numbers
Some representatives may not immediately know what you're asking for. Try these alternative phrases:
- "Can you give me the call tracking number?"
- "What is the confirmation number for this call?"
- "Can you note my account that I called today to verify benefits?"
At minimum, get the representative's name and ID number, and note the exact date and time you called.
Don't Lose Your Documentation
What the Answers Mean
Understanding your coverage with real dollar examples
Here's how to interpret common responses and calculate what you'll actually pay. These examples assume a typical therapy session with an allowed amount of $150.
Scenario A: $30 Copay, No Deductible for Mental Health
What they told you: "Your mental health copay is $30 per visit. Mental health services are not subject to deductible."
Your cost:
- Session 1: $30
- Session 10: $30
- Session 20: $30
Total for 20 sessions: $600
This is the most predictable scenario. You pay $30 every session regardless of other medical expenses.
Scenario B: $1,500 Deductible, Then 20% Coinsurance
What they told you: "Your deductible is $1,500, you've met $0. After deductible, you pay 20% coinsurance."
Your cost:
- Sessions 1–10: $150 each (full allowed amount) = $1,500 to meet deductible
- Session 11 onward: $30 each (20% of $150)
Total for 20 sessions: $1,500 + (10 × $30) = $1,800
You pay more upfront, but costs drop significantly once you meet your deductible. Other medical expenses also count toward your deductible.
Scenario C: High-Deductible Plan ($3,000 HDHP)
What they told you: "You have a $3,000 deductible and have met $0. After deductible, you pay 20%."
Your cost:
- Sessions 1–20: $150 each (full price) = $3,000 to meet deductible
- Session 21 onward: $30 each (20% of $150)
Total for 20 sessions: $3,000 (all applied to deductible)
HDHPs have lower premiums but higher out-of-pocket costs. If you have an HSA, you can use pre-tax dollars for therapy.
Scenario D: Deductible Already Met
What they told you: "Your deductible is $1,500 and you've already met $1,500."
Your cost:
- If copay plan: Just your copay (e.g., $30) from session 1
- If coinsurance plan: Just your coinsurance (e.g., 20% = $30) from session 1
Great news! You've already met your deductible from other healthcare this year.
Out-of-Pocket Maximum Benefit
If you've had significant medical expenses this year, ask about your out-of-pocket maximum. Once you hit this limit, your insurance pays 100% of covered services.
Example: If your out-of-pocket max is $4,000 and you've already paid $3,800 in medical costs this year, you only need to pay $200 more before therapy is free for the rest of the year.
Red Flags to Watch For
These answers require follow-up or clarification
"You have a separate behavioral health administrator"
What it means: Your mental health benefits are managed by a different company (like Optum, Magellan, or Carelon).
Action needed: Get that company's name and phone number immediately. Call them to verify benefits—the main insurance number can't give you accurate mental health information.
"I show the provider as out-of-network"
What it means: Either we're not in-network, or there's a directory error (common).
Action needed: Call our office to double-check. If we confirm we're in-network, call your insurance back with our NPI number and ask them to verify again. Directory errors happen frequently.
"We show you're not eligible" or dates don't match
What it means: There may be an issue with your coverage enrollment.
Action needed: Contact your employer's HR or benefits department immediately. Do not schedule appointments until this is resolved—claims will be denied.
Representative seems unsure or keeps saying "it depends"
What it means: You may not be getting accurate information.
Action needed: Politely ask to speak with a supervisor or a specialist in mental health benefits. If answers are still unclear, call back later and speak with a different representative.
"Your employer sets the benefits" or "This is a self-funded plan"
What it means: Your employer pays claims directly, not the insurance company. The carrier just administers the plan.
Action needed: Benefits may differ from standard plans with that carrier. Request your Summary Plan Description (SPD) from HR for the official benefit details.
Special Case: Self-Funded Employer Plans
About 67% of covered workers have self-funded plans
Many employers don't actually buy insurance—they pay claims directly from company funds and just hire an insurance company (CareFirst, Aetna, etc.) to administer the paperwork. Your card may say "CareFirst," but your benefits are determined by your employer, not CareFirst.
How to Identify a Self-Funded Plan
Look for these clues on your insurance card or documents:
- Card says "Administered by" instead of "Insured by"
- Fine print: "[Carrier] provides administrative services only and does not assume financial risk"
- UMR branding (UMR plans are 100% self-funded)
- Your Summary Plan Description mentions "ERISA" or "self-funded"
Why This Matters for Verification
Benefits can be customized: Your employer can choose different copays, deductibles, or covered services than the carrier's standard plans. What's true for your coworker's "CareFirst" plan may not apply to yours.
State mandates may not apply: Self-funded plans are governed by federal ERISA law, not state insurance regulations. Some Maryland mental health requirements may not apply.
Different appeal rights: If a claim is denied, you appeal through the plan's internal process and then to the U.S. Department of Labor—not the Maryland Insurance Administration.
Verification Tip for Self-Funded Plans
Need Help Verifying?
Our billing team is here to assist
Don't want to call your insurance yourself? Our billing team can help verify your benefits before your first appointment. Contact us with your insurance information and we'll do our best to confirm your coverage and estimate your costs.
Contact our billing team:
[PHONE NUMBER]
[EMAIL]
Important Disclaimer
Even when we verify benefits, coverage is not guaranteed. Final determination of benefits is made by your insurance company when claims are actually processed.
The information we receive from insurance representatives is only as accurate as what they provide. This is why getting call reference numbers is so important—it creates documentation if the information later proves incorrect.
After Your Verification Call
Final steps to complete before your appointment