Working with Unsupported Insurers
September 26, 2022
What Are Unsupported Insurers?
While Nirvana prides itself on offering top-quality out-of-network insurance support, not all insurance providers make that easy. Some insurers are error-prone or have delayed claims adjudication cycles. Others are not electronic-friendly. These issues jeopardize the good customer experience Nirvana works hard to deliver. While we can’t support all insurers, we are still committed to helping make insurance as easy as possible.
We provide this resource for anyone who needs to verify benefits with or file claims to the insurers Nirvana does not currently support. For a full list of Nirvana-supported plans, please refer to our FAQ page or search plans using the Insurance Provider section of our Out of Network Reimbursement Calculator.
How to Check Client Benefits for Therapy
For insurers not supported by Nirvana, you can collect much of the same information that we would display on our platform and provide the client with a benefits check. You can also share this article with your clients if they would like to verify their out-of-network mental health benefits on their own. The following steps break down how to do this, with an example.
1) Obtain Insurance Information
From the client’s insurance card, locate the following:
- The client’s insurance ID number
- The client’s date of birth
- The provider-specific hotline to call - this is usually located on the back of the client’s insurance card
2) Call the Insurer
When you call the insurer, you will be asked to provide your client’s name, date of birth, and insurance ID. You will also be asked to provide your individual NPI number, and practice address, as well as your tax ID in some instances.
Next, ask for information about the client’s coverage for routine outpatient out-of-network mental health sessions. You may also provide the CPT code(s) you plan to use for the client’s sessions, and even the client’s diagnosis code.
The insurance representative will tell you how long the client has been covered, whether or not their out-of network benefits for this service are active, and whether a prior authorization might be needed for sessions to be covered.
Also obtain the following information:
- The client’s total and remaining deductible
- The client’s total and remaining maximum out-of-pocket
- The client’s coinsurance amount, if any
Note that the coinsurance amount may be quoted differently by each insurer or representative. For example, a Beacon Health Options representative may say the client is responsible for 20% of the allowed amount, while a Meritain Health representative may say the plan covers 80% of the allowed amount. They both mean the same thing but it can certainly be confusing at times!
3) Determine the Client’s Benefits
Provide the client with the following information:
- Remaining deductible – You obtained this information from the insurer
- Number of sessions it will take to reach the deductible. To calculate this, divide the remaining deductible by the UCR rate (contact Nirvana to obtain the appropriate rate). Round up any decimals.
- Estimated reimbursement per session once the deductible is met – To calculate this, multiply the UCR rate by the percentage of the coinsurance that the insurance company pays (For example, if a client has a 30% coinsurance, their insurance company pays for 70%).
To easily calculate the above, see the attached spreadsheet and input the benefit information you’ve collected from the insurance company.
What if my client’s sessions require prior authorization?
Occasionally your client’s insurance company may ask for a prior authorization (also referred to as “pre-auth”) to be obtained before they will cover or reimburse a session.
It’s important to confirm if prior authorization is required because some insurers may even financially penalize clients for submitting claims without one when it’s required. Penalties may include covering less of the claim or not covering the claim at all.
When you call to verify benefits, the representative will let you know whether authorization is required or not, and if there is a limit to the number of sessions covered under that authorization. Some limits are as high as 100 visits, while others are as low as 10 or 12.
If your client’s sessions require pre-auth, you can initiate the process by transferring to the authorization department while on the phone with the insurance company. Some insurers also allow authorization requests to be submitted online. Keep in mind that you will need to include the authorization number on any claims submitted to avoid denials.
How to File Out of Network Client Claims
While Nirvana strives to support as many insurance plans as possible, manually filing insurance claims for therapy may be the best method if we do not support a client’s plan. Below are some tips to help you complete and submit out-of-network claims .
1) Gather essential information
You will need:
- A copy of the client’s insurance card
- A Superbill*
- Proof of payment, in some cases
*A Superbill is a document that a clinician pulls directly from the electronic health record (EHR). It should include the client’s date of service, the CPT code(s), the client’s diagnosis codes, and clinician and practice information that the insurer will use for billing.
2) Determine How to Submit Claims
Insurers may prefer to receive their claims in various formats. Some have online portals, while others require paper forms. Each insurer is different, so please refer to their websites for more information.
Some relevant insurance portals with links can be found here:
- Meritain Health
- Fidelis Care
- Beacon Health Strategies
- Tufts Health Plan
3) Create and Submit Your Claim
This step varies by insurer and typically involves copying information from the client’s insurance card and Superbill and pasting it into an online or paper form. Some insurance providers may accept a Superbill on its own, as long as it’s accompanied by a receipt. Contact the client’s insurer directly if you’re not sure how to complete the form. Keep in mind that if authorization is required for services, you may need to include the authorization number on any claims to prevent claims from being denied.
4) Monitor the Claim
Depending on the insurer and the method of submission, it may take between 1-4 weeks for reimbursement to be issued. Once you’ve submitted the claim, you can follow up in one to two weeks to make sure it was received. Many insurers will not provide updates unless requested. If you don’t see any progress in 30 days, we recommend that you follow up (either through the insurer’s portal or phone support channel) to see if there is anything the client or therapist can provide to help the claim process.
5) Preparing for Denials and Rejections
Claims can be denied or rejected for a multitude of reasons. The good news is that most denials and rejections can be fixed, or avoided altogether by determining the client’s benefits before services are rendered.
A claim rejection occurs before the claim is accepted for processing and is usually caused by incorrect data on the claim or Superbill itself. One common reason for claim rejection is a typo in the member’s ID number or date of birth. Missing information such as a modifier, diagnosis, or place of service can also lead to rejection.
A claim denial applies to a claim that has already been processed but was found to be unpayable. Denials are more often related to specific limits of a client’s plan. Here are some example situations that could cause claim denials:
- Therapy is not covered with the selected diagnosis code
- Therapy is not covered at the selected place of service
- The claim has been selected for a medical necessity review
The reason for the denial will always be listed on the Explanation of Payment (EOP) but you may need to call the insurer to determine the best way to resolve the denial. In the event that your claim is denied or rejected, it’s best to act quickly. Insurers often set time limits for submitting claim corrections or additional documentation such as medical records.
How Does Nirvana Work With Unsupported Payers?
While Nirvana can’t support all mental health insurers, we are still committed to reducing the headaches insurance can cause. We hope this resource is helpful for anyone verifying benefits or filing claims to the insurers Nirvana does not currently support.
If you have any questions not addressed in this article, please contact us at email@example.com.