How Long Does Out-of-Network Reimbursement Take for Therapy?

Key Takeaways

Out-of-network reimbursement for therapy typically takes four to six weeks.
Your insurer's EOC or your employer's SPD document lays out typical wait times for your specific plan.
You can reduce wait time by filing claims online and checking your superbill for errors before submitting.

Most clients using out-of-network benefits to help pay for therapy should expect to wait four to six weeks for reimbursement.

That can create some anxiety for clients new to using out-of-network benefits. When cash flow is tight, the wait for reimbursement feels long. And clients may not be 100% clear on exactly how much they'll be reimbursed.

This article answers key questions new clients often have about out-of-network reimbursement, including typical wait times, the factors affecting them, and measures clients can take to speed up reimbursement.

How long does out-of-network reimbursement take?

Broadly speaking, reimbursement for out-of-network benefits takes anywhere from two (best case scenario) to twelve weeks (less-than-ideal scenario).

Best case scenario: Reimbursement in two to three weeks. This is most common from large insurance companies with robust out-of-network plans, with all claims filing and reimbursement done electronically.
Typical scenario: Reimbursement in four to six weeks. This is the typical wait time from smaller insurance companies, and when claims submissions and reimbursement checks are sent by mail.
Less-than-ideal scenario: Reimbursement in six to eight weeks, or up to twelve weeks. If a claim is denied and needs to be resubmitted, you may wait several months before you're reimbursed.

How do you find out the wait time for out-of-network reimbursements?

You can find the typical reimbursement wait for your particular plan in:

The Evidence of Coverage (EOC). A comprehensive, legally-binding document provided by your insurer that outlines your health insurance coverage in plain language.
The Summary Plan Description (SPD). If you have coverage through your employer, they must provide you with an SPD explaining your benefits and how they relate to your employment in plain language.

Both of these documents are different from a Summary of Benefits, which is mainly used for comparing different plans. The EOC or SPD explain your specific coverage in clear, legally-binding terms.

Prompt Payment laws

Besides terms of coverage for your specific plan, Prompt Payment laws in your state may set a maximum limit on how long you can expect to wait for reimbursement.

These laws differ from state to state. They're meant to limit how long insurance companies can make healthcare providers wait for reimbursement after a claim has been filed. The most common time limit is 30 days, but some states set a limit of 45 days.

Important caveat: Prompt Payment laws in most states apply only to healthcare providers, not to plan enrollees filing out-of-network claims. Meaning, in the majority of cases, the time limits set by Prompt Payment won't apply to you.

However, in some states—including New York—Prompt Payment laws do apply to out-of-network claims. Other states use ambiguous language in their laws, making it uncertain whether they apply only to providers or to enrollees as well.

What affects reimbursement time for out-of-network claims?

Your insurer sets the typical wait time for claims reimbursement. But within that limit, there are a number of factors affecting exactly how long you will wait. Taken together, they could mean the difference between a wait of two weeks or a wait of six weeks.

Volume

If it's a busy time of year for your insurer—or if they are a small company rapidly expanding their customer base—then you may face a longer wait time for reimbursement.

The end of the calendar year, from November through December, is one of the busiest times of year for many health insurance companies. This is the period when new enrollees are more likely to sign up. That can create processing delays for out-of-network claims.

Complexity

More complex claims with longer superbills may take longer to process.

For instance, if you submit a superbill for six therapy sessions rather than just one, it's possible you could wait longer to be reimbursed.

Also, if a superbill includes multiple CPT codes or a new diagnosis, the insurance company may take longer to process it.

Superbill errors

A minor mistake on a superbill from your therapist could mean your claim is rejected and you need to submit one with new, corrected information.

For instance,

An incorrect address or a misspelled name
Missing or inaccurate CPT or IDC-10 codes
Inaccurate dates
Calculation errors
Incorrect or missing SSNs, EINs, or ITINs

‚Ä¶could all lead to a claim being rejected.

Insurers refer to these as "clean claims:" Everything you're claiming qualifies for coverage, but because of an error on the superbill, they can't be processed.

In most cases, you can fix these clean claims by having your therapist prepare a corrected superbill and then resubmitting it. But it will mean a longer wait for reimbursement.

Claim filing errors

Even if your superbill is accurate and error-free, you might make an error submitting a claim.

For instance, forgetting to upload a copy of the superbill—or uploading it in an unreadable format—could lead to the claim being rejected. Or providing incorrect banking information could cause reimbursement hiccups.

It's important to familiarize yourself with your insurer's online claims portal before filing for out-of-network benefits. That reduces the likelihood of errors leading to extended wait times.

Filing and payment methods

Filing hard copy out-of-network benefits claims by mail can significantly increase the wait before you're reimbursed. And if you opt to receive a check in the mail rather than a bank transfer—or if that's the only option your insurer gives you—then the problem will be compounded.

Whenever possible, choose digital methods—an online claims portal and reimbursement by bank transfer—to reduce wait times.

What should you do if a claim takes too long to process?

If a claim is taking too long to process, you can contact your insurance company directly.

Call Member Services

This is the number on the bank of your insurance card. Ask:

What is the current status of your claim? Provide the claim number.
What is the standard processing time for out-of-network claims? This should align with the EOC or SPD.
Is there anything missing that's causing a delay?
When can you expect the problem to be resolved?

When you speak to a representative, make sure to note their name and employee ID, as well as the reference number for the call.

Contact the Claims Department

If Member Services can't resolve the issue, ask to be transferred to the Claims Department, or ask for a number to contact the Claims Department directly.

In most cases, Member Services is only able to check the status of your claim. The Claims Department may be able to expedite the reimbursement process or make necessary updates to your claim so it will be processed.

Contact the Appeals and Grievances Department

If the wait for reimbursement has extended beyond a reasonable timeframe, and if the Claims Department is unable to resolve the issue, you can file a formal grievance.

Request the address or online portal for filing a formal grievance. Before you file a grievance, ask for the grievance timeline. Federal laws require the insurer to respond to your grievance within a defined window.

Contact your plan's Member Advocate or Ombudsperson

Many large insurers have dedicated member advocates that can help with delayed or complex claims. Find out if your plan has one and contact them. They may be able to speed up the process of tracking down your claim and completing the reimbursement process.

Get help from a third party

If you can't get help internally from your insurance company, there are other resources you can turn to:

Your HR department. If you're insured through your employer, HR may be able to act as your advocate or help you navigate the issue with your insurer.
Your state's Department of Insurance. File a complaint online. Insurance companies take these complaints seriously because regulators track them. You can find your state's department in the NAIC Directory.
Your state's Insurance Commissioner. In serious cases—including unresponsiveness or suspected bad faith delays—your state's Commissioner can intervene.
The Centers for Medicare and Medicaid Services (CMS). If you have a Marketplace or ACA plan, CMS can help you deal with delayed out-of-network claims.

How can you get faster out-of-network benefits reimbursements?

While much of the claims process it out of your hands, there are a few steps you can take to ensure the shortest reimbursement wait possible.

Make sure your claim is accurate. Review your superbill thoroughly, and ask your therapist for clarification if needed. And make sure you know the ins and outs of online claims submission before you submit a claim. Small errors can lead to lengthy delays.
Go digital. Online submissions and reimbursement via bank transfer eliminates any delays due to using the postal system.
Use Thrizer. If your therapist uses Thrizer, you can skip the claims submission process entirely. With Thrizer Pay, after meeting your out-of-network deductible, you pay only coinsurance and any uncovered fees. Thrizer handles the rest, eliminating the wait for reimbursement. And even if your therapist doesn't use Thrizer, you can use the Superbill Uploads feature for only $2 per session pre-deductible and $2 per session + 1% superbill amount post-deductible.

How do you budget for out-of-network claims reimbursement waits?

If you see a therapist regularly, covering the cost upfront while you wait to be reimbursed for out-of-network benefits can put a pinch on your cash flow.

A few steps you can take to make managing it easier:

Tap a savings account. If you're confident you'll be reimbursed, use rainy day funds to pay for the portion of therapist fees covered by out-of-network benefits. Then, once you're reimbursed, top up your savings with the amount you borrowed.
Factor it into your budget. Make the upfront cost of therapy a recurring expense in your monthly budget. Then make the reimbursement amount for each session recurring revenue, scheduled four to six weeks after each session.
Use funds in a Health Savings Account (HSA) or Flexible Spending Account (FSA). If you have an HSA or FSA through your employer, you can use the funds for out-of-network therapy tax free. When you're reimbursed, add the funds back into your account.

Summary

Plan to wait four to six weeks for out-of-network reimbursement, but for digital submissions with large companies, the wait may be as short as two to three weeks.
Review the EOC or SPD for your plan to find the wait time for your specific plan—these documents use plan language and they're legally binding.
Mailed (vs. digital) claims submissions, superbill errors, high-volume periods (especially in November and December), and complex claims may all increase wait times.
If a claim is delayed, contact your insurer's Member Services, Member Advocate, and/or Claims Department.
If you hit a roadblock dealing with insurance directly, filing a complaint with your state's Department of Insurance can help get the ball rolling again.
Online filing, accurate superbills, and services like Thrizer can all help to speed up (or, in the case of Thrizer, remove) the wait for insurance reimbursement.
Factor therapy into your monthly budget and borrow money from savings accounts to cover therapy costs until you're reimbursed—that can help you avoid cash flow pinches.

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First time claiming out-of-network benefits? Get a crash course from What Are Out-of-Network Benefits? And How Do You Use Them?

This blog post is provided for informational purposes only and is not intended as legal, business, medical, or insurance advice. Laws relating to health insurance and coverage are complex, and their application can vary widely depending on individual circumstances and state laws. Similarly, decisions regarding mental health care should be made with the guidance of qualified health care providers. We strongly recommend consulting with a qualified attorney or legal advisor, insurance representative, and/or medical professional to discuss your specific situation and how the laws apply to you or your situation.