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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.
Broadly speaking, reimbursement for out-of-network benefits takes anywhere from two (best case scenario) to twelve weeks (less-than-ideal scenario).
You can find the typical reimbursement wait for your particular plan in:
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.
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.
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.
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.
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.
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,
…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.
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 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.
If a claim is taking too long to process, you can contact your insurance company directly.
This is the number on the bank of your insurance card. Ask:
When you speak to a representative, make sure to note their name and employee ID, as well as the reference number for the call.
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.
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.
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.
If you can’t get help internally from your insurance company, there are other resources you can turn to:
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.
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:
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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.
