Insurance Verification
PHA has clinicians who are on panel with the following insurance companies: Highmark Blue Shield, Capital Blue Cross, Medicare, Quest, Tricare, UPMC, and CHIP. If you do have coverage through one of these insurers, it is likely that you will have coverage for services we provide; there are exceptions, however. Our dedicated office staff will do their best to understand and explain your coverage. It is strongly recommended to contact your insurer directly to clarify your coverage. At a minimum, you will want to find out such things as: whether they will reimburse for services to an “out-of-network provider,” what your deductible is, and what your copay or coinsurance is. DELETE the sentence prior to and the link itself. We do that all online now.
Using Your Insurance Coverage
If your PHA therapist is on the provider panel for your insurance plan, our office will bill your insurance company directly, typically electronically. Until you have met your deductible, you will be responsible for the full session amount that your insurance company has contracted with your clinician. After you have met your deductible, you will be responsible for payment only of your 1.) copay and/or 2.) coinsurance, which is a designated amount each session or percentage of the session fee that your insurance company considers your exclusively your financial responsibility. See your insurance policy for details. Our office support staff or your clinician may be able to help you understand your policy. Please discuss it with them. However, please be mindful that you, not our office support or your therapist, are responsible for knowing whether your insurance will cover the services you receive.
If your PHA therapist is not on the provider panel for your insurance plan, be prepared to pay for the entire session fee at the time of service. Then you are welcome to submit your claims to the insurance company yourself to obtain out-of-network benefits, if available.
Sometimes, if your insurance company allows it, your therapist can be reimbursed directly from your insurance carrier, even if he or she is not on their panel. If such an arrangement is made, please be reminded that this is done strictly as a courtesy for our clients. It is important to remember that our contract for services, however, is with you. If your insurance company does not cover or reimburse us for services, you are responsible for those expenses.
Services Ineligible for Insurance Coverage
Please be aware that to legitimately submit claims to your insurance company, two things need to be true: First, you must be seeking help for a diagnosis that is considered eligible for coverage (e.g., ADHD, depression, anxiety, etc.); Second, the services you are receiving must be relevant to the treatment of that diagnosis.
Sometimes people seek psychotherapy for legitimate problems, but it is not related to a medical diagnosis at all (e.g., relationship or couples therapy or court-ordered evaluations may fall into this category). Please discuss this with our office support staff during scheduling.
Do not be deterred if you do not have insurance coverage. Look at therapy as an investment in your wellness to improve the quality of your life. While not having insurance coverage may be inconvenient, insurance coverage need not be a necessity. Carefully consider how to fit therapy into your budget and alternative funding sources (i.e. a church benevolence fund). Additionally, some people elect to not submit bills to insurance even when they do have coverage.
A Word of Caution Regarding Submitting Claims to Insurance
Despite having insurance coverage that would allow them to be reimbursed for outpatient mental health services, some elect not to submit those claims to their insurance carrier for reimbursement and to pay instead out of pocket. There admittedly are downsides to submitting claims to insurance companies for coverage.
Should you decide to submit claims to insurance (most people do), PHA will do this electronically if your therapist is on panel. We provide all the information your insurance company needs to process the claim through our billing software. This caution is not meant to discourage you from submitting mental health claims to insurance, although we want to fully inform you.
Your insurance company will not provide coverage for a mental health claim unless that claim is submitted along with a diagnosis of a mental health disorder, as well as an eligible procedure code. If you do submit claims to insurance, there will be a mental health diagnosis code in your (or your child’s) permanent medical record. If you or your child are already receiving medication for anxiety, depression, ADHD, etc., submitting additional claims to insurance will not make any difference or impact upon what is already contained within the medical record. This “protected health information” or PHI, including service and diagnoses codes, become a permanent part of your insurance company’s records and is stored permanently in national medical information databases. PHA has no control over what your insurance company does with your personal information once it is in their hands for billing.
Medical Assistance
PHA is not a Medicaid or Medical Assistance (MA) provider. If you have an Access Card for Medical Assistance, be advised that Medicaid will not provide coverage for services rendered by our office. If you do have Medicaid, even as a secondary insurance, we still might be able to help you, although the Medicaid rules are complicated. Please discuss this with our office support staff.