‍This article is co-authored by Mentaya

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Key Takeaways

• For OON benefits, clients submit their own claims to their insurers
• You’ll need to provide clients with superbills so they can submit their claims
• Clearly communicate to clients their duties and your own role when it comes to OON benefits

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When starting a therapy practice, therapists are faced with the question: Will I or will I not take insurance?

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This decision boils down to three main options:
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1. Go in-network: get paneled with insurance companies, either through a company like Alma or on your own.
2. Go out-of-network: only accept private pay clients.
3. A mix: Go in-network with some insurances and take some private pay clients as well.

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Here is how the two ends of that spectrum compare:

In-network vs. out-of-network at a glance

Source: Heard’s 2026 Financial State of Private Practice Report (n=1,950 therapists). Figures are medians.

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In this article we will talk about what it means to be an out-of-network provider (options 2 and 3). If you are leaning toward option 1, start with our complete guide to insurance billing for therapists.

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Specifically we will:

• Explore reasons why some therapists choose this path.
• Explain how out-of-network billing works.
• Walk through payer-specific superbill requirements.
• Work through reimbursement examples, so you can show clients what to expect.
• Share client communication templates you can adapt.
• Highlight resources available to out-of-network providers.
• Provide you with an extensive glossary of insurance terms.

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What is an out-of-network therapist?

An out-of-network provider is not part of any insurance panels and they set their own fees. This is also called “private pay,” “cash pay,” or sometimes “fee-for-service.”

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What a lot of people don’t know is that most preferred provider organization (PPO), point-of-service (POS), and high-deductible health (HDHP) plans have both in-network and out-of-network benefits. This means that even though you are out of network, many of your clients may have out-of-network mental health coverage that reimburses them for therapy.

Why do therapists choose to be an out-of-network provider?

Top three reasons why therapists choose to be an out of network provider:

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1. More flexibility: You can choose your clients and run your practice the way you want, since it is not controlled by insurance.
2. Higher pay: Out-of-network providers can charge their full fee and avoid insurance companies taking a hefty cut of their pay.
3. More time: Being out-of-network, you can avoid time consuming administrative tasks and paperwork required by insurance companies.

The numbers back up the pay difference. According to Heard’s 2026 Financial State of Private Practice Report, the median insurance reimbursement is $107 per session, compared to a $150 median private-pay fee, a 29% gap (n=1,950 therapists surveyed; insurance reimbursement n=1,359, private-pay fee n=1,377).

How do therapy clients typically get reimbursed for out-of-network therapy?

1. Client verifies their insurance benefits

Clients often don’t know that their insurance plans may cover out-of-network services, despite them actively paying for these benefits.

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To determine whether their insurance plan includes out-of-network benefits, and how much they can expect to get reimbursed, clients can reach out to their insurance company directly. Though this is not a difficult process, many clients never get around to making the call. As a result they may opt to go with an in-network therapy provider. Unfortunately, since there is such a high demand for therapists, this may result in waiting on long waitlists, or going with a therapist that is not a good match for the client.

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A growing number of therapists are using online resources, like Mentaya's benefits checker, to confirm how much clients can expect to be reimbursed by insurance. One provider explained: “I let my clients know I charge $200 per session and I don’t take insurance, but I do work with a platform that gets clients reimbursed. I let them know most of my clients get 70% of sessions reimbursed.”

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For those with out-of-network benefits, reimbursements are often 40-80% of the plan’s allowed amount (and often less of your full fee), which can significantly reduce session costs for the client.

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As highlighted by Mentaya’s benefits checker above, based on the provider’s session fee and their client’s remaining out-of-network deductible you can calculate how many sessions need to occur before the client will start to get reimbursed.

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2. Therapists provide a superbill

Clients need to submit a superbill or claim to their insurance company for therapy reimbursement. A superbill is a document that includes all necessary information required by insurance companies to process reimbursement for the services provided.

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To generate a superbill, therapists can use their Electronic Health Record (EHR) software or create a template with the client's name, date of service, therapist's name and credentials (including their Tax ID or NPI number), diagnosis codes (ICD-10 codes), treatment codes (CPT codes), and fees charged for each service.

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3. Client submits a superbill

Clients will then submit the superbill to their insurance, either by uploading it directly to their insurance website or by mailing it. Sometimes the insurance company may not approve the superbill due to missing or incorrect information, insufficient documentation, or exceeding coverage limitations.

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If done correctly, utilizing out-of-network benefits can serve as a bridge between in-network and out-of-network therapy, reducing the client's net costs while still allowing the therapist to get paid their full fee.

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However, why does this still sound like so much work? After all, as an out of network provider you have ultimately made the decision to distance yourself from insurance companies.

Superbills for out-of-network therapy reimbursement

A superbill acts as proof that a client paid for your services and that those services are of the type covered by their out-of-network benefits. The insurance (or “payer”) uses that information to accurately reimburse the client.

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A valid superbill includes:

• Client information, including their full name, date of birth, plan membership number, group insurance number, and address
• Therapist information, including your full name, credentials, NPI number, taxonomy code, practice address, and contact info
• Session details, including the date of each session, relevant CPT codes, and fees charged
• Diagnosis codes, indicating the client’s diagnoses using ICD-10 (most clients must have formally diagnosed conditions in order to use out-of-network benefits)
• Total amount paid by the client
• Your tax ID and signature: these aren’t always necessary, but some insurers require you to provide a Tax ID and sign the superbill. We recommend using an EIN rather than your SSN on superbills, since the document is shared with clients and insurers

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However, different payers may have different requirements for superbills. Check with individual payers first to make sure you fulfill all their superbill requirements, and adjust your superbill template if needed.

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A superbill that doesn’t conform to the insurer’s requirements will likely be rejected.

Superbill requirements for specific insurers

These are some of the most widely-used insurers who provide OON benefits for therapy, and how you tailor your superbill to each. Requirements change, so confirm against the insurer’s current form.

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• UnitedHealthcare. The superbill should show the patient name, your Tax ID, diagnosis codes, CPT/HCPCS procedure codes (with any applicable modifiers), units for each code, the billed amount for each code, and the place of service code. UnitedHealthcare notes that a copy of your W-9 may be needed for out-of-network providers, and Oxford and Surest plans use their own claim forms. (See: How to submit a UnitedHealthcare claim.)
• Cigna. Provide an itemized bill including your name and credentials, address, Tax ID, date of service, ICD-10 code, procedure code, and charge. Cigna does not accept receipts or balance-due statements in place of an itemized bill, and clients must submit a separate form for each provider and each family member. (See: Cigna Member Claim Form.)
• Aetna. The client attaches an itemized bill with proof of payment, or asks you to complete the provider section of Aetna’s claim form. The bill must show the patient’s name, the date(s) of service, the condition being treated, the type of service, and the patient’s relationship to the plan member (the employee). (See: Aetna Claim Form.)
• Anthem Blue Cross. The superbill must include the provider’s name, address, and tax ID, plus the patient name, service, date, place of service, charge per service, diagnosis code, and procedure code. The form linked here is Anthem Blue Cross’s California form; Anthem plans in other states use their own forms. (See: Anthem Blue Cross (California) Claim Form.)
• Humana. In addition to the typical superbill information, include proof of payment (for example, a “paid in full” note and the payment method). (See: Humana Members Claims and Forms.)
• Blue Cross Blue Shield (BCBS). BCBS plans are run state by state, so requirements and forms vary. Have your client use the claim form from their own plan’s member website.

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Payer superbill requirements at a glance

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Out-of-network reimbursement rates for therapy

Reimbursement rates vary between insurers, and two clients with the same insurer may have different reimbursement rates.

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In many cases, total reimbursement is limited by the plan’s allowed amount: the maximum a payer will count toward reimbursing their member for a particular OON service. Plans use different names for it, including “allowed amount,” “eligible expense,” and “usual, customary and reasonable” (UCR) or “reasonable and customary” charge. Mentaya calls it the maximum reimbursable charge (MRC).

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The allowed amount may be a dollar amount or a percentage. If it’s a percentage, that percentage is multiplied by a benchmark amount to determine the maximum amount a payer will count. Here are two examples.

Example 1: your fee is well above the allowed amount

• Insurer’s benchmark amount: $100
• Allowed amount: 110% of the benchmark
• Out-of-network benefit: 70%
• Deductible already met
• Provider’s bill: $200

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First, the insurer calculates the allowed amount: $100 × 110% = $110

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Then they calculate the reimbursement: $110 × 70% = $77

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So:

• The insurer pays $77, which is about 38% of the $200 fee
• The client’s coinsurance share of the allowed amount is $33
• The amount above the allowed amount is $90 ($200 − $110 = $90)
• The potential total the client owes is $123 ($33 + $90 = $123)

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In this example, the plan treats $110 as the maximum eligible charge. The extra $90 may be balance billing and may not count toward the client’s out-of-pocket maximum, depending on the plan.

Example 2: your fee is at or below the allowed amount

The numbers below are illustrative. Plans generally pay based on the lesser of your billed charge and the allowed amount.

• Allowed amount: $160
• Out-of-network benefit: 80%
• Deductible already met
• Provider’s bill: $150

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Because the $150 fee is below the allowed amount, the insurer works from $150: $150 × 80% = $120.

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• The insurer pays $120
• The client’s net cost is $30 ($150 − $120 = $30)

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The same 70-80% benefit can feel very different to a client depending on how your fee compares to the plan’s allowed amount. If the client has not yet met their out-of-network deductible, they will typically pay your full fee until they do.

Client communication templates for OON benefits

Putting together a client communication plan is one of the most effective steps you can take to ensure OON reimbursement goes smoothly for your clients.

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The aim is to communicate clearly to your client what they need to do to submit their claims, as well as the steps you’ll take to support them.

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Here are five templates for client communication you can adapt to your needs. They include emails you send each client informing them of how OON billing works, plus a script they can follow to verify their benefits.

1. Intake email: how out-of-network payment works

Subject: How payment and insurance reimbursement work at [Practice Name]

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Hi [Client first name],

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Thanks for choosing to work with me! Before our first session, I want to explain how payment works.

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I’m an out-of-network provider, which means I don’t bill insurance directly. My fee is $[fee] per [45/60]-minute session, due at the time of service. [Monthly/After each session], I can give you a superbill, an itemized receipt you can submit to your insurance company for possible reimbursement.

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A few things worth knowing:

• Reimbursement isn’t guaranteed. It depends on your specific plan. Many PPO and POS plans include out-of-network benefits, but many HMO and EPO plans don’t.
• Your plan pays a percentage of its “allowed amount,” not of my fee. That amount is often lower than my rate, so what you get back may be less than you expect.
• You may have a separate out-of-network deductible. It’s often higher than your regular deductible, so you may pay the full fee for a while before any reimbursement starts.
• A superbill includes a diagnosis code. Your insurer will see it and may keep it on file. Submitting for reimbursement is entirely your choice, and I’m happy to talk through it.

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I’ve included a short list of questions to ask your insurer so you know what to expect before we begin. [Optional: I also work with Mentaya, which can submit claims for you.]

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Take care,
[Name, credentials]

2. Client script: verifying out-of-network benefits

(Include this as a document attached to your intake email.)

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Call the member services number on the back of your insurance card and say: “I’d like to verify my out-of-network outpatient mental health benefits.”

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Ask:

1. Does my plan include out-of-network benefits for outpatient mental health?
2. What is my out-of-network deductible, and how much have I met so far?
3. After the deductible, what percentage does the plan pay?
4. How does the plan calculate the allowed amount for out-of-network therapy? What would it be for CPT codes 90791 (intake), 90834 (45 minutes), and 90837 (60 minutes) in my area?
5. Are there session limits, or does the plan require preauthorization or a referral?
6. Are telehealth sessions reimbursed the same way?
7. What is the deadline for submitting a claim, and how do I submit it (portal, mail, fax)? Is a claim form required?
8. Is mental health handled by a separate company or mailing address?

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Before you hang up: write down the representative’s name, the date, and a call reference number.

3. Superbill delivery email

Subject: Your superbill for [date range]

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Hi [Client first name],

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Your superbill for sessions from [dates] is available in [secure client portal]. I’m sending it there rather than by email because it contains health information.

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To submit it:

1. Log in to your insurer’s member portal (or download their claim form) and start a new out-of-network claim.
2. Upload the superbill. If they ask for proof of payment, use the payment receipt [attached/on the last page].
3. Submit it soon. Filing deadlines vary by plan, and I recommend submitting monthly rather than saving them up.
4. Keep a copy. Your insurer will send an Explanation of Benefits (EOB) once it’s processed.

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If your insurer asks for something that isn’t on the superbill, such as my NPI or Tax ID, let me know and I’ll add it. I can’t guarantee what your plan will pay, since that decision is up to your insurer.

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Take care,
[Name, credentials]

4. Claim denied or paid less than expected

Subject: Re: your claim

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Hi [Client first name],

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I’m sorry the claim didn’t come out the way you hoped. Here’s what I’d suggest:

1. Read your EOB and look for the reason. Common ones are missing information, the deductible not being met yet, a missed filing deadline, or the plan not covering out-of-network care.
2. If the reason is missing or incorrect information, send me the EOB and I’ll correct the superbill so you can resubmit.
3. If the plan simply pays less than my fee, that’s usually the allowed amount at work. Call your insurer and ask how they calculated it.
4. You have the right to appeal. If your insurer requests clinical records or a letter from me, I can provide them once you sign a release authorizing it.

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Please let me know if you have any questions.

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Take care,
[Name, credentials]

5. Short reminder nudge (text or portal message)

Hi [Name], a reminder that your superbill for [month] is ready in [portal]. Many plans have filing deadlines, so submitting this month is the safest bet. Let me know if your insurer asks for anything else.

Don’t forget the Good Faith Estimate for clients who pay out of pocket

If a client is paying out of pocket and not submitting an insurance claim, a Good Faith Estimate is generally required under the No Surprises Act, which took effect January 1, 2022. According to CMS, providers generally must give uninsured or self-pay patients an estimate of their expected costs when the patient asks for one or schedules care at least 3 business days in advance, and a client may be able to dispute a bill that is $400 or more above the estimate. How this applies to your practice depends on your situation, so consult counsel or your state board. For a rundown of the paperwork to have in place, see our guide to the complete list of policies and paperwork for your therapy practice.

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How to remove the frustration of dealing with insurance

While it seems like a happy middle ground, all the insurance paperwork and responsibility is handed over to the client, who might not have the motivation, resources, and/or knowledge to complete the process properly.

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Fortunately, companies like Mentaya exist to make the process easier, for both the therapist and their clients. They handle everything from instantly verifying benefits to automatically submitting claims, which helps therapists who want to be private pay, while saving clients up to 80% on therapy.

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Outsourcing ways to help clients through companies like Mentaya can go a long way.

Nuts and bolts: key insurance terms

Here are some important insurance terms that therapists should be familiar with to help their clients understand what they mean.

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Deductible: This is the amount a person has to pay out-of-pocket for health services before their insurance benefits kick in.

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Premium: This is the amount a person pays every month for their insurance plan.

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Out-of-pocket max: This is the maximum amount a person has to pay with their own money for covered healthcare services in a plan year. Once this maximum is reached, the insurance company generally pays for 100% of covered costs for the rest of the year. Deductibles, co-insurance, and co-payments count towards this maximum, but plan premiums do not. Out-of-network costs often do not count toward the in-network out-of-pocket max, though some plans have a separate out-of-network max.

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Co-payments: This is the amount a person pays for their health services. For example, if a session costs $100 and a person's deductible has already been paid, their co-pay may be only $20 for the visit.

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Co-insurance: Basically, the same as co-payments but instead of a fixed dollar amount, it is the percentage of that amount. For example, if a session costs $100 and a person has a coinsurance rate of 20% after meeting their deductible, they would pay $20 for the session.

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Superbill and claims: A superbill is an itemized document that lists the services provided and the payment received. A therapist can provide a superbill to their client, who can then file a claim with their insurance company. The insurer decides whether the services are covered and medically necessary.

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Reimbursement: Insurance includes reimbursement policies in which a person may pay out of pocket for a service, but can receive money back after submitting a claim. Plans differ on their reimbursement policies, so it's important for clients to understand their individual benefits.

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Allowable amount: This is the maximum amount an insurance company will consider for a specific healthcare service. Can also be known as eligible expense, payment allowance, negotiated rate, or “reasonable and customary” (UCR) charge.

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Timely filing limit: Another way to say the deadline for submitting a claim to an insurance company for reimbursement of a covered healthcare service. The time limit varies from 90-365 days, depending on the insurance plan.

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Mentaya helps therapists attract and keep more private pay clients, while being a part of making mental healthcare more accessible. No paperwork, just meaningful work. Use the code HEARD for a 30-day free trial.

Visit our Therapist Tax Center and Tax Deductions for Therapists Hub for everything you need to know about taxes as a practice owner. If you're just starting out, here's everything you need to know about How to Start a Private Practice as a Therapist.

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Summary

• Providing complete, accurate superbills to clients helps ensure they are reimbursed for OON claims
• It’s up to your client to submit their claims, but you can support them by telling them how to verify their benefits
• Some insurers require you (the provider) to fill out part of the claim form for clients submitting OON claims
• Reimbursement rates vary between insurers, plans, and employers, and are usually based on the plan’s allowed amount rather than your full fee
• Creating template documents (client communications, superbills) can speed up your admin when it comes to helping clients with OON benefits

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This post is to be used for informational purposes only and does not constitute legal, business, or tax advice. Each person should consult their own attorney, business advisor, or tax advisor with respect to matters referenced in this post.

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