Understanding Your Insurance Options and Reimbursement for Mental Health Services
Use this form to verify your out-of-network insurance plan benefits before starting care at Kellen Mental Health. Taking a few minutes to check your benefits can help you avoid unexpected costs and plan for treatment. If you’re interested in OCD treatment, Exposure and Response Prevention (ERP), or other specialized therapy, visit our OCD Treatment and ERP service pages to learn more.
Many clients use their out-of-network benefits even when KMH is not an in-network mental health provider. Depending on your plan, you may be eligible for reimbursement for mental health services after your appointments. Since every policy is different, we recommend confirming your benefits directly with your insurance company.
Before completing the form below, we also suggest reviewing our FAQs page, which explains how reimbursement and payment work so you know what to expect before your first appointment..
Verify Your Insurance Coverage Before Your Therapy Session
The questions below will help you understand your insurance coverage for therapy. Calling your insurance provider before your first therapy session can save time and reduce confusion later.
When speaking with your insurance representative, be sure to have your patient information, member ID, and policy details available. Ask about your deductible, copays, coinsurance, and whether your policy includes network coverage for out-of-network providers.
You should also ask whether your plan covers the listed CPT codes, requires specific diagnosis codes, or needs prior authorization before receiving care. Having this information ready will make the process smoother for both you and your provider.
Out-of-Network Insurance Verification Form
Please call the 800 number on your insurance card and complete this form with a customer service representative via telephone. It is important that you understand your insurance coverage prior to starting services at KMH.
Client Name
- DOB:
- SSN:
Insured Name:
- DOB:
- SSN:
Insurance Company:
- Insurance Phone Number:
- Mental Health Insurance (may be different than health insurance):
- Claims Address:
- Client Insurance ID#:
- Group #:
Mental Health Services
1) “Do I have mental/behavioral health coverage?” □ YES □ NO
If YES, continue.
2) “Do I have Out-of-Network benefits?” □ YES □ NO
If YES, continue.
3) “Do I have an Out-of-Network deductible?” □ YES □ NO
If YES, “What is my out-of-network deductible?”
“How much of my out-of-network deductible has been met?”
4) “Please verify that the following services are covered under my policy? If YES, what percentage?”
In-Person Sessions:
- Individual Therapy, 30 minutes (CPT Code 90832): □ YES □ NO _____%
- Individual Therapy, 45 minutes (CPT Code 90834): □ YES □ NO _____%
- Individual Therapy, 60 minutes (CPT Code 90837): □ YES □ NO _____%
- Family Therapy, without patient present (CPT CODE 90846): □ YES □ NO _____%
- Couples, Marriage, & Family Therapy, with patient present (CPT CODE 90847): □ YES □ NO _____%
- Group Therapy (CPT Code 90853): □ YES □ NO _____%
- Psychiatric Diagnostic Evaluation (CPT Code 90792): □ YES □ NO _____%
- Level 3 Visit – Psych. Followup (CPT Code 99213): □ YES □ NO _____%
- Level 4 Visit – Psych. Followup (CPT Code 99214): □ YES □ NO _____%
Video Sessions:
- Individual Therapy, 30 minutes (CPT Code 90832-95): □ YES □ NO _____%
- Individual Therapy, 45 minutes (CPT Code 90834-95): □ YES □ NO _____%
- Individual Therapy, 60 minutes (CPT Code 90837-95): □ YES □ NO _____%
- Family Therapy, without patient present (CPT CODE 90846-95): □ YES □ NO _____%
- Couples, Marriage, & Family Therapy, with patient present (CPT CODE 90847-95): □ YES □ NO _____%
- Group Therapy (CPT Code 90853-95): □ YES □ NO _____%
- Psychiatric Diagnostic Evaluation (CPT Code 90792-95): □ YES □ NO _____%
- Level 3 Visit – Psych. Followup (CPT Code 99213-95): □ YES □ NO _____%
- Level 4 Visit – Psych. Followup (CPT Code 99214-95): □ YES □ NO _____%
5) “Do I need an authorization to receive any of these services?” □ YES □ NO
If YES, “What is my authorization number?”
“How many sessions are authorized?”
6) “What forms do I need to submit for reimbursement?”
7) “Do you require the providers signature on the superbill?”
8) “What is the most efficient way to submit these forms?”
Note: KMH is not responsible for coverage or reimbursement. Please be advised that time spent performing insurance-related requests exceeding 15 minutes is not included in the session rate and will be billed at your provider’s hourly rate. Coaching sessions, wellness services, workshops and recommended testing through third-party companies (e.g. neuroendocrine and pharmacogenetic testing) are not eligible for insurance reimbursement.
Understanding Therapy Superbill Reimbursement and Claims Submission
If your policy includes out-of-network services and benefits, KMH can provide a therapy superbill after eligible appointments. A superbill contains the information your insurance company may need when submitting a superbill for reimbursement.
The superbill includes items such as procedure code, diagnosis codes, provider information, and dates of service. Your insurance company uses this information during the claims submission process to determine whether services qualify for reimbursement.
Many clients initially pay out of pocket for services and are later partially reimbursed based on their policy benefits. Requirements for submitting superbills vary between insurance companies, so always confirm the preferred submission method directly with your carrier.
Choose KMH for Compassionate Mental Health Services
At KMH, we believe understanding your benefits should be simple. While we cannot guarantee reimbursement, we’re happy to provide the documentation needed to support eligible out-of-network claims and help you navigate the process.
Whether you’re seeking therapy for anxiety, depression, OCD, ERP, relationship concerns, or other mental health needs, our experienced team is here to provide compassionate, evidence-based care. We encourage all clients to verify their benefits before starting treatment to make informed financial decisions.
Complete the Out-of-Network Insurance Verification Form above, then contact us to schedule your appointment. We look forward to supporting your mental health journey while making the insurance process as clear as possible.