Out-of-Network Billing for Therapists: 7 Essential Steps
Out-of-network billing for therapists means billing a client’s health plan, or handing the client a receipt to submit, when you have no contract with that plan. You set your own fee, and the plan pays according to the client’s out-of-network benefits. This guide walks through seven steps to do it cleanly.
What is out-of-network billing for therapists?
Out-of-network billing for therapists is billing for clients whose plan you have not contracted with. In network, you accept the plan’s contracted rate. Out of network, you set your fee, and the plan pays based on the client’s benefits and its allowed amount, the most it will count for the service. Some plans pay nothing outside the network: HealthCare.gov says a health maintenance organization (HMO) typically does not pay for care outside its network, apart from emergencies (checked 10/24/26). That is why you verify first. Our comparison of in-network vs out-of-network credentialing covers the trade-offs.
7 steps for out-of-network billing for therapists
- Verify out-of-network benefits. Ask for the out-of-network deductible, coinsurance, how the plan sets its allowed amount, claim filing instructions and the filing deadline. Our insurance verification checklist for therapists lists the questions.
- Set your fee and write down your policy. Put the fee, payment terms and cancellation rules in your consent paperwork before the first session.
- Give a Good Faith Estimate when one is required. The section below explains when.
- Document every session. The note must support the code you bill. Psychiatrists bill an evaluation and management (E/M) visit and any psychotherapy add-on code, and each may be paid at its own out-of-network rate.
- Choose how the plan gets the bill. You file the claim, a billing service files it, or the client submits a superbill. The table below compares them.
- Track timely filing. Each plan sets its own deadline for out-of-network claims. Note it the day you verify benefits.
- Follow up on payment. Read the electronic remittance advice (ERA), the payment detail the plan sends back, and chase denials and low payments.
Claim or superbill: how the plan gets the bill
A claim goes from your practice to the plan on a standard claim form. A superbill is an itemized receipt the client sends in. The plan’s rules decide who receives payment, so confirm that when you verify.
| You (or a service) file the claim | Client submits a superbill | |
|---|---|---|
| Who sends it | Your practice or billing service | The client |
| Who tracks it | You, through the remittance | The client, with your help if you offer it |
| Who fixes errors | You correct and resubmit | Client and plan, unless you reissue the superbill |
| Where payment goes | Set by the plan and any assignment of benefits | Usually to the client |
Good Faith Estimates and the No Surprises Act
A Good Faith Estimate (GFE) is a written estimate of expected charges. Under the No Surprises Act, providers must give one to uninsured and self-pay individuals. CMS’s April 2022 provider FAQ describes this as clients with no applicable coverage or clients who do not plan to file a claim with their plan (CMS FAQ, checked 10/24/26). See the glossary entry for a good faith estimate.
Timing, per a February 2022 CMS presentation: when a visit is scheduled at least 3 business days ahead, the estimate is due within 1 business day of scheduling. When it is scheduled at least 10 business days ahead, or the client asks for cost information without scheduling, it is due within 3 business days (CMS presentation).
For insured clients who plan to file a claim, the April 2022 FAQ says HHS deferred enforcement of the requirement to send estimate information to the plan until rulemaking. Confirm the current status on CMS’s No Surprises page or with counsel before you rely on it.
Private payers, Medicare and Medicaid
Private payers
Out-of-network billing for therapists looks different at every private plan: benefits, deductibles and the allowed amount all vary. Where the law and your paperwork allow it, the client may owe the gap between your fee and the allowed amount; our post on balance billing for therapists explains the limits.
Medicare and Medicaid
Medicare covers outpatient mental health visits from listed provider types, including clinical psychologists, clinical social workers and counselors; after the Part B deductible the client usually owes 20% of the Medicare-approved amount (medicare.gov, checked 10/24/26). CMS presents enrollment as the route for providers who plan to bill Medicare, with an opt-out for those who do not. Do not assume a superbill gets a Medicare client reimbursed. Confirm your enrollment status first. Medicaid is different again: federal rules require state Medicaid plans to limit participation to providers who accept the state’s payment as payment in full (42 CFR 447.15).
State rules
Rules on out-of-network disclosures and billing clients can vary by state. Check your state insurance department or ask counsel; do not apply a rule from one state to another.
Can a therapist bill insurance if they are out of network?
Yes, in many cases. If the client’s plan has out-of-network mental health benefits, you can file the claim or give the client a superbill, and the plan pays according to those benefits. If the plan has no out-of-network coverage, as is typical for an HMO, the client pays you directly. Verify benefits before the first session.
What to ask before you outsource
- Does it file the claim, or only prepare superbills?
- Who verifies benefits and tracks timely filing?
- How does it handle denials, and what reports do you get?
- Will it sign a business associate agreement (BAA) for patient health information?
What to do Monday morning
- List your out-of-network clients and the plan for each.
- Check that each has verified benefits and a signed fee policy on file.
- Read the remittances on last month’s unpaid claims.
The short version: out-of-network billing for therapists
Out-of-network billing for therapists comes down to seven steps: verify, set your fee, estimate when required, document, choose claim or superbill, watch the deadline, and follow up. Medicare and Medicaid follow enrollment rules, not the superbill route. Write your policy down and run the same checklist for every client.
How MCM South helps
MCM South Medical Billing Service, LLC bills out-of-network claims for psychotherapists and psychiatrists. Our insurance verification and eligibility checks service covers the benefit check in step 1.
Keep going
Related reading
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FAQ
What is a superbill?
A superbill is an itemized receipt with your details, the client’s details, dates of service, codes and fees. The client sends it to their plan for possible reimbursement. It does not guarantee payment.
Do I need a Good Faith Estimate for every client?
No. CMS ties the requirement to uninsured and self-pay individuals, including insured clients who do not plan to use their coverage. Confirm how it applies to each client with counsel or CMS guidance.
Is billing a client directly the same as being out of network?
Not exactly. Out of network means you have no contract with the client’s plan. Billing a client directly can mean they pay you and choose whether to seek reimbursement. Many practices do both.
Do prescribers bill out of network differently?
The process is the same, but psychiatrists bill E/M visits and psychotherapy add-on codes, and the plan may pay each at its own out-of-network rate. Verify both when you check benefits.
Where MCM South works
MCM South Medical Billing Service, LLC works with psychotherapists and psychiatrists in our ten currently served states: Georgia, Massachusetts, Connecticut, Texas, Florida, New York, Colorado, Tennessee, North Carolina and Illinois. We serve solo and medium-size practices that bill mental and behavioral health. Founder Michael Williams has worked with insurance payers in all 50 states. Browse the state and regional billing guides for rules that vary by state, or see our billing services.
This post is operational guidance for billing, not legal advice. Rules change, so confirm with the payer or your counsel.
