I have found myself covering this information so often that I decided to make it available for others: 
 
     When talking with your insurance carrier:
 
    You will need to find out if your insurance company “carves out” mental health to a sub-contractor.  If so, you will probably need to contact the subcontractor, often a “behavioral health company.”
 
     Ask if the following are covered by your insurance:
 

• Psychiatric eval as well as consultation for second opinion if you will be receiving medication management or other psychiatric services at another provider but neurofeedback or psychiatric consultation with me.

 

• Psychotherapy with a psychiatrist

 

• Med management with a psychiatrist

 

• Biofeedback and/or neurofeedback with the psychiatrist or a tech

(Biofeedback can include hand-warming, heart-rate variability biofeedback and neurofeedback….make sure you ask carefully.  Some insurance companies will pay for neurofeedback, but want it coded as psychotherapy.  Others have a flat rate they pay for any biofeedback.  Some do not cover any biofeedback in any form.
 
 
    Ask how your in-network coverage differs from out of network.
 
    From the beginning, ask if it is possible to be covered for your treatment with the out-of-network psychiatrist AS IF SHE IS IN NETWORK (This is sometimes referred to as a “special exception” or “special accommodation”, or “ad hoc agreement”).  What this usually involves is your request, and some lack of available of in network providers suitable for you.  If they agree, then they will contact the provider and attempt to work out a special case agreement with the provider, negotiate a fee, and make the authorizations necessary.
Depending on your situation, you may want to find out if your company covers group therapy and marital or family therapy
 
 
Also find out the following: 
 

• Your deductible, and the dates when they start a new deductible period

 

• Your yearly or lifetime maximum dollar benefit

 

• Are you limited to the number of sessions they cover per year

 

• Your copay. 

 

• Ask them if visits have to be pre-authorized, and to pre-authorize your visits with me

 
 
    Ask how much they pay…. whether your copay stays the same or increases over time.   Here be shrewd and persistent.  Some insurances refuse to tell you the dollar amount they pay until they know what the provider charges.  Ask if they have a “limiting charge”, (on which they pay a percentage –and what IS that percentage….then you pay the remaining percentage as well as the difference between the limiting charge and the charge the provider charges.)   Alternatively, they may pay a percentage of the actual charge.  That actual charge may be the insurance allowed amount for in network docs, or the “agreed upon fee” if they do an ad hoc agreement. 
 
     If they insist on knowing what the provider charges, give them an estimate, such as $600 for an initial visit and $250 for follow up visits involving psychotherapy.  (You may need to divide the code for follow-up visits to $125 for the med mgmt. code and 125 for the psychotherapy code.). 
 
     If you are interested pursuing insurance coverage for the neurofeedback/biofeedback, ask about those charges and codes too, as follows, keeping in mind that insurance may not distinguish between biofeedback and neurofeedback the code is same either way:

     Neurofeedback with Dr. Pesaniello is $250 for eeg neurofeedback.

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     If it is PirHEG training or HRV biofeedback or hand temperature training, Dr. P can do this for $250 a session, and it is not coded as neurofeedback, but as relaxation training along with/as part of psychotherapy with aim of improved self-regulation.  The distinction has to do with the kind of devices used and the process.  In this case, you do not need to ask about the coverage for biofeedback.  Only ask about biofeedback/ Neurofeedback for eeg neurofeedback). 
Neurofeedback with a tech supervised by Dr. Pesaniello: $125 and the CPT code is 90901. Ask if there are limited conditions in which this is covered, if so, what are they.  If they won’t tell you ask if it is covered for:

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• migraines (G43.909),

• traumatic brain injury (F07.81),

• ADD/attention disorders (F90.0), and

• mood (F31.31for bipolar and F33.0 for depression).

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     If they insist that you provide the diagnosis code, that is the number in parentheses.  It is important to know if they cover any one of these, since many patients have more than one diagnosis, you may qualify under one of them.
 
     They will also ask for the “CPT code” or “procedure code”.   In that case, be armed with the following codes: 
 
     All individual visits for meds and therapy include the med mgmt. code below, plus a psychotherapy code from the next set.  Two codes each time:
the med management codes:  99212, 99213,99214,
individual visits for psychotherapy:
         90832, 90833, 90836,90838 this depends on length.  I typically use the 90636, rarely 90833 for short sessions
initial psychiatric eval:
         99204, 99205, or 90792
90853 for group therapy
90847 for family therapy
95816 for quantitative eeg
95957 comprehensive analysis of qeeg
 
    Clarify the differences in your out-of-pocket expense if you see someone in network vs out of network.   If the difference is significant, and you would like to see an out of network physician, you may have to be insistent about wanting a single case agreement:
   
     How to do this?  Say that you live in a psychiatric underserved area for starters, as that provides more leeway to those approving coverage.  State what you want and expect them to be able to provide to you as an insured member.  (A highly qualified and available psychiatrist and the option to not have “split treatment” at a public clinic (what most of the other options here are).   IF you work or are planning to work eventually in a clinic, state that for confidentiality reasons you need to not have to interface with people at public/high volume clinics for reasons of confidentiality…. Use everything you can think of that indicates need for the accommodation.   For example, tell them you want to see a physician, and your preferences for male or female, if you feel that is necessary (tell them you have your reason).  Tell them you want to see someone who can see you weekly at least initially, or who can address the medical issues impinging on mental health concurrently and provide ongoing collaboration with your physicians (for pain or other stress-related medical conditions), that you want someone who is able to provide weekly psychotherapy, has openings, and is in a reasonable driving distance.   Tell them you do not want split treatment, if you want me to do both meds and therapy.  (“Split treatment” is when meds are with one person, therapy with another).  If true, challenge them to not insist you engaged in care that may be compromised from the beginning by forcing you into a high volume, split treatment clinic.
 
     If they give you a number of in network providers who they say can offer these things, check it out.  Often, they will say they have in-network psychiatrists, but when you call, you learn you will not see the psychiatrist except for the initial eval, (if that), and that the psychiatrist will not see you weekly for your therapy or even your med follow-up …. You may soon be seen only every three months by the psychiatrist in these clinics, while your therapy is relegated to someone else, often someone with less training in psychotherapy.  Most in network psychiatrists are at high volume clinics and spend minimal time with patients, and often have high turnover…may be gone before the next med check.  Clinic docs usually won’t do med eval and management for patients in therapy elsewhere.  So, they are not available to you unless you change your therapist to a clinic therapist.  (This saves money for the insurance but may not be best for you.)
 
     Usually, to get the single case agreement, you will have to call back the insurance company and tell them none of the providers are available/acceptable.  So, you want them to authorize you to see the psychiatrist you have found, and to authorize it as a special exception, as if she is in network. (This option may give you a copay-only or less out of pocket expense You want initial eval and follow up sessions authorized as an ad hoc or special case agreement.
 
    Some insurance companies offer this option, especially in psychiatric shortage areas like the Eastern Shore.  Emphasize this