Out-of-network ADHD psychiatrist reimbursement in New Jersey

If the psychiatrist you want to see is not in your health plan's network, the usual pattern is simple: you pay the clinician's fee, then send a claim to your insurer and get back whatever your plan's out-of-network benefit allows. New Jersey has one of the stronger out-of-network laws in the country, but it was written mainly for surprise bills, not for a patient who chooses an out-of-network doctor for planned care. This page explains how reimbursement works, what the 2018 law does and does not do, and what clinicians and insurers in New Jersey must tell you.

Nothing here describes Dr. Shershow's fees or insurance arrangements. The office can tell you the current fees and how insurance works with the practice, and the basics are on the fees and insurance page.

How out-of-network reimbursement works

Every plan sets an allowed amount, which HealthCare.gov defines as the maximum amount a plan will pay for a covered service. When a clinician charges more than that, you may have to pay the difference. Reimbursement for an out-of-network visit usually works in this order:

1. You pay the clinician's full fee at the visit.
2. You submit a claim with an itemized statement.
3. The insurer applies its allowed amount for that service, not the fee you paid.
4. Your out-of-network deductible comes off first, if you have not met it.
5. The insurer pays its share of what remains (for example, a percentage of the allowed amount) and you pay the rest as coinsurance.
6. Anything the clinician charged above the allowed amount is also yours to pay.

That last step is why two people with the same fee can get very different checks back. What matters is your plan's out-of-network deductible, its coinsurance and how it calculates the allowed amount.

Your plan type decides whether there is any benefit at all

Read your own plan documents rather than relying on the label. Ask the insurer two things directly: whether your plan has an out-of-network benefit for outpatient psychiatric visits, and how much of your out-of-network deductible you have met this year.

What New Jersey's 2018 out-of-network law covers

The Out-of-network Consumer Protection, Transparency, Cost Containment and Accountability Act (P.L.2018, c.32, N.J.S.A. 26:2SS-1 et seq.) took effect on August 30, 2018. Its billing protections cover two situations:

• Inadvertent out-of-network services: care from an out-of-network provider when you use an in-network facility and in-network services are not available there.
• Emergency or urgent services.

In those cases, the provider may not bill you more than your in-network deductible, copayment or coinsurance. The statute also says its arbitration and billing sections do not apply to a person who "knowingly, voluntarily, and specifically selected an out-of-network provider." Booking a planned evaluation with a psychiatrist you know is out of network is that kind of choice. So for most adults seeking ADHD care in an office or by video, the law's balance-billing protection does not apply. Its disclosure rules, below, still do.

What an out-of-network clinician must tell you

Section 5 of the law (N.J.S.A. 26:2SS-5) sets disclosure duties for health care professionals. Before non-emergency services, a professional must tell you, in writing or on a website, which health plans they participate in, and tell you again verbally or in writing at the time of the appointment. If the professional is not in your plan's network, the law says they must, in terms you can understand:

• Tell you before scheduling a non-emergency procedure that they are out of network and that the amount or estimated amount they will bill is available on request.
• When you ask for the service and its CPT (billing) codes, give you in writing the amount or estimated amount they will bill and the CPT codes.
• Tell you that you will owe more than your usual copayment, deductible or coinsurance and may owe costs above what your plan allows.
• Advise you to contact your insurer about those costs.

If the professional's network status changes between that notice and the service, they must tell you promptly. Ask for the CPT codes in writing. You need them for the next step.

What your insurer must tell you

Under section 6 of the law (N.J.S.A. 26:2SS-6), a carrier must give members, for each plan:

• A clear description of the plan's out-of-network benefits, including how it calculates the allowed amount.
• On request for a specific CPT code, the allowed amount, the part the plan will pay and the part you will pay, with an explanation that you owe the gap between the allowed amount and the provider's charge.
• Examples of out-of-pocket costs for frequently billed out-of-network services.
• Written and online information that lets you estimate your cost in your region or ZIP code.
• A phone hotline, operated at least 16 hours a day, for questions about network status and out-of-pocket costs.

These duties apply to plans issued by New Jersey carriers. They give you the right to a real number before you book: call the insurer with the CPT codes and ask what it allows and what it would pay.

Filing the claim

1. Before the first visit, confirm the out-of-network benefit and ask what the plan allows for the codes the clinician gave you. Write down the date and the call reference number.
2. After each visit, ask the clinician for an itemized statement showing the date, the CPT codes, the diagnosis codes, the clinician's identifiers and the amount paid. People often call this a superbill. Check your insurer's claim form for anything else it requires.
3. Submit the claim through the insurer's portal or by mail, and keep copies.
4. Read the Explanation of Benefits. It shows the allowed amount, what went to your deductible and what the plan paid.
5. If the payment looks wrong, call first, then use the plan's appeal process. New Jersey's appeal steps are in appealing an insurance denial for ADHD in New Jersey.

If you are not using insurance at all

If you pay on your own without billing insurance, federal rules give you the right to a written Good Faith Estimate when you schedule care at least 3 business days ahead or ask for one. When you schedule 3 to 9 business days ahead, it is due within 1 business day; when you schedule 10 or more business days ahead, within 3 business days. Health savings and flexible spending accounts are another way to soften the cost; see HSA, FSA and taxes for ADHD costs.

Before you decide

Compare the whole first year, not one visit: the evaluation, the expected number of follow-up visits and what your plan returns on each. If the numbers do not work, the alternatives are covered in what to do when you can't find an in-network ADHD psychiatrist in New Jersey and low-cost ADHD care in New Jersey. For the broader coverage picture, see does insurance cover adult ADHD in New Jersey, and for how the evaluation itself works, see the adult ADHD evaluation page.