Will My Insurance Cover Therapy? A Helpful Form

Insurance Verification Form for Therapy Benefits

Why Verify Your Therapy Insurance Benefits?

A common question we are asked at Therapy With Heart is, “how do I know if my insurance covers therapy?” Understanding your insurance coverage for mental health services is an important step in making informed decisions about your care. This form will guide you through a conversation with your insurance company to help you understand your out-of-network benefits for therapy sessions.

Before You Call:

  • Gather your insurance card and any relevant policy information.
  • Have a pen and paper ready to take notes.
  • Be prepared to wait on hold or be transferred to different departments.

Call your insurance company at the Member/Customer Services line. They may ask for your patient ID number. Each insurance carrier organizes its phone menu options differently, but you should listen for the options of checking benefits and eligibility and checking mental or behavioral health benefits. If possible, choose to speak to a live representative. If this is not a menu option, you may be able to reach one by verbally asking for a representative or for customer service. You may be transferred before reaching the representative who can tell you your benefits. Note the date you call and the call reference number.

Client Name: _________________________

Date: _________________________

Insurance Company: _________________________

Member/Customer Service Phone Number: _________________________

Call Reference Number: _________________________

  1. Benefit Period:(The year your coverage is active) _________________________
  2. Out-of-Network, Outpatient Mental/Behavioral Health Benefits:
    • Individual or Family Benefits (or both): _________________________
    • Deductible:
      • Individual: _________________________
      • Family: _________________________
    • Amount Met Towards Deductible:
      • Individual: _________________________
      • Family: _________________________
    • Coinsurance Rate (Percentage patient pays): _________________________
    • Out-of-Pocket Maximum:
      • Individual: _________________________
      • Family: _________________________
  1. Pre-Authorization Requirements:_________________________
  2. Claims Address:_________________________

Additional Notes: _________________________

How Do I Know if my Insurance Covers Therapy? An Example:

Let’s say the representative gives you these benefits:

Benefit period: 9/1/15-8/30/16

Deductible: $1,000 Amount met towards deductible: $300

Coinsurance rate: Insurance responsibility: 60% Patient responsibility: 40%

Out-of-pocket maximum: $5,000


These benefits are applicable during your benefit period. This means that on 9/1/16, a new benefit year begins. The benefit year is important to know because it tells you when the accumulation towards the deductible starts over. Many insurance companies will tell you the effective dates of the policy before they tell you the benefit period. This can be confusing, because both of them are dates and may be given at the beginning of the call, but make sure you ask for the benefit period specifically. You can ignore the effective dates for this worksheet.

Often, a deductible must be met before reimbursement is possible. In this example, that means that the patient has to spend $1,000 out of pocket before reimbursement can begin. Insurance companies will reimburse a percentage of the usual and customary fee for a therapy session. They will not tell you the usual and customary rate, but it is determined by typical session costs in your region. Often, this rate is lower than the actual fee you paid for your session.

The percentage of the usual and customary fee that the insurance company covers is known as the coinsurance rate. Be sure to find out what percentage the insurance company will cover and what percentage you will cover after the deductible is met. In this case, the insurance company will cover 60% of the fee after the deductible is met. For this example, let’s say the usual and customary rate is $100. The insurance company will send back $60 for every session after the deductible is met. The patient will have had 60% of the usual and customary rate reimbursed.

Your insurance company will put a limit on how much money you spend before they cover out-of-network mental health services at 100%. They will either limit the amount you pay out of pocket in general – the out-of-pocket maximum – or they will limit what you pay after the deductible as part of your coinsurance responsibility – the coinsurance maximum.

Special thanks to my colleagues, Dr. Laurie Watson, creator of the Foreplay Radio Sex Therapy program and Cornelious (Con) Sheehan from Emotional and Relationship Health Counseling Associates for their assistance in this blog. www.csheehanjr.com


If you have any questions about Therapy With Heart’s services please contact us.


Rachel Thomas


(480) 203-2881
8737 E. Via De Commercio, Suite 200 Scottsdale, Arizona 85258