Insurance Coverage For Mental Health Services

Some insurance companies pay for mental health services using the same processes that pay for medical services. Others pay for these services using a special mental health insurance company. The number of mental health visits covered by your insurance may be different than the number of medical visits covered.

Visits with a psychologist, psychiatrist, psychiatric nurse practitioner, psychiatric physician’s assistant, mental health therapist or behavioral analyst are billed as mental health services.

Our clinic can tell you if Seattle Children’s is contracted with your insurance company for mental health services. Contracted means we are in your insurance plan’s network and services should be paid using “in-network” benefits.

Some insurance plans are contracted for medical care, but not for mental health care if they use a managed mental health company to manage the mental health benefit. Visit the following link for more information: seattlechildrens.org/clinics/paying-for-care/insurance/mental-health-coverage.

If we do not have a contract, this means we are “out-of-network.” In most cases you will need to contact your insurance company and ask for help to find a provider that is in your insurance plan’s network and accepts your insurance.

Here are questions you can ask your insurance company to learn more about your child’s mental health insurance benefits:

• What is my deductible?
• What is my co-pay or co-insurance for mental health care?
• Do all mental health services apply to my deductible?
• Are the providers at Seattle Children’s Psychiatry and Behavioral Medicine Clinic in network? Here’s information your company may need to answer this question:
  • Types of providers your child may see at Seattle Children’s: psychiatrist, psychiatric nurse practitioner, psychiatric physician’s assistant, psychologist, mental health therapist or behavioral analyst
  • Tax ID for Seattle Children’s is 91-0564748
• Is authorization required for services? If yes, what happens if visits are not authorized?
• Are there any diagnoses or billing codes that are not covered? (See “Common Procedure and Diagnosis Billing Codes” on the last page.)
• Clinic visits at Seattle Children’s are billed as an “outpatient hospital visit” instead of an “office visit.” How will my insurance cover this type of visit?
• Is a mental health facility charge covered by my insurance plan?

A facility charge is for hospital expenses for a clinic visit that are separate from the professional expertise of the medical provider. The facility charge includes costs for running the “facility,” like supplies, equipment, exam rooms and other Seattle Children’s staff.

You may be billed a facility charge for a mental health clinic visit depending on your insurance and the clinician providing care:

1. Most visits with a psychiatrist, psychiatric nurse practitioner or psychiatric physician’s assistant for a visit to discuss or manage your child’s medicines include a hospital facility charge (revenue code 510).
2. All in-person services with a psychiatry fellow, psychiatry resident, psychology fellow, psychology resident or other psychology trainee are billed with a hospital mental health facility charge (revenue codes 900-916).

Insurance plans cover facility charges differently. It is important to ask your insurance company what you may owe for a mental health facility charge.

Visit seattlechildrens.org/clinics-programs/billing for more information.

You will receive a separate professional charge for services from a psychiatrist, psychiatric nurse practitioner or psychiatric physician’s assistant.

Services delivered by a licensed psychologist or mental health therapist are billed as a professional charge only.

Insurance regulations and Washington state law determine which insurance you need to use first. This is called primary insurance.

If your primary insurance will not pay for care because the provider is not in network, then the second insurance will not pay for the care either. This is because you are expected to get care from a provider that is in network with your primary insurance. You cannot choose which insurance to use for care – the plans coordinate coverage based on rules.

It is important that all valid insurance plans are listed on your child’s registration so accurate billing will occur.

We contract with Apple Health (Medicaid) and their managed care plans (Molina, Coordinated Care, CHPW, Wellpoint and United Community).

No. Seattle Children’s is a contracted provider with Apple Health/Medicaid and is not allowed to accept payment from a family whose child is enrolled in this plan.

Seattle Children’s has a generous financial assistance program. Apply online at seattlechildrens.org/finasst or call 206-987-3333 to speak with a financial counselor.

If you use a language other than English, call 1-866-583-1527, choose your language and ask to speak to a financial counselor.

Authorization: Many insurance companies or the company they hire have to review and approve (authorize) the patient’s care plan before they agree to pay for services. We request authorizations from insurance companies after visits are scheduled and before we see patients.

Coinsurance: Your share of the fee for a covered service. Some benefits require that you pay both a copay and coinsurance, depending on the service.

Copay (also called copayment): The fee you pay at the time of service (most often for an office or emergency department visit).

Deductible: The amount you pay each year before your insurance plan will pay according to your benefits. Some services are excluded from the deductible requirement; your payer can identify these. Most deductibles start January 1 of each calendar year.

In-network coverage: Covers your care from a provider who is contracted with your insurance company. It is best for you to use in-network coverage so you can benefit from a lower deductible, a lower copay amount, and/or more allowed visits per year.

Out-of-network coverage: Covers your care from a provider who is not contracted by your insurance company. We don’t recommend you use out-of-network coverage as you are likely to have a higher deductible, a higher copay and/or coinsurance amount, and/or limited visits per year. Many plans do not offer out-of-network coverage.

• Psychiatric Diagnostic Evaluation: 90791 or 90792
• New Patient Evaluation and Management: 99203, 99204, 99205 (depending on length or complexity of visit)
• Return Patient Evaluation and Management: 99213, 99214, 99215 (depending on length or complexity of visit)
• Individual Therapy: 90834 (sessions that are 38-52 minutes) and 90837 (sessions that are 53+ minutes)
• Patient Group Therapy: 90853
• Multiple Family Group Psychotherapy (for parent groups): 90849
• Family Psychotherapy (without patient): 90846
• Family Psychotherapy (with patient): 90847

• Unspecified Disruptive Behavior Disorder, Impulse Control and Conduct Disorder: F91.9
• Attention Deficit Hyperactivity Disorder: F90.2
• Autism Spectrum Disorder: F84.0
• Major Depressive Disorder, Unspecified: F32.9
• Generalized Anxiety Disorder: F41.1