Health insurance fees

Health insurance benefits:

Dr. Hersha only accepts Blue Cross Blue Shield (BCBS) benefits at this time. If your behavioral health services are not covered by BCBS, psychotherapy sessions and evaluations provided by Dr. Hersha will be considered ‘Out of Network’

Use the form below to obtain useful information regarding your Out of Network Benefits:

To determine whether your insurance covers psychological or counseling services, you need to call your insurance provider and request the information. (Coverage details also may be available on your insurer’s web site).

In the event that you have to call your insurer, make sure you have your insurance identification card, a pen or pencil, and a printout of this page. Do not feel shy about requesting this information; as the customer, you have a right to this information.

Your insurance provider’s phone number is usually toll-free, and is located on the back of your insurance card. Your insurer may require you to be pre-authorized to receive mental health benefits, and direct you to a managed health care company whose job is to “manage” your use of my services.

When interacting with your insurance provider’s representatives, state that you are calling to find out what coverage you have for services provided by an out-of-network provider who is a licensed psychologist. The representative will ask for your name, date of birth, policy holder, policy holder identification number, and group number.

The insurance representative may ask for specific information to determine whether I qualify as an out-of-network provider. My identification and credentials are as follows:

• Hersha Diaz, Psy.D. Licensed Psychologist in the State of New York , NY License # 018832-1

• My Federal Employer Identification Number (EIN) number 463463432

• My National Provider Identification (NPI) 1689909269

Remind them that I am not in their panel and do not work under their fee schedule.

The representative will probably ask what the diagnosis is. Tell the representative that the diagnosis is _________________________________ (I will give it to you on your super bill or tell you directly). If you do not yet have a diagnoses ask the representative if there are any diagnoses given in counseling situations that are not covered.

After you answer all of the representative’s questions, ask “To whom am I speaking?”
Write down the representative’s name__________________________.

Then ask “In the future, what is the best phone number to call with future inquiries about mental health benefits?”
___________________________________________

Next the representative will ask what procedures are going to be performed. If the representative does not ask, tell the representative that you have questions about the coverage for a number of procedures and that you have the codes for these procedures.

Provided below is a procedures checklist that may apply to you (depending on what services you will receive from me), as well as codes (CPT, or Clinical Procedure Terminology).

CPT code 90791

– Insurance coverage provided: Yes ___ No ____.

– Rate charged by Dr. Diaz: $250 for 60 minute session.

– Insurer reimbursement: ______.

– Is there a maximum dollar amount or maximum number of interviews allowed for this service? (Typically there are 2 to 4 intake interviews)

CPT code 90834, 90847

Individual – Insurance coverage provided: Yes ___ No ____.

– Rate charged by Dr. Diaz: $200 (45 minute session)

– Insurer reimbursement: ______

– Is there a limit on the number of sessions I can have in any one day? Yes ___ No ____ Or in any one week? Yes ___ No ____.

– Is there a maximum dollar amount for this service? ________.

– Is there a yearly maximum? _____________.

– Is there a lifetime maximum? ____________________.

Couples (if applicable)
Some insurance companies will not cover couples counseling. If they do:

– Insurance coverage provided: Yes ___ No ____.

– Rate charged by Dr. Diaz: $250 for 60 minutes

– Insurer reimbursement: ______

– Is there a limit on the number of sessions in any one week? ___

– Is there a maximum dollar amount for this service? ________.

– Is there a yearly maximum? _____________.

– Is there a lifetime maximum? ____________________.

Now ask the representative, for any of the above CPT codes you inquired about:

Are there any other restrictions or limitations we have not talked about? ___________________________________________________________

Will Dr. Diaz, as an out-of-network provider, be expected to fill out any additional forms such as description of the problems that brought me to therapy including symptoms, past history of symptoms, prognosis for change, etc? Yes ____ No ____.

Will Dr. Diaz be asked to have a telephone case review on your file with an insurance representative? Yes ___ No ___.

What deductible must be satisfied?________________________________.

How much of my deductible is already satisfied? ____________(if you have had recent procedures and the bill has not been processed, the computer will not have this information).

At this point, if you have decided to proceed and use your insurance benefits, you may be assigned an
Authorization Number. Write it down:______________________________

Once again ask for your representative’s name:__________________________.

After ending the conversation, record the date:__________ and time ____________ of phone call.

This should provide you with most of the information that you need to know about how much you will be reimbursed by your insurance company for your treatment.

*Dr. Hersha does provide a sliding scale fee for clients who present with financial hardship and can attend morning or afternoon sessions.

Call Dr. Hersha Today

(347) 746-0712

or email : appointment@drhersha.com

MAKE AN APPOINTMENT

ADDRESS

11-11 44th Drive

Suite O

Long Island City

NY 11101

CONTACT

(347) 746-0712

appointment@drhersha.com

FOLLOW DR HERSHA