Patient Billing & Insurance Guide
Understanding your insurance benefits is important. From identifying potential billing issues and making payments to navigating deductibles and changes in costs, knowing how your coverage works can help you avoid confusion and unexpected expenses.
Billing Quick Facts
Copays
A set amount that a patient pays to their provider when services are rendered.
Example:
Your plan says: $25 copay for outpatient mental health visits. You pay $25 at each appointment. Your insurance covers the remaining approved amount.
Important Notes:
Copays usually apply even if you haven’t met your deductible. Copays do not always count toward your deductible (depends on your plan). Copays typically do count toward your out-of-pocket maximum.
Deductibles
A deductible is the amount you must pay out of pocket each year before your insurance begins covering services.
Example:
Your deductible is $1,000.
You must pay $1,000 in covered services before insurance starts paying its portion.
Key Points:
Deductibles reset every calendar year (January 1 for most plans). Some services may be exempt from the deductible.
Mental health benefits often fall under medical deductible rules.
Co-insurance
Co-insurance is the percentage of costs you pay after your deductible has been met.
Example:
Your plan: 20% co-insurance.
Session cost: $150 (insurance allowed amount).
After deductible, insurance pays 80% ($120).
You pay 20% ($30).
Important:
Co-insurance only applies after your deductible is satisfied.
The percentage is based on the insurance-approved rate, not the provider’s full fee.
Out of Pocket
The out-of-pocket maximum is the most you will pay for covered healthcare services in one year.
Once you reach this limit:
Your insurance pays 100% of covered services for the rest of the year.
Example:
Your out-of-pocket maximum is $5,000.
After paying $5,000 (copays + deductible + co-insurance),
Insurance covers 100% of covered services.
Note:
Monthly insurance premiums do not count toward your out-of-pocket maximum.
Non-covered services do not count toward this limit.
Insurance Quick Facts
EOB (Explanation of Benefits)
An EOB, or Explanation of Benefits, is a statement sent by your insurance company after a medical service has been processed.
An EOB is not a bill. It explains:
What service was provided
How much the provider billed
How much the insurance company paid
What portion of the cost may be the patient’s responsibility
If you receive an EOB after a visit to Mindwell Behavioral Health, it simply summarizes how your insurance processed the claim.
TPA (Third-Party Administrator)
A TPA, or Third-Party Administrator, is a company that manages administrative services on behalf of an insurance plan.
These services may include:
Claims processing
Benefits administration
Provider network management
Customer support
Some employers or insurance plans hire a TPA to handle these functions instead of managing them directly.
Claim
A claim is a request for payment submitted by a healthcare provider to an insurance company after services are provided.
The claim includes:
Patient information
Diagnosis codes
Procedure codes
Date of service
Once the insurance company processes the claim, they send an Explanation of Benefits (EOB) to the patient.
Medical Necessity
Insurance companies pay for services they determine to be medically necessary.
A service is considered medically necessary when it is:
Appropriate for diagnosing or treating a condition
Consistent with accepted medical standards
Not primarily for convenience
Mental health services provided at Mindwell Behavioral Health must meet medical necessity criteria for insurance coverage.
AOC (Add-On Codes)
AOC stands for Add-On Codes. These are special billing codes used in healthcare when an additional service is provided in conjunction with a primary service during the same visit.
Add-on codes:
Cannot be billed alone
Must be used together with a primary service code
Reflect additional work performed by the provider
For example, certain therapy services or extended services may include add-on codes when appropriate.
Carve-Out
A carve-out refers to a situation where a specific category of healthcare services is removed from a standard insurance plan and managed separately.
For example, some insurance plans carve out:
Behavioral health services
Pharmacy benefits
Substance use treatment
In these cases, those services may be administered by a separate company or insurance provider, even though they are still part of your overall health coverage.
Coordination of Benefits (COB)
Coordination of Benefits applies when a patient has more than one insurance plan.
One insurance plan is designated as the primary payer, while the other becomes the secondary payer.
The primary insurance pays first, and the secondary insurance may cover some or all of the remaining balance depending on the policy.
Prior Authorization
Prior authorization (also called pre-authorization) is approval from your insurance company required before certain services can be provided.
Some insurance plans require authorization for:
Certain psychiatric services
Medication management services
Intensive treatment programs
If prior authorization is required, the provider or administrative team typically submits the request to the insurance company.
FAQ about billing or refunds?
Where can I pay my bill?
Through our patient portal, account holders can make online credit card payments, view statements and payment history. Account holders can also access this information from the patient portal for all accounts in which they are linked to.
What is my financial responsibility for services?
Patients are responsible for:
- Copayments required by their insurance plan
- Coinsurance amounts
- Deductibles not yet met
- Any services not covered by insurance
If insurance does not cover a service, the patient may be responsible for the full cost of the visit.
Why is there a cost difference between an initial assessment and future sessions?
The initial assessment is more of an involved process. During the initial session, we gain a comprehensive understanding of your presenting concerns and how they affect different aspects of your life. With this knowledge, we develop a personalized treatment plan tailored to your specific needs and goals.
Subsequent sessions will focus on working towards your therapeutic goals. Our approach involves exploring your patterns of thinking, feeling, and behavior to develop greater insight, while equipping you with the necessary tools to achieve your desired outcomes.
What forms of payments do you accept?
We take all major credit/debit cards, FSA/HSA cards, cash and checks.
How much will therapy cost without health insurance benefits?
At MindWell Behavioral Health, we believe in fee transparency – the cost of therapy without any health insurance is typically $100 or $150 per session, varying depending if it is an initial evaluation or follow-up sessions.
However, many people do have out of network benefits weaved into their insurance plans without their knowledge. Depending on your plan and healthcare spending, your insurance company will reimburse you for your sessions. Usually, insurance companies cover a percentage of your "out of network" costs after you reach your deductible, which is the amount you're expected to pay out of pocket before insurance starts making payments as per the contract. The specific deductible and reimbursement percentage vary from person to person and plan to plan, but generally, insurances reimburse 60%-80% of their reasonable and customary rate after meeting the deductible. It's possible that you've already met your deductible through other healthcare expenses!
Reach out today to check your health insurance benefits!
How is My Visit Cost Determined?
We strive to make quality care affordable and transparent, ensuring our patients avoid unexpected bills. To do this, we accept a wide range of insurance plans. However, the cost of your visit depends on several factors related to your specific insurance coverage. While we do our best to provide accurate estimates, the most reliable way to determine your visit cost is by contacting your insurance provider directly.
Like most healthcare providers, we submit claims to your insurance provider before sending you a statement. Your insurer determines your out-of-pocket costs through the following process:
- You receive care.
- We submit a claim to your insurer.
- Your insurer reviews the claim and checks your plan details.
- They calculate your out-of-pocket cost based on your coverage.
- We receive the insurer’s determination and bill you accordingly.
- You receive a statement with the final cost.
Since insurance processing times vary, it may take a week or longer to receive your bill.
Why isn’t my portal balance matching my explanation of benefits?
There may be several reasons why your portal balance does not match your Explanation of Benefits (EOB). One possibility is that the office has not yet received the EOB, which would result in it not being posted. It may be helpful to check with the office for further clarification.
Who can I contact if I have questions about my bill?
Patient Billing Phone number - (609) 237-7101
Patient Billing E-Mail address - billing@mindwellcare.com
We accept referrals from hospitals, providers, and other community-based programs and supports.
We accept referrals from hospitals, providers, and other community-based programs and supports.
Individuals can also contact our office to speak with one of our admissions coordinators by
Mercer County, Ewing
Tel (609) 237-7100
Fax (609) 616-7904
Email - info@mindwellcare.com
Camden County, Pennsauken
Tel (856) 831-7000
Fax (856) 831-4991
Email - yourcareteam@mindwellcare.com
Making your first appointment can be one of the most difficult steps in your mental health journey.
At MindWell Behavioral Health, we make it simple.
Our experts provide in-network and out-of-network therapy and psychiatry services, covered by insurance, through Telehealth and In-person appointments.