Fees & Insurance

Individual Therapy

$150.00 – $200.00

Navigating health insurance can be complex. Understanding your responsibilities is crucial for seamless care.

    • Deductible: The amount you pay for covered healthcare services before your insurance starts to contribute. Example: If your deductible is $1,000, you pay the full cost of services until this amount is met.

    • Copay: A set fee you pay for specific services, such as $20 per therapy session. varies year to year.

    • Coinsurance: The percentage of costs you pay after meeting your deductible. For instance, with a 20% coinsurance, you pay 20% of each service, and your insurance covers the remaining 80%.

    • Out-of-Pocket Maximum: The highest amount you’ll pay for covered services in a year. After reaching this cap, your insurance covers 100% of eligible expenses.

    In-Network vs. Out-of-Network Benefits

    • In-Network Benefits: Services provided by professionals who have agreed to lower rates with your insurer, typically resulting in lower out-of-pocket costs for you.

      • Out-of-Pocket Costs: This is the total amount you are personally responsible for paying for healthcare services, including deductibles, copays, and coinsurance. These costs apply until you reach your Out-of-Pocket Maximum, after which your insurance covers 100% of covered expenses for the remainder of the plan year.

    • Out-of-Network Benefits: Services provided by professionals not in your insurance’s network, often resulting in higher out-of-pocket costs and potentially lower coverage by your plan.

    Mental Health Benefits

    • Some plans include diagnosis-specific mental health benefits that vary by condition. Be sure to check these details, as they can affect your mental health coverage.

Health Insurance

  • Please be advised that a quote of eligibility and benefits is not a guarantee of payment. 
  • All benefits and claim payments are subject to eligibility, medical necessity and the terms, conditions, limitations, exclusions and payment provisions of the patient’s health benefit plan at the time the services are rendered.
  • Benefit amounts are usually not based on billed charges and might be significantly less than billed charges.
  • Your health insurance company will only pay for services that it determines to be “reasonable and necessary.”
  • Our office will make every effort to bill your insurance in a timely manner.
  • If your carrier determines that a particular service is not reasonable and necessary, or that a particular service is not covered under the plan, your insurer will deny payment for that service and it will become your responsibility.
  • We recommend you to be familiar with and verify your benefits with your insurance company prior to your services at Progressing through Therapy, PLLC.
  • Please be aware, that even then, it is still not a guarantee of benefits or payment.
Definition of Medical Necessity

Definition of Medical Necessity

At Progressing Through Therapy, we emphasize that our services are distinctly different from life coaching. To ensure clarity, we adhere to the following criteria for determining the Medical Necessity of our services:

  1. Purpose: Medical Necessity has the following focus and goals:
    • Reduce or alleviate the individual’s symptoms.
    • Return the individual to baseline or improve their level of functioning.
    • Prevent imminent deterioration that would lead to a need for admission to a more intensive level of care.

    Individual therapy should be considered when:

    • The individual is experiencing symptoms or impairments that are impacting their day-to-day functioning, relationships, work, or school performance.
    • The individual has been unable to alleviate their symptoms on their own and/or is in need of additional assistance to relieve their symptoms.
  2. Nature of Service: The service must not be experimental, investigational, or cosmetic, except as allowed under North Carolina G.S. 58-3-255.
  3. Appropriateness: The service must be necessary for and appropriate to the diagnosis, treatment, cure, or relief of a health condition, illness, injury, disease, or its symptoms.
  4. Standards: The service must adhere to generally accepted standards of medical care within the community.
  5. Convenience: The service must not be provided solely for the convenience of the insured, the insured's family, or the provider.

Understanding Medical Necessity and Health Insurance Coverage for Mental Health Services

When it comes to using health insurance to pay for mental health services, the concept of "medical necessity" plays a crucial role. Here’s a brief explanation to help you understand why some services may be covered by insurance while others may not:

What is Medical Necessity?
Medical necessity refers to the requirement that a service must be essential for diagnosing, treating, curing, or relieving a health condition, illness, injury, or disease. For mental health services, this means the treatment must address a condition that significantly impacts your daily living activities and is considered outside the norm by societal standards.

Why Some Services are Covered:

  • Diagnosis and Treatment: If the service is necessary for diagnosing or treating a mental health condition that affects your ability to function in daily life, it is likely to be covered.
  • Accepted Standards: The service must align with generally accepted medical standards within the mental health community.
  • Medical Evidence: There must be medical evidence supporting the need for the service, ensuring it is not experimental or purely for convenience.

Why Some Services are Not Covered:

  • Non-Essential Services: Services considered non-essential, such as those for personal development or general life improvement without a specific medical diagnosis, may not be covered.
  • Experimental Treatments: Experimental or investigational treatments that lack sufficient medical evidence or approval may not be covered.
  • Convenience-Based Services: Services provided primarily for the convenience of the patient or provider, rather than out of medical necessity, are typically not covered.

Key Takeaways:

  • Medical necessity ensures that only essential and effective treatments are covered by insurance.
  • Understanding this concept helps you navigate what mental health services your insurance may or may not cover.
  • Always check with your insurance provider and mental health professional to determine coverage for specific services.

Our goal is to provide clarity and support, helping you access the necessary mental health care you deserve.

Cancellations

  • We reserve your 55-minute appointment time just for you. WE DO NOT DOUBLE-BOOK OUR PATIENTS  so that we may provide optimum treatment outcomes for all our patients.
  • Cancelled appointments with less than 24 hours’ notice will be charged $75.00.