Insurance Coverage, Benefits, and Claims

Mental Edge Counseling, LLC. is currently contracted with the following insurance companies:

  • Aetna

  • Amerihealth Caritas of Delaware

  • Blue Cross Blue Shield of Delaware

  • Cigna

  • Highmark Health Options

  • Humana

Insurance and Potential Costs

Although your insurance company may be listed above, there are times when your behavioral health coverage is under a different insurer. If this occurs, then your coverage will be out-of-network. Out-of-network means thats Mental Edge Counseling, LLC. does not have a contract with that company and you may be responsible for a higher deductible, copay, or coinsurance. With your understanding that you may have a higher out-of-pocket expense with using your out-of-network benefits, then we will bill your insurance company as a courtesy. It is also important to know that traditional medicaid does not cover out-patient mental health services for anyone under the age of 18. We use every effort to verify this information monthly, but there may be instances when this information will change. If this situation occurs, and your Managed Care (AmeriHealth or Health Options) does not pay, the total amount of the service will be your responsibility.

There could be times when an insurance may not pay for a claim. If this is to happen, then a member of the financial team will review the claim and contact the insurance company. If the claim was not paid due to an error on our part, we will correct the claim and resubmit it to the insurance company. If the claim was not paid due to an error on the insurance company, then we will have the insurance company send the claim back to be reprocessed. However, if there is no error, then you will be responsible for any portion not paid by your carrier.

At times, insurance companies may audit claims that they have paid. They have up to two years from the date of service, the payment of the claim, the receipt date of the claim, or the receipt of the appeal. This process is known as the "look back period" and is common among all of the insurance companies. If the insurance company determines that they have paid for a claim in error, then they will reverse their payment. This means that the insurance company will contact Mental Edge Counseling, LLC. to issue them a refund. If that is to happen, then we will then contact you for payment for that service.

  • Magellan

  • Medicare

  • Medicare Railroad

  • Optum (United Healthcare)

  • Tricare (Humana)

Insurance benefits

There are times when insurance benefits may seem contradictory. For example, group therapy may be covered, but marriage counseling is not. There will be certain times that a particular diagnosis is not covered, but treatment for that diagnosis will be covered. There may be times when a referral from another physician is required or a particular procedural code requires an authorization. We may also run into instances where your medical insurance is under one insurance company but your behavioral coverage is under another. We realize how frustrating and confusing insurance can be at times so we hope that providing the following information can make your billing experience as personal as your care.

Once becoming a client with Mental Edge Counseling, LLC., we will contact your insurance company to determine your insurance benefits. We will ask them a series of questions that pertain to behavioral health. We will provide a copy of this information to you at your first visit. If you have any questions, you can contact a member of our financial team and they can better assist you. If your questions pertain to your coverage, you will need to contact your insurance company. However, if you need assistance contacting your insurance carrier, we will be more than happy to help you.

Unfortunately, verifying your benefits does not always guarantee that your insurance company will cover certain services. Insurance companies always explain that any verification of covered services is not a guarantee of payment. Payment and coverage are determined by a number of factors once a claim is received.

Once the insurance company has received the claim, they will determine payment based on the following information:

  • If you have met either your in-network or out-of-network benefits - which consist of deductibles, copays, or coinsurances

  • If there are any exclusions or pre-existing conditions that may apply

  • If the service is covered by your plan

  • If the reason for the service is not covered - which would be your provider's treatment and diagnosis.

The billing code, as well as the diagnosis code, that we submit to your insurance company will be for the actual service provided. Unfortunately, we are unable to change that service code in an attempt to receive payment from the insurance company, therefore; any service not covered by your insurance will be your responsibility.

Professional Fees

Settling Balances

CareCredit