THERAPY FEE AGREEMENT & NO SURPRISES ACT
PRIVATE PAY
$250 - Initial Intake Session (includes 55 minute session, baseline symptoms assessment, and treatment planning)
$200 - Regular 55 minute Therapy Sessions (typically scheduled weekly with eventual reduction towards termination)
$50 - Additional Therapy Time $50/each 15 minutes
$150 - Emotional Support Animal Letter
$200 - Therapy Letters rate is $200/hour (Diagnosis, FMLA, Disability, HRT, Treatment Summaries)
$300 - Gender Affirming Surgery Letters
$100 - Sending Full Medical Records
IN-NETWORK INSURANCE COVERAGE
Addison Therapy Associates (ATA) believes in affordable and accessible mental health care and has chosen to offer various insurance plans as an In-Network Provider. Most, but not all, of our providers are in-network with many plans, however insurance availability for each provider can vary. Addison Therapy Associates providers are contracted with various insurance panels including: AETNA, BCBS, CIGNA, EVERNORTH, MERITAIN, MULTIPLAN, OPTUM, UMR, SCOTT & WHITE HP. When utilizing insurance for mental health your final costs are driven by your specific insurance plan benefits and contracted rates. We will attempt to provide a complimentary benefits verification for a more accurate quote when possible.
Typical therapy process involves the following billing CPT codes:
Intake Appointment: CPT 90791, +90785 – Cost is driven by your insurance company and *contracted rate.
Intake symptoms baseline assessment: CPT code 96136 (unless more in-depth assessment required) - Cost is driven by your insurance company and *contracted rate.
Weekly Therapy Sessions: CPT 90837, +90785 – Cost is driven by your insurance company and *contracted rate.
*Contracted rate – this is the rate set by your carrier for the service codes listed above. As contracted providers who offer these services as an In-Network provider we are legally obligated to follow this contract and rates are non-negotiable when using your insurance coverage.
OUT OF NETWORK COVERAGE
Addison Therapy Associates is also able to submit out-of-network claims on your behalf if the provider you wish to see is not in-network. Many clients are often surprised their insurance provides out-of-network benefits for therapy. Out-of-network reimbursement would be based on your individual benefits, and it is your responsibility to confirm whether your provider is considered in-network or out-of-network with your plan. All out-of-network sessions are billed at the Private Pay Rate at the time of service.
NOTICE: ATA is at times available to provide assistance in helping you receive the benefits to which you are entitled; however, if your clinician is an out-of-network provider, or if your insurance plan does not provide reimbursement for the service you are seeking (for any reason), you (not your insurance company) are responsible for full payment. While your provider may assist you in obtaining a quote of your benefits, it is ultimately your responsibility to verify that this quote is accurate and to ensure you understand the scope of your benefits. Additionally, a quote of benefits is not a verification and insurance reimbursements are based on actual information and claims submitted and is subject to eligibility, terms, limitations, and exclusions of your health care program.
Should you choose to file claims to your insurance, please be aware your contract with the health insurance company requires claims include information relevant to the services rendered. Providers are required to include a clinical diagnosis and sometimes additional clinical information which may include copies of your entire Clinical Record. In such situations, your clinician will make every effort to release only the minimum information that is necessary for the purpose requested. Dallas Therapy Associates has no control over what the insurance company will do with it once it is in their possession.
NO SHOW / LATE CANCEL POLICY
Once an appointment is scheduled, that time is reserved only for you. If you are unable to attend a session, contact your provider at least 48-hours in advance and there will be no charge. Sessions missed without any contact are a fee of $150 collected at the time of your scheduled session. Sessions cancelled with less than 48-hours notice incur a fee of $125 collected at the time of cancellation. The only exceptions to this policy are inclement weather (ice), a death in the family, or what you and your individual provider may have agreed upon. If you miss or cancel an appointment without providing 48 hours’ notice and are unable to reschedule within the same week, you, not your insurance company, will be required to pay the cancellation fee at time of original scheduled appointment.
$150 - No Show, No call
$125 - Cancel less then 48 hours notice
Each provider retains ability to adjust their own cancellation policy
NO SURPRISES ACT OF 2022
ATA does not qualify to notify about surprise billing, but we want you to know your rights and the facts about the No Surprise Act that became effective January 1, 2022.
ATA does not qualify as a “facility” and is not contracted with insurance carriers as a facility. The providers at ATA can be contracted as individual providers under the group details or are directly supervised by a contracted provider. ATA bills in-network insurance claims as individual providers under the group contract. ATA will never bill for a “facility” or location and a provider and will only bill as an individual rendering provider for your care.
You have the right to always choose your provider for in-network and out-of-network services. In-network out of pocket expense are directly connected to your specific coverage plan and should be verified with your insurance carrier.
For more information: https://www.cms.gov/nosurprises
