Using Aetna Out-of-Network Benefits for Therapy

If you have Aetna insurance and want to see a therapist who isn't in their network, you may still be able to get partial reimbursement through your out-of-network (OON) benefits. Here's what Aetna's OON coverage actually means for therapy clients — and how to make the most of it.

Does Aetna Cover Out-of-Network Therapy?

It depends on your specific plan. Aetna offers many different plan types, and not all of them include OON benefits:

• PPO plans — Most Aetna PPO plans include OON benefits. You can see any licensed therapist and receive partial reimbursement after your OON deductible is met.
• HMO plans — Aetna HMO plans generally do not cover OON care except in emergencies. If you have an HMO, seeing an OON therapist will typically mean paying the full cost yourself.
• EPO plans — Exclusive Provider Organization plans usually have no OON coverage either.
• HDHP/HSA plans — High-deductible plans paired with HSAs may offer OON benefits, but you'll typically need to meet a higher deductible first.

Check your Summary of Benefits and Coverage document, or call the number on the back of your Aetna member card. Ask specifically: "Do I have out-of-network mental health benefits?" and "What is my OON deductible for behavioral health?"

How Aetna Calculates OON Reimbursement

When you submit a superbill for an OON therapy session, Aetna pays based on their "allowed amount" — not necessarily your therapist's actual fee. The allowed amount is Aetna's determination of the Usual, Customary, and Reasonable (UCR) rate for that service in your geographic area.

For example, if your therapist charges $200 for a 60-minute session (CPT code 90837) but Aetna's allowed amount for that service in your zip code is $160, Aetna will base its reimbursement calculation on $160 — not $200. After your OON deductible is met, Aetna will pay a percentage of that $160 (commonly 60-70%), and you are responsible for the rest, plus the difference between $160 and $200.

Learn more about how insurers set these rates in our guide to how insurance companies calculate reimbursement.

What You Need: The Superbill

To get reimbursed by Aetna, you need a superbill from your therapist. This is a detailed receipt that includes all the information Aetna needs to process your claim:

• Your therapist's name, NPI number, and license number
• Your name and date of birth
• Dates of service
• CPT code for each session (for example, 90837 for a 60-minute session)
• ICD-10 diagnosis code
• Fee charged per session and total amount paid

For the complete list of required fields, see our superbill checklist. A missing field is the most common reason Aetna rejects a claim.

How to Submit a Claim to Aetna

Aetna offers several ways to submit an OON claim:

1. Aetna member portal — Log in to your account at aetna.com, go to "Claims," and select "Submit a Claim." You can upload the superbill as a PDF or image. This is usually the fastest method.
2. Aetna mobile app — The Health app lets you photograph and submit claims from your phone.
3. Mail — Send the superbill with a completed claim form to the address on the back of your member card. Keep a copy for your records.

Claims are generally processed within 30 days. You'll receive an Explanation of Benefits (EOB) showing what Aetna paid, what you owe, and any deductible applied.

Aetna's OON Deductible vs In-Network Deductible

Most Aetna plans have separate deductibles for in-network and out-of-network services. Your OON deductible is almost always higher — sometimes two to three times the in-network deductible. Once you meet the OON deductible for the year, Aetna begins paying its share of each OON session for the rest of the calendar year.

Track your progress toward the deductible in your Aetna member portal, or review each EOB as it arrives. Once you've met the deductible, make sure to re-submit any claims you may have been paying out of pocket.

Aetna Behavioral Health: A Note for Mental Health Claims

Aetna routes mental health claims through Aetna Behavioral Health, a separate division. If you call about a therapy claim, ask to be transferred to behavioral health customer service. They are better equipped to answer questions about mental health benefits, prior authorization requirements, and OON reimbursement rates.

For more on how to navigate the OON reimbursement process from start to finish, see our Aetna insurance guide for therapy clients.