Using Blue Cross Out-of-Network Benefits for Therapy

Blue Cross Blue Shield (BCBS) is one of the largest health insurance networks in the United States. If you have BCBS coverage and want to see an out-of-network therapist, you may be entitled to partial reimbursement — but the rules vary by plan and by state. Here's what BCBS patients need to know about using OON benefits for mental health care.

The BCBS Network: Understanding the Complexity

"Blue Cross Blue Shield" is actually a federation of 35 independent, locally operated companies. Your plan may be administered by BCBS of Michigan, Anthem BlueCross in California, BCBS of North Carolina, or another local affiliate — and each operates somewhat differently. When you call about your OON benefits, you're talking to the local affiliate that administers your plan, not a single national entity.

That said, most BCBS PPO plans follow similar structures for out-of-network mental health coverage.

Does Your BCBS Plan Cover Out-of-Network Therapy?

As with other insurers, it depends on your plan type:

• BCBS PPO — Most PPO plans include OON benefits. After meeting your OON deductible, BCBS pays a percentage of its "allowed amount" for each therapy session.
• BCBS HMO / BlueSelect / LocalBlue — These plans typically do not cover OON care except emergencies. Seeing an OON therapist will be an out-of-pocket expense.
• BCBS BlueCard — If you have a BCBS plan from one state but live or work in another, BlueCard connects your benefits. OON coverage still depends on your underlying plan type.

Check your plan's Summary of Benefits and Coverage document, or call member services to ask specifically: "Does my plan have out-of-network behavioral health benefits?"

How BCBS OON Reimbursement Works

When you see an OON therapist and submit a superbill, BCBS processes your claim as follows:

1. BCBS determines the "allowed amount" for the service in your geographic area — this is their version of the Usual, Customary, and Reasonable (UCR) rate.
2. Your OON deductible is applied. Until you've met it, you pay 100% of the allowed amount.
3. After your deductible is met, BCBS pays their coinsurance share — typically 60-70% of the allowed amount — and you pay the remainder.
4. You also pay the difference between your therapist's actual fee and BCBS's allowed amount, if the therapist charges more.

To understand how UCR rates affect what you get back, see our guide on how insurers calculate reimbursement.

Submitting a Superbill to BCBS

To get reimbursed, you need a complete superbill from your therapist. BCBS will need:

• Your therapist's full name, NPI number, and license number
• Your name, date of birth, and BCBS member ID
• Date of each session
• CPT code (e.g., 90837 for 60-minute individual therapy)
• ICD-10 diagnosis code
• Fee charged and amount you paid

For all required fields, see the complete superbill checklist. You can submit claims through the BCBS member portal, mobile app, or by mailing a claim form with the superbill attached.

BCBS Mental Health Parity Requirements

Under the Mental Health Parity and Addiction Equity Act (MHPAEA), BCBS plans that cover mental health must do so on terms no more restrictive than physical health coverage. This means the OON deductible for mental health should not be higher than the OON deductible for other medical care, and visit limits should not be more restrictive.

If you believe your BCBS plan is applying more restrictive rules to mental health OON benefits than to comparable physical health services, you have the right to appeal. Ask for the plan's criteria for medical necessity determinations for behavioral health.

The BlueCard Program: Coverage When Traveling

If your BCBS plan is from your home state but you're seeing a therapist in a different state, the BlueCard program usually applies your home plan's OON benefits. If the therapist participates in any BCBS network, they may be treated as in-network — even if they're not in your home plan's network. Call member services before scheduling to confirm how your specific plan handles cross-state providers.

More BCBS Resources

For a plan-specific guide to using your BCBS benefits for out-of-network therapy, including which BCBS affiliates have the most comprehensive OON mental health benefits, visit our Blue Cross Blue Shield insurance guide.