Therapy Reimbursement Estimator
See how much your clients may recover from their out-of-network benefits. Enter your CPT code, insurance carrier, state, and session fee for an instant UCR range and estimated reimbursement.
Reimbursement Estimator
Estimates out-of-network reimbursement based on UCR rates
UCR estimates are based on industry benchmarks and vary significantly by plan, geographic area, and benefit year. These figures are for informational purposes only and do not guarantee any specific reimbursement amount. Always verify benefits with the patient's insurance carrier.
What Is UCR and Why Does It Matter?
Usual, Customary, and Reasonable (UCR) is the benchmark rate an insurance plan uses to determine how much it will pay for an out-of-network service. Each carrier maintains its own UCR database, which is influenced by geographic market data, provider specialty, and benefit plan design.
When your client has out-of-network (OON) benefits, their plan pays a percentage of UCR — typically 50–70% after the deductible is met. Your charged fee must be at or below UCR for the client to maximize their reimbursement; fees above UCR are not covered.
How This Estimator Works
The estimator uses a tiered UCR lookup table built from publicly available fee schedule benchmarks and carrier-reported data:
- State cost tier: States are grouped into high-cost (CA, NY, MA, WA, CO, CT, NJ, MD, OR), mid-cost (TX, FL, IL, PA, GA, VA, AZ, NC, MN, MI, OH), and standard markets — each tier has distinct UCR ranges.
- Carrier adjustment: BCBS tends to pay slightly above average; UHC, Cigna, and Humana trend below. The estimator applies a ±$5–15 adjustment per carrier.
- OON reimbursement range:Calculated as 50–70% of the UCR range, representing the typical range after the patient's deductible and coinsurance.
Tips for Maximizing Client Reimbursement
- Set your fee at or just below the UCR ceiling — not above it. Anything over UCR comes entirely out of pocket.
- Provide clients with a superbill immediately after each session. Plans often have strict timely-filing deadlines (90–365 days).
- Encourage clients to call their carrier to verify OON benefits and their current deductible balance before starting treatment.
- CPT 90837 (53+ min) typically reimburses significantly more than 90834 (38–52 min) for nearly the same session length. Use the longer code when clinically appropriate.
Generate a Superbill for OON Reimbursement
Clients cannot submit for reimbursement without a proper superbill. Superbilled generates compliant superbill PDFs with all required fields — diagnosis codes, CPT codes, NPI, provider signature, and more — in seconds.