Insurance – Cerebral

Insurance terms

Term

Definition

Cost sharing

Cost sharing is the part of medical costs a client has to pay themselves, even if they have insurance. This includes copays, coinsurance, and deductibles [defined below].

Copay

A copay is a fixed fee a client pays each time they have a session or are prescribed medicine.

Coinsurance

Coinsurance is part of the bill the client pays after they’ve paid their deductible. For example: 20% of the cost.

Deductible

A deductible is an amount a client pays before their insurance starts to pay.

Superbill

An invoice that self-pay clients can submit to their insurance company for potential reimbursement.

Explanation of Benefits [EOB]

An EOB is a statement a client gets when a claim is submitted on their behalf that tells them what their clinician did, how much it cost, what their insurance paid, and what they still need to pay. It's not a bill, but it helps clients understand their costs.

Single case agreement

A single case agreement occurs when an insurance company tells a client that if they fill out a form, services provided can be considered in-network for their insurance.

⚠️ Cerebral does NOT engage in single case agreements.

✅ DO: If we receive a request for a single case agreement, inform the client that we can only provide them with an invoice they can submit for potential out of network reimbursement.

Insurance FAQs

Question	Answer
What does it mean if the client’s insurance company says that their reimbursement went towards their deductible?	This means that instead of receiving a check to reimburse for services, the amount that the client would have received was applied to help the client meet their deductible.
What is Cerebral’s tax ID?	California: 83-4662816. All other states: 85-3753458.
A client asked why we didn’t post for a certain invoice. What do we tell them?	Inform the client that we are a subscription service and insurance carriers are billed by sessions, so we are submitting their invoices to their insurer in a way that maximizes their reimbursement while remaining compliant. Clients can contact their insurance company for more information.
How do we address questions regarding insurance claims, requests for billing NPI, billing tax IDs, or diagnosis codes?	Redirect the ticket to the billing team by changing the assignee on the ZenDesk ticket to the ‘Account Reconciliation Team’. The Billing team checks the Account Reconciliation bucket in ZenDesk daily.

RTE [Real Time Eligibility]

ℹ️ RTE [real time eligibility] is an automatic process that instantly verifies insurance coverage for clients whose carrier is enrolled in RTE. This became available to new clients during sign up effective 7/11/24 and was added to the reactivation flow 10/25/24.

🗒️ Effective 4/4/25, an estimated copay will be available in RTE.

Clients will be prompted to click the ‘Check my coverage’ button within the onboarding or reactivation flow.

If in-network:
- Plan options will be displayed based on their coverage.
- The insurance information entered will automatically populate in the ‘Insurance Management’ tab of the client’s EMR with the status as ‘In-Network’.
If out-of-network, clients can continue on a $0/month fee-for-service plan or self-pay plan.
- Refer to the Out-of-network insurance section of this SOP for more information.

If clients encounter any issues, they will have the option to either continue without insurance or click a ‘Contact us’ button.
- If clients click the ‘Contact us’ button, they will be prompted to fill out our out-of-network typeform.

Entering/updating a client’s insurance information

ℹ️ Clients can enter/update their insurance information via the following triggers:

During sign up
Using the ‘check my coverage’ button in their account
Submitting a ‘Check insurance coverage’ EMR task

The steps below detail the client experience when utilizing the ‘check my coverage’ button in their Cerebral account.

Client logs into their Cerebral account.
Client selects ‘My Account’ from the dropdown menu.

Client locates the ‘Insurance Information' field and selects the ‘Check my coverage’ button.

Client enters their insurance information and uploads photos of their insurance card in the form that automatically populates.

In-network insurance

ℹ️ In-network insurance refers to services received from a provider that has a contract with a client’s insurance company, allowing eligible clients to receive services at reduced rates.

🗒️ Eligibility:

There is no monthly subscription cost for clients utilizing insurance.
Any additional charges for cost sharing [i.e. deductibles, copays, or co-insurance] are the client's financial responsibility and are outlined in their insurance plan.
✅ Direct clients to contact the member services line on the back of their insurance card for more information.
Effective 1/29/24, we can treat clients who have Medicare Advantage plans [Medicare Part C] on both an in-network and out-of-network basis.

⚠️ CerebralRX is NOT covered by insurance.

General insurance question [send where the client reached out]:

Hi [client name], thank you for reaching out. We accept insurance with some providers and are adding more. Log in and go to 'My Account' to see if you're covered for in-network billing.

If you're covered for in-network billing, there will be no monthly subscription cost. Any extra costs like deductibles, copays, or co-insurance are still your responsibility based on your insurance. Check your benefits or contact your insurance for details.

If you’re not covered for in-network billing, you also have the following options:

Option 1: Continue on our $0/month fee-for-service plan. We will automatically submit out-of-network claims to your insurance after each session.

Option 2: Sign up for a self-pay plan for therapy, medication management, or both. You can ask for a superbill at the end of each billing cycle to seek possible reimbursement from your insurance. Check our plans and prices here: https://cerebral.com/plans/.

If you have an HSA or FSA, you can also use those funds to pay by entering your card as your payment method.

Learn more about how insurance works at Cerebral here: https://support.getcerebral.com/hc/en-us

Let us know if we can help with anything else!

Invoice notifications

ℹ️ Invoice notifications are automatically created once a week and can be tracked via the Candid Invoice Report. Clients will be invoiced for the balance indicated in the report *7 days from the date of the invoice notification.

*Exception: Invoice notifications for payment plans are sent on Tuesdays to inform clients that they will be billed on that Friday.

Context: We have to wait for the invoice to occur on Friday in order to send the Stripe link for them to pay with Klarna.

Payment plans

ℹ️ Payment plans allow clients to pay bills in a series of smaller payments over time.

⚠️ Eligibility:

Only available as an option for insurance clients.
Only for clients who have NOT utilized Klarna in the last 365 days.
Payment plans can only be extended to clients with an unpaid invoice.

Denied claims

ℹ️ An insurance company can deny a claim for any of the following reasons:

Eligibility: Client is not eligible for coverage through their insurance.
Out of Network [NOT Medicare]: Client is not in network or was not on the date of service.
Out of Network [Medicare]: Client is not in network or was not on the date of service and has Medicare.
Coordination of Benefits: The clients COB (coordination of benefits) needs to be updated.
Demographic updates: Name, DOB, etc. on file compared to what insurance has on file does not match.
Referral Required: Client needs their PCP to submit a referral to their insurance company.
Prior authorization required: Client’s insurance requires a prior authorization.

Out-of-network insurance

ℹ️ Out-of-network insurance refers to services received from a provider that does not have a contract with a client’s insurance company, resulting in higher out-of-pocket costs.

🗒️ Clients whose insurance carrier we’re out-of-network with have the following options:

Continue with a $0/month fee-for-service plan.
- Fill out our insurance typeform.
- We will automatically submit out-of-network claims to their insurance after each session.
Sign up for a self-pay plan for therapy, medication management, or both.
- Sign up here.
- Ask for a superbill at the end of each billing cycle to seek possible reimbursement from their insurance.
- Use the promo code TRY20 for their first month of self-pay per our Credits & Refunds > Promo Codes SOP.
Use HSA or FSA funds to pay by entering their card as their payment method.

Reimbursement

Any out of network reimbursement provided is entirely up to a client’s insurance company.
If a client is eligible for reimbursement through their insurance company, they can expect to receive their reimbursement 4 to 6 weeks after the claim has been submitted.
If a client or a Clinician on a client’s behalf requests an invoice, follow our Itemized Invoices (Superbills) SOP.

OON reimbursement question: Self-pay clients [send where the client reached out]:

Hi [client name], thanks for reaching out.

For possible reimbursement from your insurance, you can ask for a superbill at the end of each billing cycle. Just send us a message through your account.

You need to have attended at least one session in the billing cycle, and the bill for that cycle must be paid. We can only give superbills for past billing cycles, not the current one.

Remember, insurance might not cover everything, and you may need to pay your deductible first.

If you are eligible for reimbursement through your insurance company, you can expect to receive your reimbursement 4 to 6 weeks after the claim has been submitted.

If you have any questions, please let us know. We are here to help!

OON reimbursement question: Clients on $0/month plan [send where the client reached out]: