A carrier pays a therapist based on its allowed amount for each code, not the practice's billed fee. In-network, the allowed amount is the contracted rate. Out-of-network, it's the plan's own allowance. To compare carriers, use your EOBs, contract rate exhibits and the in-network rate files that health plans have posted since July 2022.
Last verified: November 9, 2026.
General information, not financial or legal advice. Payer contracts, state insurance law and plan documents control what you are paid. This article explains public concepts and sources as of November 9, 2026, and it quotes no carrier's rates.
The one number that decides payment: the allowed amount
HealthCare.gov defines the allowed amount as "the maximum amount a plan will pay for a covered health care service," and notes it "may also be called 'eligible expense,' 'payment allowance,' or 'negotiated rate.'" The rest of the claim is arithmetic based on it:
Billed charge: your practice's fee, the same for every payer.
Allowed amount: the payer's figure for that code under that plan.
Patient responsibility: the deductible, copay or coinsurance, applied to the allowed amount.
Plan payment: the allowed amount minus the patient's share.
Adjustment: the difference between your billed charge and the allowed amount. In-network, your contract usually requires you to write it off.
This is why raising your billed fee doesn't raise in-network payment. It changes the write-off, not the allowed amount.
How in-network rates are set
When you join a network, the contract usually includes a rate exhibit or fee schedule. It lists the allowed amount for each code you bill, or a method for calculating it. Carriers express these exhibits in different ways. Some list a dollar amount per code. Others define rates by reference to a benchmark, such as a percentage of a Medicare fee schedule for a given year. Whatever the format, ask for the exhibit in writing before you sign, and confirm:
Which codes are listed. Make sure 90791, 90832, 90834, 90837, 90847 and any add-on or crisis codes you use are there.
Whether rates differ by license. Many payers, like many Medicaid programs, pay master's-level clinicians less than psychologists or psychiatrists.
Whether a benchmark is frozen to a year. "X% of Medicare 2024" is not the same as "X% of current Medicare."
Telehealth terms. Check place of service, modifiers, and whether audio-only visits pay at the same rate.
Term, renewal and amendment rules. Know how and when rates can change.
If an exhibit uses Medicare as its benchmark, you can check it against CMS's public figures. Our guides cover the 2026 Medicare rates for therapy codes and how to look up your locality.
How out-of-network reimbursement works
If you are out-of-network, you have no contract with the carrier, so there's no agreed write-off. Typically:
The patient pays your fee, and you give them a superbill: an itemized receipt with diagnosis and procedure codes, dates, your NPI and tax ID.
The patient submits it to the plan.
If the plan has out-of-network benefits, it applies its own out-of-network allowed amount, then the patient's out-of-network deductible and coinsurance, and pays the patient its share.
Your fee minus the plan's payment is the patient's cost.
Three practical points:
Out-of-network benefits vary by plan type. Many HMO and EPO plans pay nothing out-of-network except in limited cases, while many PPO plans do pay. Only the patient's plan documents or a benefits check can tell you which applies.
The out-of-network allowed amount is set by the plan. It's often below the billed fee, and plans differ in how they set it. The patient may owe the difference.
Balance-billing protections are limited here. Federal No Surprises Act protections against balance billing focus on emergency care and certain services at in-network facilities. They usually don't cover a patient who chooses an out-of-network therapist's office. State law may add protections, so check your state's rules. If the patient is uninsured or self-pay, the good faith estimate rules apply. See good faith estimates and your website.
Comparing carriers with public data
Rate surveys and forum threads are a poor basis for contract decisions. Three public, primary sources are better.
1. Your own EOBs and remittances
Your explanation of benefits and electronic remittance advice (ERA) records are the most accurate data you have. Build a simple table: payer, plan or product, code, license, date of service, allowed amount. After a few months you'll know each carrier's real allowed amount for each code, including any plan-to-plan differences inside the same carrier.
2. Transparency in Coverage machine-readable files
CMS says that since July 1, 2022, most group health plans and individual and group insurers have had to post public machine-readable files with:
in-network negotiated rates for covered items and services;
out-of-network allowed amounts and historical billed charges.
These files are the only primary public source of commercial negotiated rates. They are also very large. CMS says "specific technology may be needed to download and read these files," and expects third-party developers to process them. To find a carrier's files, CMS suggests searching for "machine readable files," "transparency in coverage," "in-network rates" or "out-of-network allowed amounts" along with the plan or insurer name.
What changes next. On October 5, 2026, HHS, Labor and Treasury finalized amendments (CMS-9882-F). According to the CMS fact sheet:
In-network rate files will be posted per provider network, not per plan.
The in-network and out-of-network allowed amount files move from monthly to quarterly updates.
The out-of-network reporting threshold drops from 20 claims to 11, with data grouped by market type.
New Taxonomy and Utilization files will show which provider-rate combinations were left out and which providers actually billed.
Plans must post a .txt file in their website's root folder pointing to the files. Starting October 1, 2027, they must also put a footer link titled "Price Transparency" or "Transparency in Coverage" on their homepage.
The in-network and allowed amount changes apply five months after Federal Register publication. The new contextual files apply after 11 months. In practice, behavioral health rates should become easier to isolate, because the taxonomy rules aim to remove rates that don't apply to a provider's specialty.
3. Government benchmarks
Medicare: CMS's PFS Look-up Tool and RVU files give every code's national and locality amount, as covered in our guides above.
Medicaid: under 42 CFR 447.203, states must publish fee-for-service rates and compare outpatient behavioral health E/M rates with Medicare. See state Medicaid behavioral health fee schedules.
What state insurance departments can tell you
State insurance departments license carriers and handle consumer and provider complaints. The NAIC's Consumer Insurance Search (CIS) lets you look up an insurer's legal company name and open report options for it, and directs users to their state insurance department for licensing questions. Use it to confirm exactly which legal entity issued a plan, which helps when a contract, EOB and directory all use different brand names. For prompt-pay or network-adequacy problems, your state insurance department's provider complaint process is the primary channel.
A simple comparison worksheet
For each carrier you are considering or already contracted with, record:
| Field | Where it comes from |
|---|---|
| Allowed amount for your top 3 codes, by license | Rate exhibit or EOBs |
| Benchmark and year (if any) | Rate exhibit |
| Telehealth terms | Contract, provider manual |
| Average days from claim to payment | Your ERA dates |
| Denial and rework rate | Your billing system |
| Credentialing and recredentialing burden | Your records |
| Share of your current inquiries from that carrier's members | Your intake log |
The last row matters as much as the rate. A lower-paying carrier that sends a steady flow of referrals may serve a practice better than a higher-paying one nobody in your area has. Your own numbers will tell you which is which.
Tell patients which carriers you take
Patients look for therapists by insurance before almost anything else. Name each carrier and plan you are in-network with. Say plainly when you are out-of-network and offer superbills. Keep that list consistent with payer directories. The free ClinicStats audit includes an "Insurance or self-pay prices stated" check that shows whether your site names plans or prices, and it explains how the score is built on the methodology page. Run a free scan.