Out-of-network TMS means the TMS team does not have a contract with your health plan, so the plan pays only what its out-of-network benefit allows, if it has one. You usually pay the clinic's fee up front or as you go, then you or the clinic send the plan a claim (often called a superbill), and the plan reimburses part of its "allowed amount" once your out-of-network deductible is met. New York's Department of Financial Services (DFS) puts it plainly: out-of-network cost-sharing is usually higher, and you pay the difference between the allowed amount and the provider's actual charge.
Two things surprise people most. First, the plan's medical-necessity rules for TMS still apply out of network, so a course can be fully paid by you and still denied. Second, out-of-network benefits come mainly with PPO or POS plans, so a plan without them may pay nothing at all. Check both before the first session.
Does your plan pay anything out of network?
DFS describes it this way: "If your policy has an out-of-network benefit (usually called PPO or POS coverage), you can get care from out-of-network providers." If your plan has no out-of-network benefit, a superbill will not produce a reimbursement, though the record may still help in an appeal or a network exception (see below).
Call the member services number on your card and ask these questions, writing down the date, the representative's name and a call reference number:
- Does my plan have out-of-network benefits for outpatient mental health services?
- Is transcranial magnetic stimulation (CPT 90867, 90868 and 90869) covered out of network?
- Is prior authorization required out of network, and who must request it, me or the provider?
- What is my out-of-network deductible, how much of it is met, and what is my coinsurance after it?
- Is there a separate out-of-network out-of-pocket maximum?
- How do you calculate the allowed amount, and what will you pay for one session of 90868?
- Where do I mail or upload claims, and what is the filing deadline?
How the money works: allowed amount, deductible, coinsurance, balance
Four numbers decide what you get back. The clinic's charge is what the TMS team bills. The allowed amount is the figure the plan decides the service is worth; out of network it is often lower than the charge. Your out-of-network deductible must be paid before the plan contributes. After that, the plan pays its share of the allowed amount, and you pay your coinsurance plus the gap between the charge and the allowed amount, often called the balance.
| Term | What it is | What to ask |
|---|---|---|
| Charge | The TMS team's fee for each code | A written fee list per CPT code before you start |
| Allowed amount | What the plan recognizes for that code | The plan's method and an approximate dollar figure |
| Out-of-network deductible | What you pay in full before reimbursement starts | How much is left this plan year |
| Coinsurance | Your percentage of the allowed amount after the deductible | The percentage, and whether it differs for mental health |
| Balance | Charge minus allowed amount; usually yours to pay | Whether the clinic will discuss its fee if the gap is large |
A full course is many sessions, so small per-session gaps add up. A standard course for depression is often about 30 to 36 sessions, five days a week. Timing matters too: a course that straddles January can mean meeting two deductibles.
New York requires plans to explain their math
New York Insurance Law section 3217-a requires state-regulated insurers to describe how they set out-of-network reimbursement, to state it as a percentage of the "usual and customary cost," and to give examples of anticipated out-of-pocket costs. On request, the insurer must also "disclose the approximate dollar amount that the insurer will pay for a specific out-of-network health care service," though that estimate is not binding. Ask for it in writing for codes 90867 and 90868. The text is on the New York State Senate site.
Prior authorization still applies out of network
Paying a provider yourself does not switch off the plan's TMS policy. The plan will check the same criteria it uses for in-network care: diagnosis, failed medication trials, rating scales and, for some plans, a psychotherapy trial. The guide to medication requirements by plan compares them, and the prior authorization guide lists the documents.
Cigna shows how this works in practice. Evernorth removed prior authorization for TMS from March 6, 2026, but only for its contracted providers: "Noncontracted providers must continue to obtain prior authorization for TMS." Its FAQ adds that out-of-network TMS remains subject to medical-necessity review, network exception requests still need prior authorization, and some plans' benefit documents may differ, so the details must be confirmed at the benefit check. Other plans have their own rules; ask yours directly and get the answer in writing.
If you skip authorization and the plan later decides the course was not medically necessary, the whole course can be denied after the fact. That is the most expensive mistake in out-of-network TMS.
What a TMS superbill should contain
A superbill is an itemized receipt with the codes your plan needs to process a claim. Ask the TMS team before you start whether they provide one, how often (weekly batches are easier to track than one bill at the end), and whether they submit claims for you. A complete TMS superbill lists:
- Your name, date of birth, address, and member ID
- The treating clinician's name, credentials, National Provider Identifier (NPI) and tax ID, plus the practice address
- The diagnosis code. Medicare's New York billing article and Optum's policy cover F32.2 and F33.2, major depressive disorder, severe, without psychotic features.
- Each date of service, with the CPT code for that day
- The charge per line, the amount you paid, and the date paid
- The place of service and the clinician's signature
| CPT code | What it describes | How often it usually appears |
|---|---|---|
| 90867 | Initial treatment, including cortical mapping, motor threshold determination, delivery and management | Once at the start; Medicare allows the planning service once per treatment episode |
| 90868 | Subsequent delivery and management, per session | Each routine treatment day |
| 90869 | Subsequent motor threshold re-determination with delivery and management | When the motor threshold is re-checked; Anthem in New York sends every 90869 request to peer review |
| 0889T to 0892T | Accelerated, MRI-guided theta-burst (SAINT-type) treatment | Only for that protocol; Aetna and Cigna treat these codes as experimental |
Keep copies of every superbill, your rating-scale results and the authorization letter together. If a claim is denied, that file becomes your appeal packet.
Submitting claims and reading the explanation of benefits
When a plan does not pay a claim in full, it must send you an explanation of benefits (EOB). In New York the EOB must show the provider, the date and description of service, the provider's charge, the amount the plan will pay, the reason for any denial or reduced payment, and how to appeal. Compare each EOB with your superbill line by line. Common problems are a missing authorization number, a session billed twice, or a code processed under the wrong benefit.
If the plan denies or underpays, the steps in appealing a TMS denial in New York apply to out-of-network claims too. New York's external appeal covers denials made because a service is out-of-network.
When you can get out-of-network care at in-network cost
New York has two routes worth knowing about.
Network adequacy rules
Since July 1, 2025, New York's behavioral health access rules require plans to offer an initial behavioral health appointment within 10 business days of the request. If the network cannot meet that, insurers must allow out-of-network care "at the in-network cost-sharing rate." Whether a plan applies this to a TMS course is a question to put to the plan in writing; keep a record of each in-network clinic you called and the wait you were quoted.
Out-of-network referral requests
You can also ask your plan to approve an out-of-network provider because no in-network provider has the training and experience to meet your needs. If the plan refuses and you appeal, DFS says your doctor must send a written statement that the in-network providers the plan suggested lack that training and experience, and must recommend an out-of-network provider who can provide the service. This works best for something the network truly cannot provide, not for convenience.
Does New York's surprise bill law help?
Usually not for TMS. A surprise bill in New York is a narrow category: for example, an out-of-network provider treats you during a visit with your in-network doctor, or your in-network doctor sends a specimen to an out-of-network lab, and you did not sign a written consent acknowledging the out-of-network charges. DFS states that "It is NOT a surprise bill if an in-network provider is available and you choose to receive services from an out-of-network provider" outside a list of hospital-type specialties. A planned TMS course you choose is normally that situation. DFS's surprise bill page has the full rules if your case is unusual.
Paying the gap
Health savings account (HSA) and flexible spending account (FSA) money can be used for "medical care" as the tax code defines it, which IRS guidance says includes psychiatric care. Confirm with your account administrator before you rely on it. If you decide not to use insurance at all, you are entitled to a Good Faith Estimate when you schedule care at least 3 business days ahead or when you ask for one. The guide to TMS cost without insurance covers self-pay in detail, and the overview of whether insurance covers TMS explains in-network coverage.
The same out-of-network process applies to other psychiatric care; the practice's pages on out-of-network psychiatry and fees and insurance describe its general policies. For TMS-specific questions, start with the TMS therapy page or browse the full TMS guide.
Sources
- Health Insurance Coverage Information for Mental Health and Substance Use Disorder Treatment. New York State Department of Financial Services, 2025. dfs.ny.gov
- NY Insurance Law Sec. 3217-A (Disclosure of information). New York State Senate, 2026. nysenate.gov
- Surprise Medical Bills. New York State Department of Financial Services, 2026. dfs.ny.gov
- Transcranial Magnetic Stimulation for Treating Physical Health Conditions (2026T0536W). UnitedHealthcare, 2026. uhcprovider.com
- Billing and Coding: Transcranial Magnetic Stimulation (A57528, version 5). Wellpoint Federal, CMS Medicare Coverage Database, 2026. cms.gov
- TMS prior authorization requirement removal - FAQ for contracted providers (PCOMM-2026-021). Evernorth Behavioral Health, 2026. campaigns.cigna.com
- Behavioral Clinical Policy: Transcranial Magnetic Stimulation (BH803TMS112025). Optum Behavioral Health Solutions, 2026. providerexpress.com
- MCG Care Guidelines 28th edition (Anthem NY provider news). Anthem Blue Cross and Blue Shield (New York), 2024. providernews.anthem.com
- Transcranial Magnetic Stimulation and Cranial Electrical Stimulation (Clinical Policy Bulletin 0469). Aetna, 2026. aetna.com
- Transcranial Magnetic Stimulation (Coverage Policy EN0383). Evernorth Health Services (Cigna), 2026. a.static.cigna.com
- Transcranial Magnetic Stimulation (TMS). Cleveland Clinic, 2026. my.clevelandclinic.org
- DFS press release: network adequacy and access standards for behavioral health. New York State Department of Financial Services, 2025. dfs.ny.gov
- File an External Appeal. New York State Department of Financial Services, 2026. dfs.ny.gov
- Publication 969 (2025), Health Savings Accounts and Other Tax-Favored Health Plans. Internal Revenue Service, 2025. irs.gov
- Publication 502 (2025), Medical and Dental Expenses. Internal Revenue Service, 2025. irs.gov
- Good faith estimate (No Surprises Act consumer guide). Centers for Medicare & Medicaid Services, 2026. cms.gov
FAQs
Can I get reimbursed for TMS if I already paid?
Often yes, if your plan has out-of-network benefits, the course met the plan's medical-necessity criteria, and any required prior authorization was obtained. Submit itemized superbills within the plan's filing deadline.
Is out-of-network TMS ever cheaper than self-pay?
It can be, once your out-of-network deductible is met. Whether it is depends on the plan's allowed amount compared with the clinic's fee, so ask the plan for an approximate dollar amount per code first.
Who submits the claims, me or the clinic?
Either, depending on the clinic. Some submit on your behalf and some hand you superbills to send yourself. Ask before you start, and keep copies either way.
What if my plan says it has no record of my authorization?
Send the authorization letter or reference number with the claim and ask for reprocessing. If the claim is still denied, file an appeal; New York's external appeal covers out-of-network denials.
Will a plan reimburse accelerated TMS out of network?
Unlikely under current policies. Aetna, Cigna and Optum list accelerated protocols as experimental or unproven. See the accelerated TMS coverage guide before paying for one.
