Guide

OON fees: UCR data and the number you can defend

Summary

Set one master fee per code that reflects your time and expertise, and use it with every out-of-network client regardless of the plan. Out-of-network plans reimburse against their own allowed amount — often a percentile of a regional charge database, not your fee — so the patient's benefit, not your number, drives their refund. Give self-pay clients a good-faith estimate, and provide a superbill so an out-of-network client can seek reimbursement from their plan.

By Gale Editorial · Updated 2026-07-26. Every figure cited to a dated source. How we write.

What UCR actually means

Usual, customary, and reasonable — UCR — is the yardstick out-of-network plans use to decide what they will count toward a claim. It is not your fee. A plan sets an allowed amount for each service, commonly benchmarked to a percentile of what clinicians in a region charge, and pays the out-of-network benefit against that figure. Your billed fee can be higher; the plan simply applies the patient's out-of-network coverage to its own allowed amount.

The practical consequence is that raising your fee does not, by itself, raise what the plan reimburses — it raises what the patient owes above the allowed amount. Understanding this keeps you from setting a fee to game a reimbursement you do not control, and lets you set it for what the work is worth instead.

Build one number you can defend

Set a single master fee for each service you deliver and apply it consistently — the same 90837 fee to every out-of-network client, documented in your fee schedule. Consistency is what makes a fee defensible: a plan, a patient, or an auditor should see one price per code, not a number that moves by who is paying. Build the session fee from your actual costs — clinical time, unpaid administrative time, overhead, and the value of your training — rather than by copying a neighbor.

A defensible fee is also one you can explain in a sentence. If a client, or a plan questioning a superbill, asks why the visit costs what it does, the answer should point to the work and the market, not to a round number chosen for convenience. Write the fee down once, keep it current, and use it everywhere self-pay applies.

The good-faith estimate you owe self-pay clients

If a client is uninsured or chooses not to use insurance, the No Surprises Act requires you to give a good-faith estimate of what their care will cost before it begins 1Ref 1Centers for Medicare & Medicaid Services (2026).No Surprise Billing.That the No Surprises Act requires a good-faith estimate of expected cost for uninsured or self-pay patients before care begins, including for ongoing therapy. As of July 2026.. For ongoing therapy that means an estimate covering the expected course — the service, the code, the per-session fee, and a reasonable projection of frequency and duration — not just a single visit. It is a written document the client keeps, and it is a legal obligation, not a courtesy.

Because therapy is open-ended, the estimate is a good-faith projection, not a promise. Note the assumptions — a weekly cadence, a reassessment point — and update it if the plan of care changes materially. Keeping the estimate consistent with your master fee is what keeps it honest and keeps you out of a dispute later.

The out-of-network superbill

A superbill is the itemized receipt an out-of-network client submits to their plan to claim reimbursement, and getting its codes right is what makes it pay. It carries the dates of service, the CPT code for each session — 90791 for the intake, 90834 or 90837 for individual therapy, 90847 for family work — your diagnosis, your NPI and tax ID, and the fee you charged 2Ref 2APA Services, Inc. (2025).Psychotherapy Codes for Psychologists.The psychotherapy CPT family — 90791 evaluation, 90834/90837 timed individual therapy, 90847 family — a clinician lists on an out-of-network superbill, including time-band selection.. The oon superbill does not bill the plan directly; it gives the client the document their plan needs to apply out-of-network benefits.

An oon verification of the client's out-of-network benefits before the first session tells them what to expect — whether they have an out-of-network deductible, what percentage the plan pays, and whether a referral or authorization is required. Where you deliver care that could trigger surprise-billing protections, the notice-and-consent rules may apply; for ordinary elective outpatient therapy the superbill route is the common path.

How parity touches your out-of-network rate

The way a plan calculates its out-of-network allowed amount is itself a limitation parity law can reach. Reimbursement methodology is a non-quantitative treatment limitation under MHPAEA, which means a plan's method for paying out-of-network behavioral-health care must be no more stringent than the method it uses for comparable medical care 3Ref 3U.S. Department of Labor (2026).Mental Health and Substance Use Disorder Parity.That reimbursement methodology, including how a plan sets its out-of-network allowed amount, is a non-quantitative treatment limitation MHPAEA requires be no more stringent for behavioral health than for comparable medical care.. This rarely changes what you charge, but it matters when a plan's out-of-network behavioral-health reimbursement looks conspicuously worse than its medical equivalent — that gap is arguable, not just unfortunate.

You set your fee for your practice, not for a parity fight. But when a client's reimbursement comes back far below what a comparable medical service would return, the methodology behind that number is the kind of thing the comparability test examines — worth noting for the client, who is the one positioned to appeal it.

Public benchmarks you can point to

You do not have to invent your fee in a vacuum; several public reference points anchor it. Medicare publishes the behavioral-health services it covers and the codes for them, and its physician fee schedule that prices those codes is publicly searchable — a common floor clinicians reason from 4Ref 4Centers for Medicare & Medicaid Services (2025).Medicare and Mental Health Coverage.That Medicare publishes the behavioral-health services it covers and their codes, a public reference point when building a private-pay fee schedule. As of July 2026.. Regional charge databases report percentiles of what providers bill for each code, which is the raw material plans use to build their allowed amounts. Neither sets your fee, but together they tell you where your number sits.

Use the benchmarks to sanity-check, not to anchor low. Medicare's rate is a floor, not a target for private-pay work, and the charge-database percentiles describe billed amounts, not what plans actually pay. A fee that sits sensibly above the Medicare reference and within the range other clinicians bill is one you can defend to a client without a spreadsheet.

Common questions

No. Set one master fee for self-pay and out-of-network work that reflects your time and expertise, and use it consistently. Being out-of-network does not tie you to any plan's allowed amount — that is the plan's figure for calculating a benefit, not your price. Your contracted in-network rates are separate agreements; your out-of-network fee is the number you actually charge for the service.

The No Surprises Act requires a good-faith estimate for uninsured clients and for insured clients who choose not to use their coverage — the self-pay path. For a client billing through their plan, the estimate obligations work differently. When in doubt, provide the estimate: for open-ended therapy, a projection of the expected course and per-session fee both meets the rule and sets clear expectations.

Plans generally do not publish an exact formula. They set an allowed amount for each service, commonly benchmarked to a percentile of a regional charge database — what clinicians in that area bill for the code. The plan then applies the patient's out-of-network benefit to that allowed amount. It is the plan's number, not your fee, which is why your fee and the reimbursement can diverge sharply.

No. A superbill only gives the client the documentation their plan needs to process an out-of-network claim. Whether they are reimbursed, and how much, depends on their out-of-network benefits — deductible, coinsurance, any authorization requirement. Verifying those benefits before the first session is what prevents a surprise. The superbill enables the claim; the plan's coverage decides the outcome.

Your contracted in-network rates are separate agreements and will differ by plan. But your master self-pay and out-of-network fee should be one consistent number per code. Large, undocumented swings in what you charge the same service — a low number for one payer, a high one for another self-pay client — are hard to defend if a plan or auditor asks why the price moves by who is paying.

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References

1.Centers for Medicare & Medicaid Services (2026). No Surprise Billing. Centers for Medicare & Medicaid Services (CMS). link ✓That the No Surprises Act requires a good-faith estimate of expected cost for uninsured or self-pay patients before care begins, including for ongoing therapy. As of July 2026.
2.APA Services, Inc. (2025). Psychotherapy Codes for Psychologists. APA Services, Inc.. link ✓The psychotherapy CPT family — 90791 evaluation, 90834/90837 timed individual therapy, 90847 family — a clinician lists on an out-of-network superbill, including time-band selection.
3.U.S. Department of Labor (2026). Mental Health and Substance Use Disorder Parity. U.S. Department of Labor (EBSA). linkThat reimbursement methodology, including how a plan sets its out-of-network allowed amount, is a non-quantitative treatment limitation MHPAEA requires be no more stringent for behavioral health than for comparable medical care.
4.Centers for Medicare & Medicaid Services (2025). Medicare and Mental Health Coverage. CMS Medicare Learning Network (MLN1986542). link ✓That Medicare publishes the behavioral-health services it covers and their codes, a public reference point when building a private-pay fee schedule. As of July 2026.

https://www.gale.care/for-providers/par-oon-fee-setting-ucr · 4 sources. Competitor details are cited to dated public sources and maintained as they change; figures are estimates, not commitments. Synthetic demonstration.

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