‘Out of Network’ Billing

If you plan on using out of network benefits, listed below are the steps to follow and questions to ask your insurance company about your Mental Health Benefits. Please print or copy this form and provide all the information below to Dr. Timberlake.

1.  Call Mental Health or Behavioral Health phone number on back of card if available. If not, call the customer service number.

2.   When prompted ask for your “out of network benefits” for “out-patient mental health”

*if insurance company asks for your provider’s credentials they are:

John Timberlake, PsyD         License no: 27332  


3.  Ask if the following CPT codes are covered:

90834: yes _____             no______
90837: yes______            no ______
90847: yes______            no_______

4.  Ask if both “parity” and “non-parity” or “severe” or “non-severe” diagnosis are covered


5.  Ask for Mental Health Claims Billing Address
6.  Ask what your reimbursement amount (%) is for out of network providers


7.  Ask if the following CPT codes are covered/or if authorization is needed:

90834: yes______              no______
90837: yes_______            no_______
90847: yes_______             no_______

8.   *If asked for address (or zip code) where services provided, office address is:

4132 Katella Avenue, Suite #106

Los Alamitos, CA, 90720

Tel: 562-743-5232



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