Q: What is an allowed amount?
A: The allowed amount is the maximum amount a plan will base payment on for a covered service. For out-of-network care, your share may also include the difference between the provider's charge and that amount. Your plan documents control the calculation.
Worked example: your therapist charges $250. The plan's allowed amount for a 90834 session is $130, reimbursed at 60%. You expected $150 back; you get $78. Still real money — $312/month on weekly sessions — but plan on it accurately.
Calculate your real reimbursement
- Get the allowed amount for the exact code and ZIP code.
- Subtract any out-of-network deductible you still owe.
- Multiply the remaining allowed amount by the plan's reimbursement percentage.
- Subtract that payment from the therapist's full fee.
Using the example above: $130 × 60% = $78 reimbursed; $250 − $78 = $172 from you. The therapist's fee, allowed amount, and reimbursement rate are three separate numbers.
Do this: before starting with an out-of-network therapist, ask your plan: "What allowed amount will you use for CPT 90834 in my ZIP code, and how will you calculate my share?" Get the answer in writing if possible. Then do the math with the superbill guide →.
Sources: Definition and balance-billing explanation: CMS health-insurance terms.