Western Health Advantage Mental Health Coverage Guide
Western Health Advantage is a Sacramento-based HMO serving approximately 170,000 members in Northern California. They are an alternative to larger HMOs in the region, offering employer and individual plans.
How to Verify Your Mental Health Benefits
Before your first appointment, verify your specific benefits so you know what to expect. Here is a step-by-step process for Western Health Advantage members:
- Call 1-888-563-2250 and have your member ID card ready.
- Ask to speak with the behavioral health benefits department.
- Ask: "What is my deductible for outpatient mental health services, and how much have I met?"
- Ask: "What is my copay or coinsurance for an in-network therapy session?"
- Ask: "Do I have out-of-network benefits, and what is the reimbursement rate?"
- Ask: "Is prior authorization required for outpatient therapy?"
- Ask: "Is there a session limit per year?"
- Ask: "Are telehealth sessions covered at the same rate as in-person?"
Know Your Rights: Mental Health Parity Act
Federal law requires Western Health Advantage to cover mental health services at the same level as medical and surgical benefits. If you are denied coverage, ask for the denial in writing and reference the Mental Health Parity and Addiction Equity Act.
Want to keep track of all these details? Use our free benefits verification worksheet to organize your coverage information.
Finding an In-Network Therapist
Search Western Health Advantage's provider directory directly: Find a therapist in your area
Tips for Using the Western Health Advantage Directory
- Filter by "Behavioral Health" or "Mental Health" specialty.
- Check that the provider is accepting new patients before calling.
- Confirm the provider is in-network for your specific plan (not just Western Health Advantage generally).
- Look for providers who specialize in your specific concern (anxiety, depression, trauma, etc.).
Types of Providers Covered
Telehealth Coverage
Western Health Advantage covers telehealth therapy sessions, so you can meet with a therapist from home via video or phone.
Couples & Family Therapy
Family therapy covered under California parity requirements.
Understanding Your Western Health Advantage Coverage
Available Plan Types
Prior Authorization
Not required for outpatient therapy.
Substance Use Treatment
Western Health Advantage covers substance use disorder treatment, including outpatient counseling, intensive outpatient programs, and inpatient rehabilitation.
Common CPT Codes for Therapy
These are the billing codes your therapist will use when filing claims with Western Health Advantage:
| CPT Code | Description |
|---|---|
| 90791 | Psychiatric diagnostic evaluation |
| 90834 | Individual therapy (45 minutes) |
| 90837 | Individual therapy (60 minutes) |
| 90847 | Family / couples therapy (with patient present) |
| 90846 | Family therapy (without patient present) |
| 90853 | Group therapy |
How to Get Reimbursed (Out-of-Network)
If you are seeing a therapist who is not in Western Health Advantage's network, you may still be able to get reimbursed. Here is how:
- Pay your therapist directly at the time of your session.
- Request a superbill from your therapist after each session. This is a detailed receipt with the information Western Health Advantage needs to process your claim.
- Submit your claim to Western Health Advantage using one of these methods:
- Online: Submit through the member portal
- Fax: 1-916-563-2273
- Mail: Western Health Advantage, 2349 Gateway Oaks Dr., Suite 100, Sacramento, CA 95833
- Wait for processing. Most claims are processed within 30 days. You will receive an Explanation of Benefits (EOB) showing what was covered.
What Your Superbill Should Include
- Therapist's name, credentials, NPI number, and tax ID
- Date of service
- CPT code (e.g., 90834 or 90837)
- ICD-10 diagnosis code
- Amount charged
- Your name and date of birth
Western Health Advantage tip: Submit through the WHA member portal. California's SB 855 provides strong parity protections for appeals.
Save Money on Therapy with Western Health Advantage
Use Your HSA or FSA
Therapy is an eligible expense for Health Savings Accounts (HSAs) and Flexible Spending Accounts (FSAs). You can use these pre-tax dollars to pay for copays, coinsurance, and out-of-network therapy costs, effectively saving 20-35% on your therapy expenses.
Ask About Sliding Scale Fees
Many therapists offer reduced rates based on your income. If you have a high deductible Western Health Advantageplan or high out-of-pocket costs, ask your therapist about sliding scale options. Some therapists will also offer "single-case agreements" with Western Health Advantage at a negotiated rate.