How to Bill an Out-of-Network Insurance Claim

Understanding Out-of-Network Billing

Health insurance plans often involve networks of healthcare providers who have agreements with the insurer. When a patient receives care from a provider outside this established network, the services are considered “out-of-network.” Out-of-network services typically require the patient to seek reimbursement themselves from their insurer.

Understanding specific terminology is helpful when navigating out-of-network claims. A “superbill” is a detailed receipt provided by the healthcare provider, listing the services rendered and the associated charges. This document contains all the necessary information for an insurance company to process a reimbursement request. A “claim form” is the specific document provided by the insurer that must be completed and submitted for reimbursement.

Financial terms like “deductible” and “coinsurance” are also relevant. A deductible is the amount a patient must pay out-of-pocket before their insurance coverage begins. Coinsurance is the percentage of costs a patient is responsible for after meeting their deductible. The “usual and customary rate” (UCR) refers to the amount an insurer determines is a reasonable charge for a particular service in a specific geographic area; reimbursement for out-of-network services is often based on this rate.

Preparing for Out-of-Network Reimbursement

Before receiving services from an out-of-network provider, contact your insurance company to understand your specific benefits. Inquire about your out-of-network deductible, which may be higher than your in-network deductible, and your coinsurance rates for such services. Ask if any referral or pre-authorization is required for the services you plan to receive, as this can affect whether your claim is covered. Document these conversations, including the date, time, and the representative’s name.

You will need to collect patient demographic details, including name, address, phone number, and date of birth. Crucial provider information such as their name, address, National Provider Identifier (NPI), and Tax ID are also necessary. The dates of service, specific diagnosis codes (ICD-10), and procedure codes (CPT) for each service provided are fundamental components.

The superbill is a key document for this process, acting as a detailed summary of the services you received. Request this document from your provider; it should include the provider’s information, patient details, dates of service, diagnosis codes, procedure codes, and the amount paid.

You will also need the specific out-of-network claim form from your insurance company. This form can usually be found on the insurer’s website or requested by mail. Maintain meticulous records of all documents, including superbills, receipts, and any correspondence with your insurer.

Submitting Out-of-Network Claims

Once all the necessary information and documents have been gathered, complete the insurance company’s specific out-of-network claim form. Transfer details from the superbill, such as dates of service, procedure codes (CPT), diagnosis codes (ICD-10), and charges for each service, onto the claim form. Ensure all entries are legible and precise, including patient and provider information like NPI and Tax ID.

Along with the completed claim form, attach supporting documents. The superbill is a primary attachment. Proof of payment for the services rendered, such as a receipt, should also be included. Some insurers may require additional documentation, such as medical records, to support the claim.

There are several common methods for submitting completed claims. Mailing the form and attachments is a frequent option, and sending it via certified mail can provide proof of submission. Many insurance companies also offer online portals for electronic submission, which can often expedite the process. Faxing the documents is another method some insurers accept.

Adhere to the insurer’s specified timeframe for claim submission. Most insurance companies have filing deadlines, which can range from 30 to 180 days from the date of service, though some may allow up to a year. Submitting claims after this deadline may result in a denial of reimbursement. Instructions for submission are usually on the insurer’s website or the claim form.

After Claim Submission

After submitting your out-of-network claim, track its status. Many insurance companies provide online portals where you can monitor the progress of your claim. Alternatively, contact the insurer’s customer service department by phone to inquire about the claim’s status, noting any reference numbers provided. Claim processing times can vary, often ranging from 5 to 30 days, but complex claims may take longer.

Upon processing, the insurance company will send an Explanation of Benefits (EOB). This document is not a bill but a statement detailing how your insurance processed the claim. The EOB typically outlines the total charges, the amount the insurer allowed, what was paid by your health plan, and the amount you are responsible for. It will also indicate how your deductible and coinsurance were applied and provide reasons for any denials.

If the claim is not processed within a reasonable timeframe, or if the EOB indicates a denial or lower-than-expected reimbursement, follow-up with the insurance company. Contact them to understand the specific reason for any issues. If a claim is denied, you have the right to appeal the decision.

Appealing a denied claim involves understanding the denial reason, usually stated on the EOB. Gather any additional documentation that might support your case, such as a letter from your provider explaining the medical necessity of the services. Submit an appeal letter, often with a specific appeal form, to the insurer. There are usually internal appeal processes, and if unsuccessful, you may have the right to an external review by an independent third party. Maintain meticulous records of all communications, submitted documents, and EOBs.