How to Get Out-of-Network Coverage for Medical Care

Health insurance networks are established groups of doctors, hospitals, and other healthcare professionals who have agreements with an insurance company to provide services at negotiated rates. While receiving care from in-network providers simplifies billing and reduces out-of-pocket costs, situations may arise where out-of-network care becomes necessary or preferred.

Understanding Out-of-Network Coverage

“Out-of-network” refers to healthcare providers who do not have a contract with your health insurance plan. Insurers create networks to control costs and secure discounted rates for their members. When you use an out-of-network provider, your insurer may cover a smaller portion of the cost, or sometimes none at all, depending on your specific plan.

Health plans approach out-of-network care differently. Preferred Provider Organizations (PPOs) offer some coverage for out-of-network services, though at a higher cost. Health Maintenance Organizations (HMOs) typically do not cover out-of-network care except in emergencies or with specific pre-authorization.

The “Usual, Customary, and Reasonable (UCR) amount” or “Allowed Amount” is the maximum amount your insurer will consider paying for a specific service in a particular geographic area. If a provider charges more than this UCR amount, you may be responsible for the difference, known as balance billing.

Your “deductible” is the amount you must pay out of pocket before your insurance begins to cover costs. Out-of-network deductibles are often separate from and higher than in-network deductibles. “Coinsurance” is the percentage of the cost you pay for covered services after meeting your deductible; out-of-network coinsurance rates are usually higher. Your “out-of-pocket maximum” is the most you will pay for covered services in a plan year, but out-of-network expenses might have a separate or higher maximum.

Preparing for Out-of-Network Services

Before receiving out-of-network care, check your specific plan benefits. Contact your insurance company using the phone number on your insurance card or their online portal. Inquire about out-of-network benefits for the specific service, including UCR rates, deductibles, coinsurance percentages, and if pre-authorization is required.

Obtaining pre-authorization or pre-certification from your insurer is important for out-of-network services. This process involves the patient or provider submitting documentation to the insurer for review before the service is rendered. Documentation typically includes proposed treatment codes (Current Procedural Terminology (CPT) codes), diagnosis codes (International Classification of Diseases (ICD) codes), and medical necessity details. Always seek written confirmation of any pre-authorization to avoid future disputes.

Discuss costs with the out-of-network provider’s billing department before your appointment. Ask about the total cost and whether they will bill your insurance directly or if you need to pay upfront. Confirm they will provide a detailed, itemized bill (superbill) including CPT, ICD, and the National Provider Identifier (NPI) for the provider. This clarifies your financial responsibility.

Gather the following information and documentation:
The provider’s full name, address, and NPI, along with the date(s) of service.
A detailed, itemized superbill from the provider, listing CPT and ICD codes for each service.
Any medical records or notes supporting the medical necessity of the treatment, especially if pre-authorization was obtained.
A copy of your insurance card, front and back.

Submitting Out-of-Network Claims

After receiving out-of-network services and gathering all information, submit the claim for reimbursement. Most insurers provide a specific out-of-network claim form, which may be a standard CMS-1500 form or a proprietary form accessible through their website or customer service.

Complete the claim form by inputting patient information, provider details including their National Provider Identifier (NPI), and precise dates of service. The form requires Current Procedural Technology (CPT) codes for procedures and International Classification of Diseases (ICD) codes for diagnoses, itemized on your superbill.

Attach supporting documentation to the completed claim form. This includes the itemized superbill, any letters confirming pre-authorization, and relevant medical records that substantiate the medical necessity of the services. Make copies of all submitted documents for your records.

Claims can be submitted by mail to the address specified by your insurer or through an online submission portal. If mailing physical documents, sending them via certified mail provides proof of submission. Electronic submissions often offer faster processing times (7-14 days) compared to paper claims (30-45 days).

After submission, track your claim’s progress. Many insurers offer online portals or you can call their claims department. Once processed, you will receive an Explanation of Benefits (EOB). The EOB details how the claim was processed, including the allowed amount, the portion paid by the insurer, and your remaining responsibility. It also provides reasons for any denial or partial payment.

Appealing a Denied Claim

If an out-of-network claim is denied or paid at a lower rate, review the Explanation of Benefits (EOB). The EOB states the reason for denial, such as a service not being medically necessary, the provider not being credentialed, or a lack of pre-authorization. Understanding this reason is key to constructing an effective appeal.

Gather additional information to support an appeal. This documentation might include detailed medical notes from the provider, a formal letter of medical necessity, or evidence that no in-network provider was available for the specific care required. Include any written proof of pre-authorization.

The internal appeal process begins by submitting an appeal directly to your insurance company. This involves writing a formal appeal letter with your patient information, claim number, date of service, and a clear explanation of why the denial should be overturned. Attach supporting documentation. If your initial internal appeal is denied, you may escalate to a second level of internal review within the insurance company.

If internal appeals are exhausted and the claim remains denied, pursue an external review. Most states offer an independent review process through their state insurance departments, allowing an unbiased third party to assess the claim. Contact your state’s department of insurance for information on how to initiate this process. Independent Review Organizations (IROs) conduct these reviews, providing an impartial assessment of the medical necessity of the denied service. Maintain meticulous records of all communications, dates, and documents related to the appeal process.