What is an in-network claim?
An in-network provider is a healthcare provider who has a negotiated contract in place with your health insurance company for various services. The insurance claims for these services are generally filed directly by your provider with your insurance company. As a patient, for an in-network visit, you are only responsible for paying the copayment, deductible or for the portion of care not covered by your insurance. |
What is an out-of-network claim?
When your provider does not have a negotiated contract with your health insurance company, you are billed for the full cost of a visit directly by your provider. An out-of-network claim is a request on your behalf for health insurance company to reimburse you for a bill from a provider or a practice for medical care. |
Do all health insurance policies reimburse out-of-network claims?
No, not all health insurance policies reimburse out-of-network claims. Typically, a PPO or a POS insurance plans have some out-of-network coverage, while other EMO or HMA plans will reimburse for out-of-network health expenses only in care of emergency. Check with your insurance provider to see if your plan has out-of-network benefits. |
Does Medicare reimburse for out-of-network care?
No, Medicare in general does not reimburse for out-of-network care. You can get best results if you have a supplemental PPO plan in addition to medicare insurance. Please contact us to discuss medicare out-of-network claim filing in detail. |
How do I know if a claim is in-network or out-of-network?
An in-network provider directly bills and gets reimbursed by insurance company. You are just responsible for copayments and deductibles. While an out-of-network provider will bill you directly for all services provided. They will not send a claim to your insurance and you are responsible to work with your insurance for reimbursement. You can ask any provider whether they are in or out-of-network for your specific insurance plan. |
What is a deductible? And what is an out-of-pocket maximum?
A deductible is fixed amount of money you are expected to pay before your insurance will start paying for your care. Whereas, the out-of-pocket maximum is the total amount of money you are required to pay towards your health care before your health insurance policy begins to pay 100% of the costs. There is usually one maximum per individual and a higher maximum for the entire family. Both deductible and out-of-pocket maximum amounts are set in advance, differ from plan to plan and are determined by your specific policy. In general, amount of money that you have paid towards your deductible and out-of-pocket maximum will reset each calendar year. |
How much money will I get back?
The reimbursement from your insurance company depends on lot of factors, such as, your specific insurance plan, your deductible and the type of medical service you received. It also depends on what your insurance company determines to be appropriate reimbursement for the service. |
What data should be on my bill in order to file a claim? What if data is missing from my bill?
To process your out-of-network claim your medical bill will need to include your name, your provider’s name, provider’s National Provider Identifier (NPI) number, provider’s employment identification number (EIN, TIN or social security number), the code(s) for your diagnosis, the code(s) for any procedures, the date of service, and the total amount of the bill. All of the items listed above are mandatory for an out-of-network claim to be processed by insurance. Without any of the items listed above, insurance will most likely deny your claim. Your provider's office can provide you a bill with all this information, and is called a “superbill.” Keep in mind that your provider is required by law to provide you with this information upon request. |