Out-of-Network Benefits

Most insurance companies contract with different healthcare providers in the community to create a network. Depending on your plan, you may have what are called “out-of-network benefits.” This means that if you want to see a provider that is not in your insurance company’s network (like me!), there is still partial or total coverage available.

After paying my full fee upfront, you will mail the insurance company a “Super Bill” (a statement that I generate), as well as a claim form. Then you will receive a reimbursement check directly from the insurance company in the mail. The amount of reimbursement depends on the specifics of your plan.

The best way to learn about your out-of-network benefits is to call your insurance company. Below is a script you can use. I encourage you to have something to write with and on during your call. Documenting the date, representative’s name and call confirmation number will be helpful in case you ever need to challenge a claim. If what they share feels confusing, please write it down and I will help you sort it out.

STEP 1

Find your insurance card and flip it over. You will see a “customer service” phone number. Dial it! After giving them your basic information, including your policy number, ask for help understanding your out-of-network benefits.

Ask:

1) Do I have an out-of-network deductible?

2) Is there a percentage that the insurance company will cover for a visit with an out-of-network specialist, for billing codes 90837 and 90847?

3) Do I send in a claim form and Super Bill to get reimbursement? To which address should I mail the forms?

4) Where can I locate a claim form, if needed? Are there any other steps?

5) How long will it take the company to mail me my reimbursement check?

STEP 2

Monthly (or as frequently as you like), ask me for a Super Bill. I will email you a Super Bill. Print it. Fill out your claim form, put it in an envelope with the Super Bill, and mail it to the address you’ve written down. Pretty soon, a check will be in the mail for you. The typical turnaround is 30 days.