Out-of-network claims can be confusing. Granted is here to add some clarity to the process!
What does it mean to be out-of-network to begin with? Well, let’s start with what it means to be in-network. Doctors and hospitals have the option to contract with insurance companies to decide on pricing for specific services - eg. Dr. Smith may contract with Aetna to receive $200 for a basic office visit. When Dr. Smith submits a claim to Aetna, who then adjudicates the claim, basically deciding how Dr. Smith receives her $200 for the office visit. In this example, let’s say you have a $25 copay for this kind of office visit. This means that Dr. Smith could expect to receive $175 from Aetna, and $25 from you - ensuring that she got the full $200 that she was promised in her Aetna contract.
If a doctor is out-of-network, this means that the doctor has not agreed to receive a specific amount for a specific service. So when you go to an out-of-network doctor, they can technically bill you however much they would like to. Let’s say Dr. Johnson charges $350 for an office visit. When you go see Dr. Johnson, you would pay that full $350 upfront. Then, you would submit a claim yourself to your insurance company, in an effort to get reimbursed for any portion of the amount you paid.
In order to submit the out-of-network claim, you need three things:
A superbill, which is an itemized receipt from your provider, specifically for the purposes of out-of-network reimbursement
A claim form, which is a document from your insurance company that needs to be submitted
Proof of payment which shows that you already paid for the services
And one last thing to be aware of - timely filing. This is the amount of time you have from your appointment until you have to submit your claim. This can vary from plan to plan, and can be anywhere from 90 days to up to a year! If you submit your claim after this time period, it will get denied, so it’s very important to know this timeline.
The good news is that Granted can help you with all of this! Feel free to start a case with us and we can help you collect the information you need, as well as ensure you get any reimbursement you are eligible for.
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