You finally found a provider for your child’s needs…and then notice that they’re out of network. Suddenly, a million questions pop up. What about your deductible? How do you file an out-of-network claim? Can you get reimbursed? 

Before you panic, take a breath. We can help.

This guide is here to walk you through getting started with an out-of-network provider and help you avoid some of the most common reimbursement issues. 

There are some coverage and benefits basics to be aware of when your child is starting a new out-of-network service. Understanding the ins and outs of your health plan coverage and benefits allows you to make more informed decisions about the financial considerations associated with your child’s plan of care and their team of providers.

Much of this information may also be found in the Summary of Benefits document that’s available either in your health plan member portal or, in some cases with employer-sponsored plans, by contacting the subscriber’s human resources department. 

Some data you may need may require a live chat, messaging, a phone call to customer service, or a claim to actually be filed, but it’s worth pursuing so you can be informed of what exactly your health plan covers and includes.

First off, what is an out-of-network provider?

Your highest rate of reimbursement will always be for services with network providers. These are providers who have negotiated a contracted rate for services with your health plan. You’ll be responsible for a lower network deductible and then a percentage or fixed dollar amount share of the cost for every date of service. The network provider will submit claims and collect only your share of costs from you. The network provider will also likely handle denied or rejected claims on your behalf. You can search for network providers in your health plan portal by zip code and provider type, but always check directly with the provider for their most current contract status with your plan.

Out-of-network providers are not contracted with health plans, so they don’t have agreements for negotiated rates for services. You pay an out-of-network provider in full at the time of the service, and they’ll supply a superbill for you to submit to your plan. 

Out-of-network providers aren’t responsible for knowing the procedures and amounts of reimbursement by your plan. However, they may often assist with any treatment documentation that your plan may request. 

Reimbursement against your deductible and the share of cost will not be against the full billed amount that you pay the provider. Instead, it’s a different and often much lower “allowed amount” or “maximum reimbursable amount” that your plan will determine at the time that claims are filed.

What you should know about your plan coverage

Here are some questions you should ask your health plan about your coverage before your child starts with a new out-of-network provider.

What are the in-network and out-of-network deductibles on my plan, and do they cross accumulate or amass separately? 

You’ll want to know the percentage of share of cost for services and the out-of-pocket maximum, which both apply once the deductible is met and claims start to process for payment to you.

Does the annual deductible reset on January 1 or on another date during the year?

This allows you to budget for the new deductible and consider the purchase of a big-ticket item once the deductible is met.

For filing out-of-network claims, how many months do you have to submit superbills under the timely filing limit? 

The timing may be as short as 6 months or as long as 18 months from the date of service, but you want to be sure to get claims in while they’re still eligible to be processed.

What to know about service limits for specific services your child may use

Service limits may apply to certain services, so it’s important to know exactly how many services your child may be able to receive and if extending their service limit is an option.

Does the service your child needs have a certain number of sessions allotted per year? Are these separate bundles of visits, or are they combined? 

Often, but not always, speech therapy will have its own set of sessions allotted per year, while occupational therapy (OT) and physical therapy (PT) will have a combined set of sessions allotted per year.

Is it possible to extend a session limit with documentation, or is it a set hard cap for the year regardless of diagnosis or need?

Every health plan is different, so check with your plan’s customer service department to determine the requirements for your coverage.

What to know about pre-authorization requirements

Some health plans require that certain services, procedures, or even medications be approved prior to services being delivered in order for claims to be paid. This may be called a pre-authorization or a pre-certification.

You’ll want to understand how your health plan handles pre-authorization before your child starts their services in case they do need to get approval prior to their first appointment.

What services may need pre-authorization?

Sometimes covered services—even those on a PPO plan and without annual limits—may still require pre-authorization before claims will be paid.

How do you request pre-authorization from your health plan?

If you need to obtain pre-authorization for services, ask your plan to clarify the process to request an authorization, including who needs to submit it and the maximum additional number of treatments that may be allotted in a single request.

What to know about out-of-network allowed amounts

The greatest determination of cost for services is your out-of-network allowed amount, so you’ll want to understand how it works to more accurately determine the costs that you’ll have to cover.

What is an out-of-network allowed amount?

The out-of-network allowed amount is the dollar amount that your plan sets for out-of-network services.

The out-of-network allowed amount isn’t the amount that you pay the provider, but rather an often much lower dollar amount that the plan will first apply to an out-of-network deductible and then use as the basis to pay their out-of-network percentage. 

It’s a number that the plan will not share before a claim is filed, and it’s the only needed piece of information not available until a claim processes. 

Because of this, you may want to submit for the first date of a new service so that you can know the allowed amount without waiting to file a month’s worth of claims.

What other terms may mean an out-of-network allowed amount?

An out-of-network allowed amount may also be known as the maximum reimbursable amount or the reasonable and customary charges.

Understanding the way in which your plan provides reimbursement for the services that your child needs will help you to cover costs for their overall plan of care by balancing services that might also be available through other funding sources for which your child might qualify, such as the school district or regional center in states like California that provide that coverage for children who qualify based on diagnosis.