If your child sees an out-of-network provider as part of their treatment plan, you can choose to submit out-of-network claims to your health plan for potential reimbursement. 

According to data collected by KFF, insurers reported receiving 33 million out-of-network claims in 2023, with a denial rate of 37%. This guide includes some practical information for you to use to avoid some of the most common reasons that claims are denied.

Make sure that you obtain and submit a complete superbill 

A superbill is a document from a medical appointment or therapeutic session, and it includes all the necessary information that your health plan requires to process a claim. 

A superbill is different from the weekly or monthly invoice for services that you’ll receive from your child’s out-of-network provider. The superbill is typically made available to you after you have paid the invoice.

Most out-of-network providers will automatically produce a complete superbill, but your best bet is to review superbills for completeness before submitting to your health plan. Claims may be denied or delayed by your health plan over a simple omission of a required field, so you want to make sure everything is accounted for and correct.

A superbill should contain the following information:

Information about your child

The superbill should include the following information about your child, and everything must match what appears on their health insurance card:

• Your child’s full name (nicknames are not acceptable)

• Your child’s date of birth

• Your child’s address 

Information about the service they received

Certain codes are required to be on a superbill:

• A diagnosis code, known as an ICD-10 code (this code is 3 to 7 digits long)

• A billing code, known as a CPT code (this code is 5 digits long, and it sometimes includes a 2-digit modifier)

• A place of service (POS) code (this code is a 2-digit number)

• The date of service and cost per line item

• The total price with a note that payment has been made

Information about the provider

The service provider your child sees must include their own information on the superbill:

• The provider’s address

• The provider’s telephone number

• The provider’s licensure and tax ID number

• The provider’s NPI (National Provider Identifier) number

• The provider’s signature

Log in and file the claim

You’ll want to have a PDF version of the superbill to upload to your health plan. Make sure you scan the superbill at a lower resolution because plans often have strict file size limits for submitting.

Log into your plan, and follow the directions it outlines for how to file out-of-network claims. Filing may vary between plans, so if you’ve changed insurance recently or joined a new health plan, make sure you follow your plan’s specific instructions for filing. 

One important thing to note when filing is that your child’s age may affect how you file their claims. If your child is 12 years or older, you’ll likely need to create an individual login for them and file their claims there, or enable the privacy settings for the main subscriber to submit and view their claims in the subscriber account.

Be sure to file within the deadline for member-submitted out-of-network claims. The window for filing may be as little as 6 months to as long as 18 months after your child’s date of service. 

Once the superbill is submitted, you’ll get a message acknowledging the receipt of the claim and the timeframe to expect for completion.

Hold the plan—and yourself—accountable for processing

When it comes to insurance and filing claims, we know it can be a lot to keep track of and include lots of moving parts. To keep things from falling through the cracks, you may want to create a designated spreadsheet to keep everything in order. 

For each claim, include the date on which you submitted the claim and the promised date by which processing should be complete. You may even want to add the submitted date and the promised date to a digital or paper calendar so you can keep an eye on when you should expect the claim to be processed. This can help you remember to contact your health plan regarding the claim if that date isn’t met.

Once a claim is processed, create separate columns in your spreadsheet to fill in: 

• The claim number

• The dollar amounts applied to your deductible (or once your deductible is met, the amounts that are to be paid to you via check or direct deposit)

• The date when you actually received payment 

Don’t assume that a promise by your plan to pay automatically leads to payment. Keep checking to make sure your claim is actually processed and processed correctly.

What to do about denied claims

What happens when your superbill has been accepted by the plan for processing, but the claim has been denied and no payment has been made to you or to your deductible? 

Before you contact your plan to have the claim reprocessed, take a moment to review the claim to see if you can determine the reason for the denial. It’s much easier to call or message the plan with an idea of why the claim was denied and a remedy to correct.

The claim will show a code with a reason for the denial and contain a key to the descriptor of that code, so read the claim for that information before you contact your plan. For example, you may need to submit additional information, or the plan ignored an authorization on file.

Once you’re ready to remediate the denial with your health plan, there’s often a link in the claim area to address the denial and have the claim reprocessed. The location of this link varies by health plan (it may be in the message center, in a live chat window, or linked to the claim itself). Explore your health plan website for the easiest pathway for you to use.