Guides · Insurance coverage

How out-of-network reimbursement works

Out-of-network reimbursement is when you pay a provider who has no contract with your plan, then file a claim and your plan pays you back a share of its allowed amount, not the provider's full charge. It only works if your plan has out-of-network benefits; HMO and EPO plans generally don't cover out-of-network care except in an emergency.

What you get back depends on four numbers: the provider's charge, the plan's allowed amount, your out-of-network deductible and your out-of-network coinsurance. You owe the rest, including any amount the provider charged above the allowed amount.

Updated · Facts checked against the sources listed below

The math: allowed amount, deductible and coinsurance

  • Allowed amount: the most your plan will pay for a covered service.
  • Deductible: what you pay before the plan starts sharing costs. Check whether out-of-network care has its own deductible.
  • Out-of-network coinsurance: your percentage of the allowed amount after the deductible, typically higher than your in-network percentage.
  • Balance billing: an out-of-network provider can bill you for the difference between their charge and the allowed amount. In-network providers can't do this for covered services.
Hypothetical example for illustration only. Your plan's allowed amounts and percentages will differ. If you haven't met your deductible, the plan may pay nothing back yet.
StepAmount
Provider charges$200
Plan's allowed amount$120
Plan pays 60% of allowed (deductible already met)$72 back to you
Your coinsurance (40% of allowed)$48
Amount above allowed (balance bill)$80
Your total cost$128

How to get reimbursed, step by step

  1. Before the visit, call your plan. Ask: Do I have out-of-network benefits for this service? What is my out-of-network deductible and coinsurance, and how much have I met? How is the allowed amount set? Is prior authorization needed?
  2. Pay and get a superbill. Ask the provider for an itemized superbill with procedure and diagnosis codes and the provider's NPI.
  3. Fill out the plan's member claim form. It's usually on the insurer's website or member portal.
  4. Submit before the deadline. Your plan documents say where to file and any time limit. Keep copies of everything.
  5. Read the Explanation of Benefits (EOB). It shows the allowed amount, what went to your deductible, and what the plan paid.

How long it takes

For employer plans covered by federal rules, a decision on a claim for care you've already received is due within 30 days of the plan getting it. The plan can extend once by up to 15 days for reasons beyond its control if it tells you in advance. Plans generally can't charge a fee to file a claim or an appeal.

Original Medicare works differently. Providers who don't accept assignment can charge up to 15% above the Medicare-approved amount and may ask you to pay up front. They should still file the claim. If they won't, you can file yourself within 12 months of the service using form CMS-1490S. Medicare won't pay providers who have opted out, except in emergencies.

When you shouldn't be balance billed

The federal No Surprises Act generally limits you to in-network cost sharing for emergency care, for out-of-network providers who treat you at an in-network hospital or surgery center, and for air ambulance. If you get an out-of-network bill for those, you may not have to pay the extra amount.

If the claim is denied or underpaid

  • Check the EOB for coding errors and ask the provider to correct and resend the superbill if needed.
  • File an internal appeal. Employer plans must give you at least 180 days to appeal, and must decide appeals for care already received within 60 days.
  • Ask the provider whether they'll accept a lower amount or a payment plan. See how to negotiate a medical bill.

Gabriel books root-cause and holistic practitioners and files superbills for out-of-network reimbursement. Your plan decides what it pays. Gabriel membership is not health insurance.

Common questions

How do I get reimbursed for an out-of-network provider?

Pay the provider, get an itemized superbill, and send it to your plan with its member claim form. The plan pays its share of the allowed amount after your deductible.

Why did my insurance pay so little for an out-of-network visit?

Plans pay a percentage of their allowed amount, which is often well below the provider's charge, and only after your deductible is met. Check your EOB to see each number.

How long does out-of-network reimbursement take?

Employer plans under federal rules generally must decide a claim for care already received within 30 days, with one possible 15-day extension. Mailing and payment add time.

Do HMO plans reimburse out-of-network care?

Generally not, except in an emergency, and the same goes for EPO plans. PPO plans let you use out-of-network providers for an additional cost. Check your plan's summary of benefits.

Can an out-of-network provider bill me the difference?

Yes, for most planned care. That's balance billing. The No Surprises Act limits it for emergencies, for out-of-network providers at in-network hospitals and surgery centers, and for air ambulance.

Sources

  1. Allowed amount (glossary) HealthCare.gov
  2. Health insurance plan and network types: HMOs, PPOs and more HealthCare.gov
  3. Out-of-network coinsurance (glossary) HealthCare.gov
  4. Filing a claim for your health benefits U.S. Department of Labor, EBSA
  5. How do I file a claim? Medicare.gov
  6. Does your provider accept Medicare as full payment? Medicare.gov

This guide is general information, not medical advice. It does not replace a visit with a licensed clinician. Gabriel membership is not health insurance.