ClickCease

Schedule a Billing Analysis Phone Consultation

Free Accounts Receivable Review

Schedule a Free Medical Billing Consultation

SCHEDULE A CONSULTATION
Free Accounts Receivable Review
(973) 607-4406
Schedule A Consultation

Schedule a Billing Analysis Phone Consultation

Free Accounts Receivable Review

Schedule a Free Medical Billing Consultation

How to Get Out-of-Network Claims Paid A Complete Guide With Action Checklist for Patients & Providers

One of the most frustrating parts of healthcare billing is figuring out out-of-network (OON) medical charges. Patients typically don’t see huge bills coming, and doctors often have to wait longer or not be paid at all. But if you use the correct tactics, you can have claims reimbursed that are out of network, or at least lower your costs by a lot.

This article explains the process step by step, points out frequent mistakes, and gives you insider advice to help you get your money back.

What Out-of-Network Coverage Means

If you get care from a provider who isn’t in your insurance network, the claim is called “out-of-network.” This usually leads to:

  • More money that patients have to pay (deductibles, coinsurance).
  • The provider will send you a balance bill.
  • The insurance company pays less.

Why This Matters: Knowing your policy’s OON restrictions ahead of time will help you avoid surprise expenses, plan your negotiations and save you time.

Step 1: Look over your insurance policy

Find out what your OON benefits are

  • Look at your Summary of Benefits and Coverage (SBC).
  • Look for phrases like "Usual, Customary, and Reasonable (UCR) rate" or "Allowed Amount."
  • Check to see if you need permission ahead of time for OON care.

Things to ask your insurance company

  • Does my plan cover out-of-network (OON) services?
  • After I pay my deductible, what proportion will the plan cover?
  • How much is the OON deductible?

Step 2
Get All the Paperwork Together and Put it in Order

When insurance companies get complete, well-organized paperwork, they are more likely to approve OON claims.

What documents to get

A Bill from the Provider That Lists Each Item

Diagnostic

CPT Codes and Diagnostic Codes.

Payment Processing

Proof of payment or billing statements.

Medical records

Medical records that show medical need.

approval

Any forms for referrals or prior approval.

Step 3: Make sure you file the claim correctly

Important Tips for Submission

  • Fill out the formal claim form from the insurance company.
  • Add the provider's National Provider Identifier (NPI) number.
  • Make sure to keep copies of all the documents you send.
  • Make sure to file your claims within the insurance company's deadline, which is usually 90 to 180 days.

Step 4: Stress the Need for Medical Care

The most convincing reason to get OON claims paid is medical necessity.

How to Make a Strong Case

  • Get your doctor to write you a Letter of Medical Necessity.
  • Explain why an in-network option was unavailable or inadequate.
  • Include test results that support your case, notes from specialists, or therapies that didn't work in the past.

Step 5
Use the No Surprises Act (NSA)

You might only have to pay the in-network cost if your OON bill is covered by the NSA.

If You Meet the Following Conditions, NSA May Apply

emergency care

An OON provider gave you emergency care

Ambulance Service

You got air ambulance services from OON

You went to an in-network facility for non-emergency treatment, but you didn't know that you were being treated by an OON physician

Step 6: Appeal a Claim That Was Denied

If your OON claim is turned down

  • Ask for the denial letter in writing.
  • Find out why your claim was denied. Was it because you didn't have enough coverage, you didn't send in the right paperwork, or there were mistakes in the coding?
  • Submit an appeal with further proof and a cover letter that explains everything.

Pro Tip: Mention state balance billing laws if they are stronger than federal protections.

Step 7: Talk to the Provider about it

Sometimes, even if the insurance company won’t pay more, the provider will lower your bill.

How to Negotiate

  • Offer to pay quickly for a lower price.
  • Ask for a payment plan with no interest.
  • Use FAIR Health and other fair pricing tools to make your case for a lower fee.

Step 8
Think About Getting Professional Help

You might wish to hire someone if the amount of the claim is large

People who help with medical bills

healthcare

Lawyers who work in healthcare

Patients

Organizations that help patients

Pro Tip: These experts can find billing mistakes, work out prices, and handle disputes in a good way.

Common Mistakes That Delay or Prevent Payment

  • Filling out claim forms that aren't full.
  • Not meeting the deadline for filing.
  • Not getting pre-approval when it's needed.
  • Not providing proof that the medical care was necessary.
  • Not responding to demands for follow-up from the insurance company.

Final Thoughts

To get compensated for out-of-network claims, you need to be persistent, organized and know your rights. You can greatly increase your chances of success by getting all the paperwork together, stressing the medical need and understanding when to appeal or negotiate.

If you often deal with OON claims, whether you’re a patient or a provider, you might want to hire a medical billing company that knows both the rules of insurance and how to negotiate. You can save a lot of time and money. 

Out-of-Network Claims Action Checklist

Download & follow this step-by-step process to maximize your chances of getting your OON claims paid or reduced:

(PDF downloadable file)