8080 Academy Rd. NE, Suite A Albuquerque, NM 87111 Tel: (505) 247-9700 Fax: (505) 247-4333 firstname.lastname@example.org
The Difference Between In-Network and Out-of-Network Insurance Policies
Whether your health insurance will reimburse you for a medical service, and how much your insurance will reimburse you depends on whether you are seeing an in-network or an out-of-network provider and the type of benefits you have.
All insurance plans have networks. A network describes a group of healthcare providers who have entered into an agreement with the insurance company. These agreements or contracts govern the types of medical services for which the insurance company will pay and the amount it will pay.
Under the terms of the agreement, the healthcare provider must submit a claim for the services within a certain number of days. If the insurance company requires your healthcare provider to get an authorization for a certain service, the healthcare provider must do so. After the insurance company receives the claim, it reviews it and decides how much it will pay under the specific agreement it has with that provider. When it has finished reviewing the claim, it sends something both to you and the provider. This is often called an explanation of payment or "EOP." The EOP shows payments, adjustments, and it also tells the healthcare provider how much to bill you—
Remember though, if an authorization is not required or if the insurance company decides the service is not medically necessary, the in-network provider may be able to bill you for that service. It depends on the agreement. So even if you are seeing an in-network provider, it is always a good idea to ask what will happen if the insurance company does not pay, and what the cost will be to you.
If a health care provider is not contracted with your insurance company, then they are an Out-of-Network provider. With a few legal exceptions, Out-of-Network Providers are not governed by the same rules. Out-of-Network Providers can charge you according to their own fee schedule and they are not required to get authorizations for any services they provide to you nor are they required to file your claims.
But some insurance plans provide Out-of-Network Benefits. These policies permit you to get reimbursed when you go to Out-of-Network providers. These types of policies have separate requirements for the amount of coinsurance you must pay and they have a separate deductible for your out-of-network benefits.
Generally, an out-of-network policy will not require you to get an authorization before you have a particular medical service. But that doesn't protect you from having to pay more than you should for a procedure. While a policy with out-of-network benefits permits you to have reimbursed services from an Out-of-Network provider, the insurance company still can decide how much it will reimburse for that service and you will be responsible for paying whatever remains.
What Kind of Policy Do You Have?
Most policies are titled first with the name of the insurance provider and then, with an additional identifier and an acronym or a series of letters. For example, you may have the BCBS Senior Care Advantage Plan PPO or the BCBS Senior Care Advantage Plan HMO. It used to be that your could look at the letters tagged to your plan and figure out of you have in-network or out of network benefits. But that is not always true anymore. Some plans have a series of combined identifiers like HMO-POS. Other times, you may see a set of letters that look familiar, but do not mean what you think they mean, like PPO versus EPO.
Below is a table with some of the acronyms and their meaning. This table is meant to be a guide. Do not treat these definitions as determinative of what type of plan you have. To find out if you have out-of-network benefits always consult your policy and call your insurance company.
Getting Reimbursed from Your Insurance
Did you know, even if we’re not contracted with your insurance, you can still be reimbursed for your visits? If you have out-of-network benefits with your insurance plan, you can submit a claim and your insurance will reimburse you the allowable amount for your visit.
It’s important to note, you can only submit a claim for reimbursement IF your insurance plan includes out-of-network benefits.
If you do have out-of-network benefits, submitting a claim is generally very simple. With most insurance, all you need to do is login to your insurance portal and fill out a claim. This form will ask you questions about your care plan and visit. Pain Solutions can provide you with this information.
How to Submit a Claim
Your claim form will usually ask you for two different types of codes: CPT codes, which describe the procedure type, and ICD 10 codes, which describe the diagnosis. You can find these codes on your patient portal under the visit note (make sure you are looking at the visit note for the visit you are submitting the claim for). If you have difficulty finding these codes on your portal, you can call Pain Solutions and we will provide them to you.
Additionally, your claim summary will ask for Dr. Nairn’s NPI number (national provider identifier) and his tax ID. These two numbers verify Dr. Nairn’s credentials to your insurance. For Dr. Nairn’s NPI and tax ID, call our office or ask the front desk at the end of your next visit.
Alternatively, you can request an itemized bill from us for your visit. The bill will include all of the above codes.
If you are covered by BCBS, you need to print and fill out this form. In addition to the form, you must provide BCBS with an itemized bill. This bill will be provided to you by Pain Solutions. Once completed, these two forms can be mailed to BCBS at the address listed at the bottom of the claim form.
If you have any further questions, you can contact BCBS at 1-800-432-0750.
Please note, If you have BCBS Federal, there is a different form that needs to be filled out. Click here for instructions on how to submit a claim with your federal plan.
Cigna requires you to fill out this form and provide an itemized bill for the service. Our office will provide you with the bill at your visit. For more information on submitting claims to Cigna, click here.
If you have further questions, you can call Cigna’s customer service line at 1-800-244-6224.
Unfortunately for patients with Molina coverage, claim submission is not an option. At this time, Molina has very strict guidelines regarding reimbursement for out-of-network providers. For more information, click here.
Tricare requires you to login to your Tricare account and download their claim form. Once filled out, you can mail them the claim along with an itemized bill. Our office will provide you with the bill at your appointment. For more information on filing claims to Tricare click here.
If you have any further questions, you can call Tricare’s customer service at 1-800-874-2273.
If you are a new patient and we’re not contracted with your insurance, you can consult this website to get an idea of how much a visit with us may cost you.
With United, you can easily submit your claim through the mail. All you have to do is login to your health plan account, download the claim form, and mail it in. For further instructions click here.
If you have any further questions regarding claim submission, you can reach United Healthcare customer service at 1-866-414-1959.