A Step-by-Step Guide: Submitting Out-of-Network Claims to Health Insurance Companies

Navigating the process of submitting out-of-network claims can be a challenge for healthcare providers and their staff, especially given the complexities of insurance policies, claim requirements, and reimbursement rates. However, understanding the proper steps to take can help healthcare providers effectively manage out-of-network claims and get reimbursed efficiently for services rendered. Whether you're a solo practitioner or part of a larger medical group, this step-by-step guide will help you understand how to submit out-of-network claims to health insurance companies. PLEASE NOTE: This is a generic type of guide, so please remember to confirm out-of-network claim filing instructions with the specific insurance plan. 

Step 1: Verify the Patient’s Insurance Coverage

Before submitting any claim, it’s essential to confirm that the patient has out-of-network benefits. You can do this by:

• Reviewing the patient's insurance card: Look for information indicating that out-of-network benefits are included.

• Contacting the insurance company (the best option): Verify coverage and ask for specific details about the patient's plan, including any co-insurance, deductibles, or out-of-pocket maximums. It’s also helpful to ask for any pre-certification requirements.

Step 2: Collect Necessary Information

Gather all the information needed to submit the claim. This typically includes:

• Patient Information: Name, DOB, policy and group number, and subscriber information, if different than the patient's.

• Provider Information: Your NPI number (National Provider Identifier) TIN, practice name, and address.

• Date of Service: The exact date(s) the patient received treatment.

• Diagnosis Codes: ICD-10 codes for the medical conditions treated.

• Procedure Codes: CPT or HCPCS codes for the services rendered.

• Modifiers: If applicable, these provide additional information about the services provided.

• Charges: Itemized list of services and the corresponding fees.

Step 3: Fill Out the Claim Form

Most insurance companies require providers to submit claims using a standardized claim form, such as the CMS-1500 form for individual providers or the UB-04 form for institutional providers. The CMS-1500 form is the most commonly used for medical services in outpatient settings. You can complete the form either manually or via an electronic claims submission system (like a clearinghouse).

If submitting a paper claim, then most insurance companies will accept a printed copy of the claim straight from your practice management system. However, Medicare has very strict guidelines about how to submit paper claims to them. They will only accept the red CMS-1500 claim forms mentioned above. These claim forms can be purchased either online or in person at an office supply type of store. 

Be sure to:

• Accurately complete all required fields: Double-check patient and provider details, diagnosis codes, procedure codes, and charges.

• Include supporting documentation: Attach medical records, notes, and any other documents that support the need for the services provided. This can help avoid delays and denials.

Step 4: Submit the Claim to the Insurance Company

Once your claim form is complete, you can submit it to the insurance company in one of the following ways:

• Electronic Submission: If your practice uses an electronic health record (EHR) system or a clearinghouse, you can submit claims directly through these platforms. This method is fast, efficient, and often reduces errors.

• Paper Submission: If you're submitting a paper claim, send the completed CMS-1500 form (and any supporting documents) to the insurance company’s designated claims address. Make sure to keep a copy of everything for your records.

Step 5: Follow Up on the Claim

After submission, it's important to regularly follow up on the status of the claim to ensure it’s being processed correctly. Insurance companies may take anywhere from a few weeks to several months to review and pay out claims, but staying proactive can help identify issues early. Be prepared to:

• Monitor the Claim’s Status: Use the insurance company’s provider portal or call their claims department to check the status of your claim.

• Address Denials or Errors: If the claim is denied or rejected, review the explanation of benefits (EOB) or ERA/electronic remittance advice to understand why. Common reasons for denials include missing information, incorrect codes, or the patient’s benefits not covering out-of-network care. You may need to submit additional documentation or correct errors.

Step 6: Appeal if Necessary

If your claim is denied and you believe it was incorrect, you have the right to file an appeal. The appeals process varies by insurer but typically involves:

• Reviewing the denial letter: Understand the reason for the denial, whether it's due to missing documentation, incorrect coding, or lack of coverage.

• Submitting an appeal: Provide additional supporting documentation, a letter explaining why the claim should be reconsidered, and any other relevant information.

• Following up: Stay in touch with the insurance company to track the progress of your appeal.

Step 7: Keep Records of All Submissions and Correspondence

It’s important to maintain accurate records of all claims submissions, correspondence with the insurance company, and payments received. This helps ensure that you can follow up effectively, and it serves as documentation in case of audits or disputes. Keep:

• A copy of the claim form and all attachments.

• Any emails or letters sent to the insurance company.

• Correspondence or phone call records with the insurer.

• Payment records and explanation of benefits (EOBs).

Step 8: Set Up a System for Managing Out-of-Network Claims

Efficiently managing out-of-network claims requires consistent organization and follow-up. You may want to consider:

• Using a billing service or software: Many practices invest in medical billing software that helps streamline the claim submission process, track claim statuses, and send reminders for follow-ups.

• Hiring a billing specialist: If your practice frequently deals with out-of-network claims, having a dedicated billing professional may help ensure timely and accurate submission.

Conclusion

The process of submitting out-of-network claims can be time-consuming and intricate, but by following these steps, healthcare providers can significantly improve their chances of getting reimbursed for the services they provide. The key is to stay organized, communicate clearly with insurance companies, and address any issues quickly. With the right tools and knowledge, out-of-network claims don't have to be a headache—just another part of your practice’s routine operations.