Submitting Out of Network Claims

If you are trying to submit claims for a provider who is out of network with the insurance carrier you will most likely run into some problems. For example, if you need to call on the claim you may find that the insurance carrier will not even speak to you since you are out of network. This makes following up on the claim difficult.

Some wonder why you would want to follow up on a claim that is out of network. Sometimes it is not the provider’s choice to be out of network. Or possibly they are trying to help the patient out. In our case, it was an inpatient drug rehab that just opened, still applying to be in network, but accepted the patient as an insurance patient. They had us submit the claim but they are waiting for the payment.

We submitted the claim and then called 2 weeks later to be advised the claim wasn’t on file. We then faxed them the claim and called again 1 week later. Now we were told the claim was received and was in process. Fortunately we didn’t rest on that information. We called again 1 week later to find that the claim was ‘lost’. Now I couldn’t figure out how it could be lost since we were told it was received and in process, but this new person was now telling me that she was sending it back for processing and ‘telling them where to find the claim”.

The funny thing was that we received a letter that day with the claim being returned stating that the type of bill was not a valid type of bill code. Isn’t it amazing that we were told such different information when we called? Well our type of bill certainly was valid, but it turns out that Blue Cross just requires a different type of bill. Now we’ve resubmitted the claim with the new type of bill and you can bet we will keep calling until payment is made.

There are other problems that you can run into when submitting out of network claims. In some cases patients have no out of network benefits which means no payment will be made on the services. Usually out of network claims are paid directly to the patient and this may not be a problem for you if you are just verifying if the claim was paid. If you are waiting for the payment then it can be helpful to know when the patient is receiving the money.

For those of us who are responsible for submitting out of network claims for providers we just have to be diligent in following up on the claims. It is not an easy task but if you just stay on top of it, it can be done.


7 Responses to “Submitting Out of Network Claims”

  1. Drug Rehab Florida Says:

    Thanks for sharing this informative post . i will visit this blog again

  2. Linda Walker Says:

    I have a lot of providers who are non-par across board and I’ve never run into a carrier not willing to talk to you, in fact that would just be plain Unacceptable.

    • Kelli Sugihara Says:

      95% of our clientele are non-par, non-solicited providers (they can’t get a contract even if they wanted one). We run into insurance companies not willing to talk to us EVERY DAY. They are the BCBS plans of several states and can be downright rude when we call. We have tried submitting signed authorization forms to the carriers, having the members call to authorize the release of claims information, even doing three-way phone calls–it can be very frustrating. The “circus” described in the article of claims lost, then found, then returned, then lost again is the story of our business. We have to be on the ball or very little would ever get paid. An article with information on how to crack their armor and be able to receive actual claims information for OON providers would be most helpful!

  3. Amy keenan Says:

    I have to agree with Alice. While it is rare, we have been denied access to claims status due to some of our doctors being of out of network. The bigger problem is the insurance companies that will only send the payments (and EOB’s) to the patients.

  4. Jamie Says:

    I have found that when they pay the patients specially in drug rehab situations it is almost impossible to retrive the money from the insured and also a dangerous situation due to the diagnosis.

  5. Rachel Says:

    Does anyone have any advice for oon claim that is rec’d by ins co but not processed bc they say the providers info is not on the claim (which it is!!!) I have called once a week for the last 7 weeks and they always take the info and then resubmit but when a call is placed for followup they do not have the provider info again….I am at a loss as to how to get this matter resolved!

    Thank you!

    • solutionsmedicalbilling Says:

      When you are out of network you don’t have a lot of leverage. The only other thing I can recommend is to ask to speak to a supervisor. If that doesn’t get you anywhere you can always tell them you are going to file a complaint with the insurance commissioner.

      Good Luck!


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