BETTER FAQ’s
For Patients:
What is an out-of-network claim?
An out-of-network claim is a request for your health insurance company to reimburse a bill from a provider that does not have a negotiated contract with your health insurance company. If you are billed for the full cost of a visit directly by your provider, or they have told you they do not accept insurance, it is likely they are out-of-network.
Do all health insurance policies reimburse out-of-network claims?
No, not all policies reimburse out-of-network claims. Check with your insurance provider to see if your plan has out-of-network benefits. Typically, a PPO or a POS type plan will have some type of out-of-network coverage, while most HMO and EMO plans only reimburse for out-of-network care in the case of an emergency.
What is an in-network claim?
An in-network claim is usually filed directly by your provider with your insurance company. An in-network provider has a contract already in place with your health insurance company. For an in-network visit, you are only responsible for paying the copayment or for the portion of care not covered by your insurance.
How do I know if a claim is in-network or out-of-network?
An out-of-network provider will bill you directly for services. They will not send a bill to your insurance. You can ask any provider whether they are in or out-of-network for your specific insurance plan.
How much money will I get back?
This depends on your specific insurance plan, your deductible and the type of medical service you received.
What is a deductible?
A deductible is a set amount of money you are expected to pay before your insurance will start paying for your care. This amount is determined by your specific policy and is set in advance.
What is an out-of-pocket maximum?
The out-of-pocket maximum is the total amount of money you can be required to pay towards your health care before your health insurance policy begins to pay 100% of the costs. This amount differs from plan to plan but usually resets each year. There is usually one maximum per person and a higher maximum per family.
What data should be on my bill?
To process your claim your bill will need to include your name, your provider’s name, your provider’s employment identification number (EIN or TIN) or social security number, your provider’s National Provider Identifier number, the code(s) for your diagnosis, the code(s) for any procedures, the date of your appointment (date of service), and the total amount of the bill. A bill with all this information is called a “superbill.”
What if data is missing from my bill?
All of the items listed above are mandatory for a out-of-network claim to be processed by insurance. Without even one of the items listed above, your claim will likely be denied. Keep in mind that your provider is required by law to provide you with this information upon request.
Why is my insurer asking for my provider to enroll in their systems as an out-of-network provider and/or requesting a copy of their W9?
Out-of-Network credentialing is a new trend that insurance payers have started over the past year. They are verifying that your provider is a licensed and that their practice is a legal entity. Your claim will be on hold for processing for reimbursement until a W9 is submitted.
For Providers:
Here is a helpful resource for you to be able to continue to navigate the complex health insurance world for your team.
What goes on a superbill?
Below, we have provided a checklist of the requirements required by insurance to process an out-of-network claim. All of these items listed are mandatory and without even one of them, a claim will likely reject or deny. Please know that you as the provider, are required by law to provide your client with this information upon request.
A reimbursable superbill includes:
- Provider’s name
- Provider’s address
- Provider’s phone number
- Provider’s tax ID (EIN number)
- Date-of-service
- Amount charged
- CPT code (procedure code)
- ICD -10 code (diagnosis code)
This information your client can send to their insurance company on a member submitted claim form along with your provided superbill. Nearly all insurance companies have a mailing address to receive these types of claims. If your client’s insurance provider has an online member portal, we recommend this route for them to submit their claims.
Here is a guide on Superbill requirements for review, that includes an image example.
Please see various samples of Superbills at the end of the document in Appendix A.
How can I do a out-of-network benefits check for my prospective client?
You can do one by calling the provider contact line for the client’s insurance plan. You can find this number on their website or the back of the client’s insurance card. You will need to have your NPI number or TAX ID and the client’s insurance information handy when you make the call.
Do not call the member services line. Only call the provider line as this route moves you faster to a representative for answers.
What questions should I be asking on a benefits check call with insurance payors?
You will need to be clear with the representative that you are seeking out-of-network benefits information for the client. You should ask the following questions;
Is there an out-of-network deductible for the client?
If so, what is the amount?
How much of the deductible has the client met?
Once the deductible is met, what percent reimbursement will the client receive?
What is the allowed amount for the CPT codes for the services I will be rendering for client?
You may not receive the allowed amount right away, the insurance payor may need to do an authorization check before providing that information, however the rest of the information should be provided on the call.
Is there a way for us to submit superbills on behalf of client to their payer?
Yes, you would need to research the best clearinghouse software for your practice, if you wish to submit electronically. We recommend using ClaimMD to submit electronically. Please be advised some insurance payors prefer superbills and claim forms be faxed or mailed in. You can retrieve a claim form from the insurance payor.
What’s the difference between a type 1 NPI and type 2 NPI?
Type 1 NPI is for Individual providers or sole proprietors.
Type 2 NPI is a group/organizational NPI for practices with more than one provider.
How do I get an NPI?
You can apply for your NPI here: https://nppes.cms.hhs.gov/NPPES/Welcome.do
Do I need to put both NPIs on superbills if we have other providers in our practice?
Yes, you will note the individual type 1 NPI in the rendering provider area. Then you will note the Type 2 group/organizational NPI.
Do I need a type 2 NPI for every new practice location I open up?
No, you only need to go into your account in the NPPES system and add additional locations under the group/organizational Type 2 NPI.
Why am I being asked for my W9 and being requested to enroll as an out-of-network provider?
Out-of-Network credentialing is a new trend that insurance payers have started over a year ago. They are verifying that you are a licensed provider and your practice is a legal entity. A client’s claim will be on hold for processing for reimbursement until a W9 is submitted.
If I am enrolled as an out-of-network provider, does this change my rates?
This request does not affect your rates. It does not place you in to any contract with the payor.
Can clients get reimbursed if they are being seen by a pre-licensed provider?
Yes, this is possible as long as the supervising provider’s NPI is also noted on the superbill.
Will my clients with an HMO or EPO type plan receive reimbursement?
If they currently have an HMO or EPO type plan, they typically do not reimburse for out-of-network services. There are exceptions and an ER visit is typically the only exception that will be reimbursed.
Will my clients with a PPO or POS type plan receive reimbursement?
If they currently have a PPO or POS type plan, they typically have out-of-network benefits coverage that provides them with an option to go to a physician that is not in network. For these types of plans, the benefits are likely there but will depend on their deductible, co-insurance, and the allowed amounts.
Will my clients with Tricare or Tricare select type plans receive a reimbursement?
If they currently have these types plan, they typically have out-of-network benefits coverage that provides them with an option to go to a physician that is not in network. For these types of plans, the benefits are likely there but will depend on their deductible, co-insurance, and the allowed amounts. Their military ID will have their DoD Benefits Number (DBN). That can be found on the back of the ID card to verify eligibility and file claims on their behalf.
Will my clients with MEDICARE/MEDICAID type plans receive a reimbursement?
Covered California — allows people to purchase any type of policy via the exchange, in the case that the policy purchased by them is a PPO plan and has out of network benefits, we can absolutely submit claims on the client’s behalf.
Medi-cal — In the majority of cases Medi-cal acts as an HMO and will not reimburse unless it is an emergency.
Medi-care — You can get the best results if the patient has a supplemental PPO plan in addition to their medicare insurance.
