If you have out-of-network benefits, you can submit our charges to your plan for adjudication and reimbursement for your out-of-pocket expense. Factors like deductibles and cost-sharing may apply. For information on your specific benefits – such as what is covered, what is not, and why – please refer to the benefits guide provided by your employer or your plan at the time of enrollment or call the member number located on your insurance card.
Many plans require that you meet a deductible amount (whether in-network or out-of-network). This means that a certain amount of the claim payment will be withheld in order to meet the deductible amount within a given time period. For example, you may have a $2,000 deductible, in which case your insurer will only start paying claims once you have reached $2,000 in services paid out of your own pocket.
Some plans also have a coinsurance provision, which means that the member/patient shares in a portion of the total payment for services rendered – in addition to a deductible – by paying a percentage of the total allowable (fee) due to the practice. Your insurer will process your claim, determine if there is a cost-share amount, and reimburse you for any amount due to you from there.
For the most part, you can expect that whether you have in-network benefits or out-of-network benefits, you will need to satisfy your deductible before any benefits or reimbursement from your insurance company is extended. Patients with out-of-network benefits can expect to be reimbursed for some or most of your out of pocket expenses once their deductible is met.