Using your Out Of Network (OON) Benefits that you didn’t know you had.
Do you know how to use your Out Of Network (OON) Benefits with your health plan?
Most people don’t know that they have out of network benefits that insurance providers will reimburse. So what are OON benefits?
Most people are familiar with their in network benefits. Searching for a new Primary care physician or specialist, you are limited to using and provider that is in network with your plan. That means that the provider has a contract with your insurance company and has agreed to submit documentation and direct billing on your behalf of the services. So what if you want to see a provider that is not in network with your provider? You can choose your own provider and see whomever you want, but your insurance company doesn’t guarantee that it will pay you back in full for the service simply because the preferred provider does not have a contract with your insurance company.
For solo providers and small business owners, it’s very rare to be in network due to the amount of paperwork and filing process that insurance companies require to become an in network provider. Additionally, how many different insurance companies are out there!? It is impossible to provide for all the options and being an out of network provider is simply the best option. So how can you use your OON benefits for an out of network provider? Here are the first steps you will need to do:
Call the customer number on the back of your insurance card and ask the following questions.
1. Does my plan include out-of-network coverage for speech therapy? This would include feeding therapy as it’s covered under speech therapy.
2. Do I have an annual deductible for out-of-network services? You will want to know what that deductible is and how much you have left for the year.
3. Is there a limit to therapy visits that are covered per year?
4. Is there a limit on out-of-pocket expenses per year?
5. Is there a co-pay for therapy visits after meeting the deductible? What percentage will they reimburse?
6. Do I need preauthorization or a referral for therapy? If yes, you will need a doctors script for assessment and treatment including any medical diagnosis your child has.
7. Can I submit a superbill for reimbursement? If so, how? Some insurance companies will have their own forms to use for submitting claims. You can also use Reimbursify to submit a claim faster.
Before you call you will want to make sure to have the providers information. The insurance company will likely ask you for the providers NPI number and which therapy codes they will be billing for services.
Therapy Codes for Reimbursement (CPT) working with Little Stories would be
92523: Combined evaluation of speech sound production with language comprehension and expression
92507: for individual speech therapy sessions
92526: treating swallowing dysfunction or oral function for feeding
92526: treating swallowing difficulties and oral function issues related to feeding
It can be helpful to create a folder to keep your receipts and information in one place. Once you have established if your OON benefits will reimburse you for working with your preferred provider, you can request a superbill from the provider along with your invoice for payment. You will use the superbill and invoice to create your claim with your insurance company to request reimbursement. You should by now have a good understanding of how much you will be reimbursed for your visits. It can seem like a lot to do upfront, but having access to the provider of your choice means that you will have the outcome you desire in therapy sessions, rather than working with a provider that has a contract but perhaps not the best skill set in helping your child progress in therapy.
Don’t forget, if your insurance plan has OON benefits, you are paying for those benefits when you pay your premium, you might as well dive in and explore what they cover. There’s nothing to loose!
