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Health insurance plans generally function on a network of coverage basis. They only provide reimbursements for service providers and hospitals they have agreements with or who are listed under their plan coverage. These agreements are based on terms related to discounts and offers. Services provided by health care professionals other than these are referred to as “out of network” services and the reimbursement claims made for these services are ‘Out of Network’ claims. While some insurance companies or plans do provide out-of-network benefits, this is not the norm. 

If a particular dental care provider’s service is not covered by a health insurance company or is an ‘out of network’ service, the patient might have to pay the entire bill or a large part of it, even with an existing health insurance plan. 

Why do insured patients go for Out-Of-Network dental professionals? 

  • Out-of-network by preference
    When a patient knowingly and deliberately prefers an out-of-network dental care provider due to recommendations, word of mouth, positive work ethic, successful previous operations, or other personal reasons, they may be willing to pay extra if needed to avail these services. 
  • Negligence or confusion
    A patient may neglect the terms of service of a dental insurance plan due to ignorance or may get confused due to excessive foggy paperwork or unclear communication. As a result, they may unintentionally avail services by out-of-network dental professionals. 
  • Services offered by different dental professionals.
    It is likely that an ‘in-network hospital that a patient goes to also has dental service providers that are out of coverage of the patient’s insurance plan. Being unaware of these intricacies, a patient might avail of dental services from an out-of-network dental service provider. 
  • Extra services
    A patient may go out of network when the dental insurance company denies taking responsibility for unavoidable extra services, like private or air-conditioned rooms, due to unavailability or excess capacity of regular rooms. 

It is the responsibility of dental professionals to ensure the patient insurance eligibility and make them aware about the out-of-network protocols to avoid any future hassles in revenue flow. 

Billing an out of network claim

If a patient gets in contact with the insurance company beforehand about an out-of-network service they wish to avail, a request to claim reimbursement can be submitted to the insurer. The dental insurance company may respond positively if the request seems credible. Negotiation abilities come in handy in situations like these. Consulting a dental billing company like Capline Dental for the same can be beneficial. 

Some insurance plans have an out-of-network payment cap. If the cap is not reached yet, the insurance provider may cover a portion of the expenses, considering that the deductible has already been met. 

A well-detailed claim must be submitted to the insurer to reimburse out-of-network claims. The reimbursement can be directed towards the patient or the dental care professional. The request must adhere to and include the following: 

  • Copies of the receipts or statements that include: 
    • Patient’s name and personal details. 
    • Name of the doctor, office address, identification, etc. 
    • Date of Service. 
    • List of all services and diagnosis received by the patient with CPT codes and the amount paid respectively. 
  • A thoroughly filled claim form. Incomplete forms with missing or inaccurate information will only delay the reimbursement procedure and can also lead to claim denials.
  • On time claim submission. 

There is a limited period to submit the dental insurance claim. This period usually lasts up to twelve months from the date of service. Dental Professionals must adhere to these guidelines to avoid claim rejections.