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?
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:
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.