TABLE OF CONTENTS


How do I interpret an insured member’s OON benefits when the summary is not conclusive?

In most cases, when verifying an insured member’s OON benefits, the summary at the top of the page provides clear details on their OON deductible information, as well as their reimbursement rate, after either the individual or family deductible threshold has been met. In the example below, the insured member has already met their individual deductible of $2,500 and they should expect to receive a 70% reimbursement for covered services, as long as the fee that they paid for the services is below the maximum allowed amount as specified by their insurance plan. See here for more information on allowed amounts.  


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In some cases, the information that we receive from the insurance company is not as easy to summarize. In these cases you should click the button to “View More Details” to examine their benefits in more detail. 


 


Where to find the deductible details 

The first section you should check is called “Health Benefit Plan Coverage,” located at the top of the details. 

If the insured member has OON benefits, their deductible information will be contained in a sub-section labeled, “Family Out-of-Plan-Network" or “Individual Out-of-Plan-Network" 

 


If there is no sub-section labeled, “Family Out-of-Plan-Network" or “Individual Out-of-Plan-Network" in the Health Benefit Plan Coverage section, then it is likely that the insured member does not have OON benefits. 

Where to find the reimbursement details 

If you scroll down in the details, you will find a section labeled, “Professional (Physician) Visit - Office”.  NOTE:  though this section refers to "Physician," it actually applies to any licensed practitioner with independent practice authority, including LCSWs, PhDs, APRNs, PTs, etc. 

If the insured member has OON benefits, their reimbursement information will be contained in a sub-section labeled, “Individual Out-of-Plan-Network." The co-insurance rate that is displayed represents the amount that the insured member is responsible for, and is usually represented as a percentage. NOTE: The co-insurance rate is the inverse of the reimbursement rate that might be displayed in the summary section at the top of the Benefits Verification. In the example below, the insured member will be responsible for 30% of the fee (the co-insurance rate) and the insurance company will reimburse the other 70% (the reimbursement rate). 

 


If there is no sub-section labeled, “Individual Out-of-Plan-Network" in the Professional (Physician) Visit - Office section, then it is likely that the insured member does not have OON benefits. 

Some insurance plans call for insured members to contribute a fixed co-payment amount for OON care, rather than co-insurance rate (though this is uncommon). In these cases, the amount reimbursed to the insured member will have the co-payment amount deducted from fee the insured member paid to the practitioner. In the example below, if the insured member paid their practitioner $200 for a visit and had a co-payment amount of $40, they would be reimbursed $160. 


What if the summary contains deductible information, but not reimbursement information? 

In some cases, the summary may display OON deductible information, but it displays, "See Details" as the estimated reimbursement rate.  In these cases, Click the "View More Details" button and scroll down to the type of treatment that your practice provides (i.e., "Mental Health") to view the benefits for that type of treatment, as described below.


Where to find specific benefits for Mental Health treatments 

Since the passage of the legislation for mental health parity in 2010, most insurance policies cover mental health benefits at the same level as medical benefits, as seen in the section, “Professional (Physician) Visit - Office”.

Though uncommon, some insurance plans may offer different benefits for mental health treatment. Due to the parity laws, coverage for mental health may actually exceed that of medical coverage, for example with a greater reimbursement percentage or a lower deductible.  

If you scroll down in the details, you will find a section labeled, “Mental Health.” When you click the “View More Details” button we will display the benefits specifically for mental health treatments. 

 

 

NOTE: You may have to scroll back down to this section to view the results 

 


Where to find benefits or limitations for Physical or Occupational Therapy treatments

Some insurance plans provide details on limitations and/or precertification requirements for physical or occupational therapy treatments. 

If you scroll down in the details, you may find sections labeled, “Physical Therapy” or “Occupational Therapy” where those details are specified.


What to do if the details do not provide any relevant information

In rare cases, some insurance plans do not provide any details. In these cases you will have to contact the insurance company at the phone number provided in order to obtain this information.


What to do if our system is unable to respond?


There are cases when the insurance company that we are trying to reach is temporarily unavailable. When this happens you will see a message indicating, "Unable to respond at current time." In these cases you should try again at a later time. (These issues are usually resolved within hours and there is no need to contact us.)



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