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Zelis is dedicated to helping healthcare consumers with access to quality healthcare through our provider networks and provides assistance in understanding and navigating out-of-network bills for participating plans.

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Understanding Your Out-of-Network Medical Bill

Whether you recently visited a doctor or hospital, or are planning for future healthcare needs, understanding how out-of-network bills work is crucial for making informed healthcare choices and managing your healthcare costs wisely. Understanding your coverage details ensures you receive fair billing practices. Explore the resources below to learn more about what causes these bills and how to manage them.

Out-of-network medical bills happen when you visit a doctor or hospital that isn’t in your health plan network. 

  • In-network doctors have agreed rates with your health plan, so you pay less out of pocket. Using in-network doctors whenever possible can help minimize your expenses. 
  • Out-of-network doctors might charge higher rates, and you could be billed for costs not covered by your plan. 

Coverage Differences: 

  • Out-of-network claims are usually paid based on “usual, customary, and reasonable” rates or negotiated rates. These rates are the amount paid for a medical service in a geographic area based on the amount that providers in the area usually charge for the same or similar medical service. The UCR amount is sometimes used to determine the allowed amount. These rates may be lower than what the doctor charges, so you might pay more. 
  • Your plan might have higher deductibles or coinsurance for out-of-network services. Check your plan details to understand what’s covered. 

Balance Billing: 

  • Out-of-network doctors might send you a bill for the difference between their charges and what your plan considers fair. This is called a balance bill. 
  • This happens when a provider bills you for the difference between their charge and your health plan’s allowed amount. For example, if the provider’s charge is $100 and the allowed amount is $70, the provider may bill you for the remaining $30. A preferred provider may not balance bill you for covered services. 
  • Some states limit this practice. Check local laws or contact your health plan to know your rights and potential costs. 

Prior Authorization:

Your plan might need approval for out-of-network care before it happens. Check before your visit to avoid coverage issues. Failure to obtain approval, also known as prior authorization, may result in reduced coverage or denial of the claim. 

Submitting Claims: 

  • In most cases, the doctor will submit a claim and there will be no action required by the member. 
  • In other cases, the member will need to understand the process for submitting out-of-network claims. Typically, you’ll need to submit an itemized bill and possibly other documentation to your health plan for reimbursement. Keep copies for your records.  

Appeals Process: 

  • If your out-of-network claim is denied or not fully covered, you may be able to appeal. Learn your health plan’s process and deadlines for submitting an appeal. 

Stay Informed: 

  • Choose in-network providers whenever possible to save on expenses. 

Emergency Situations: 

  • In emergencies, you don’t always have a choice of which provider or hospital you visit. In that case, you may receive care from an out-of-network provider. Federal law protects you from unexpected bills in these cases. 
  • The No Surprises Act protects consumers covered under group health plans from surprise medical bills by prohibiting balance billing for certain out-of-network care. Those services include (1) emergency care from an out-of-network facility or provider, (2) non-emergency care from an out-of-network provider in an in-network facility and (3) out-of-network air ambulance care. 

Negotiation and Payment Plans: 

  • If you face large out-of-network bills, you can contact the number on your most recent bill to ask about payment options or financial assistance.  

Have questions about out-of-network medical bills or need assistance understanding your coverage?

Contact your health plan’s customer service team listed on your card for support or questions about out-of-network bills and coverage. 

Glossary of Terms

We get it. Healthcare can be confusing. Here are some common terms you’ll see and hear while navigating your care journey.

Appeal: A request for your health plan company to review a decision that denies a benefit or payment. If your health plan refuses to pay a claim or ends your coverage, you have the right to appeal the decision and have it reviewed by a third party.

Itemized bill: An itemized bill is a detailed list that shows all the services you received from a doctor or hospital, like check-ups or treatments, and how much each one costs. It helps you understand what you’re paying for and why.

Balance bill: When a provider bills you for the difference between the provider’s charge and the allowed amount. For example, if the provider’s charge is $100 and the allowed amount is $70, the provider may bill you for the remaining $30. A preferred provider may not balance bill you for covered services.

Medical bill: A medical bill is a list that shows how much money you owe for visits to the doctor or hospital. It tells you what services you received, like check-ups or medicine, and how much each thing costs. Medical bills help keep track of expenses and are used when paying or asking for help from insurance.

Coinsurance: Coinsurance is like sharing the cost of medical care with your health plan company. After you meet your deductible, you and your plan each pay a certain percentage of the bill. It helps make healthcare costs more manageable for you and your family. For example, let’s say your health plan’s allowed amount for an office visit is $100 and your coinsurance is 20%.

  • If you’ve paid your deductible: You pay 20% of $100, or $20. The health plan pays the rest.
  • If you haven’t met your deductible: You pay the full allowed amount, $100.

Negotiated rate: A negotiated rate is a discounted price that your health plan and the doctor or hospital agree on for medical services. It’s usually lower than the original price. This helps save money on healthcare expenses.

Usual, customary, and reasonable rates: The amount paid for a medical service in a geographic area based on what providers in the area usually charge for the same or similar medical service. The UCR amount sometimes is used to determine the allowed amount.

Deductible:A deductible is like a goal you need to reach with your own money before your insurance starts helping to pay for medical costs. Once you reach this goal, your health plan will cover more of the bills. It’s important to know your deductible so you can plan for medical expenses.

After you pay your deductible, you usually pay only a copayment or coinsurance for covered services. Your insurance company pays the rest. Family plans often have both an individual deductible, which applies to each person, and a family deductible, which applies to all family members. Generally, plans with lower monthly premiums have higher deductibles. Plans with higher monthly premiums usually have lower deductibles.

No Surprises Act: The No Surprises Act was signed into law in December of 2020 and is designed to protect patients from surprise medical bills and prohibits balance billing of a patient for certain out-of-network care. Those services include (1) emergency care from an out-of-network facility or provider, (2) non-emergency care from an out-of-network provider in an in-network facility and (3) out-of-network air ambulance care.

For additional information on the No Surprises Act visit: https://www.cms.gov/nosurprises

Denial of claim: A denial of claim happens when your insurance company decides not to pay for something your doctor said you needed. They might say it’s not covered or that more information is needed. It’s important to ask questions and talk to your doctor and insurance company to understand why.

Out-of-network: Out-of-network means going to a doctor or hospital that isn’t in your health plan’s list. It might cost more because your plan might not cover as much of the bill. It’s important to check with your plan before going to make sure you know what to expect.

Health plan: In general, a health plan offered by an employer or employee organization that provides health coverage to employees and their families.

Prior authorization: Prior authorization is like asking permission before getting certain medical care or medicines. Your doctor needs to check with your insurance first to make sure they will pay for it. It helps make sure you get the right treatment without unexpected costs.

In-network: In-network means going to a healthcare provider and/or facility, that has an agreement with your health plan. It usually costs less because your plan helps cover more of the bill. Before you go, check with your insurance to find doctors, hospitals, and suppliers that are in-network for you.

Reimbursement: Reimbursement is when you get money back for something you paid for, like medical expenses. Your insurance or someone else pays you back for what you spent, helping cover the costs.