Out-of-network denials and network gap exceptions

“Out of network” means the provider has no contract with your plan. Many plans pay nothing, or much less, for out-of-network care. Before you accept that, find out whether the denial is allowed in your case, and whether the plan has a way to treat the care as in network.

What this means

Check these first. If one fits, the plan cannot charge you more than in-network cost sharing, or has to cover the care differently.

• Emergency care. If your plan covers emergency department services at all, it must cover emergency services without prior authorization, whether or not the provider is in network, with cost sharing no greater than in network.
• An out-of-network clinician at an in-network hospital or surgery center. Such a clinician may not bill you more than in-network cost sharing unless you signed a valid notice-and-consent waiver. Some services can never be waived, including emergency medicine, anesthesiology, pathology, radiology, hospitalist and assistant surgeon services.
• A wrong provider directory. If you relied on the plan’s directory, which said the provider was in network, and it was wrong, the plan may not charge you more than in-network cost sharing.
• Air ambulance. The same bar on higher charges applies.

These come from the federal No Surprises Act. They cover job-based plans and individual or Marketplace plans, including grandfathered plans. See surprise bills for the details.

If none fits, ask whether your plan has a network gap exception. Some plans say they will cover out-of-network care when the service cannot effectively be provided in network. The federal external review rule gives this as an example: an out-of-network denial where the plan covers out-of-network care if the service cannot effectively be provided in network can be taken to independent review. Whether your plan has this term is in your plan document. Ask for it in writing.

Continuity of care. If your provider or facility leaves the plan’s network while you are a “continuing care patient”, you may choose to keep in-network terms with that provider for up to 90 days. A continuing care patient has a serious and complex condition, is receiving inpatient care, is scheduled for non-elective surgery, is pregnant, or is terminally ill.

What to do

1. Read the explanation of benefits and the denial. Find the provider’s name, the network status the plan assigned and the reason. (You.)
2. Check whether a protection above applies. Use the surprise bill checker. If one applies, ask the plan to reprocess the claim at in-network cost sharing and ask the provider to stop balance billing. (You.)
3. Ask the plan for its network gap process, in writing. Ask whether an exception exists, who decides, and how long it takes. (You.)
4. Gather proof that the network cannot meet your need. Keep a list of in-network providers you contacted: names, dates, and what each said (no appointments, no experience with your condition, a wait that is too long for your condition). Print the directory pages. (You.)
5. Ask your doctor for a letter. It should say why this provider or this type of care is needed, and what in-network options were considered. The clinician letter on out-of-network necessity is the model. (Your doctor.)
6. Ask for a case manager. FAIR Health, a nonprofit that publishes cost data, advises asking the plan for a case manager, and checking that the explanation of benefits shows the right cost sharing and how long the arrangement lasts. (You.)
7. File the request or appeal before the deadline. Use the out-of-network gap appeal letter. Employer and non-grandfathered individual plans must allow at least 180 days after you receive the denial. If the denial is final, you have at least four months to ask for external review. Check the date on your notice, which controls.

What the plan may say, and what to say back

“The provider is out of network. Out-of-network care is not covered.” Ask whether the plan has a network gap exception or covers out-of-network care when no in-network provider can provide the service. Ask for the plan language that applies.

“You can see an in-network provider.” Reply with your list: who you called, on what dates, and why each in-network option cannot meet your need. Attach your doctor’s letter.

“Your provider’s contract with us ended.” If your provider just left the network and you are a continuing care patient, ask the plan in writing to cover you on in-network terms for up to 90 days.

The rule

A continuing care patient whose provider or facility leaves the network may elect to continue in-network terms with that provider for up to 90 days. 42 United States Code (U.S.C.) 300gg-113

Watch for

• Your plan, not federal law, decides the gap exception. We found no federal right to in-network coverage of out-of-network care outside the cases above. Do not skip your plan’s document.
• Prior approval. Get a written approval and a written rate before non-emergency out-of-network care. Patient groups advise getting written confirmation that in-network clinicians will use in-network labs and facilities.
• Eligibility denials. A denial that says you are not covered at all is not eligible for federal external review.
• Self-funded plans follow the federal process for external review, not the state’s.

What next

• Out-of-network underpayment: when the plan paid, but too little.
• Surprise bills and the No Surprises Act: who is protected and how to complain.
• Emergency room claim denied: the emergency rules in detail.
• Out-of-network and emergency care topic page: every related guide and letter.