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Specialty AHIMA Certifications for Medical Coders and Billers
How to Coordinate Benefits in Medical Billing

How to Prepare an Out-of-Network Medical Billing Claim

When a patient is being seen out-of-network, the medical coder or biller must verify benefits before any costs are accrued by the provider. To insure that the provider and patient both understand their responsibilities you should do the following:

  1. Verify that the patient has out-of-network coverage.

    Some plans specify an out-of-network payment cap that may be much less than billed charges. The plan then may assign responsibility for the remainder of the balance to the patient. Sometimes this balance is quite large, and most people have difficulty paying it.

    Occasionally an out-of-network claim processes to allow full-billed charges and then pays according to the plan, usually 60 or 70 percent after the deductible has been met.

  2. Ask what, if any, language in contained in the plan benefit that defines exactly how out-of-network claims are processed.

  3. If possible, verify what methods may be used to price out-of-network claims, which lets you know how much payment can be expected.

    The payer representative will always provide the out-of-network deductible and co-insurance responsibility, but that’s usually the extent of the information you’ll receive. Although getting the payer to divulge the provisions of the plan in question is very difficult, it’s worth a try.

Regardless of whether the claim is in- or out-of-network, always treat the payer with respect and give each one equal consideration. The claim should be billed in good faith and be a truthful representation of the work done by the provider.

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