So much of our collective focus has been on the implications of the upcoming health care reform law that many have taken their eyes off a potentially upcoming deadline  for filing an Out-Of-Network Benefits claim, which could cost a pretty penny.

According to a recent article posted by Healthcare Navigation: “out-of-network benefits are an important protection even though payment rates from insurers have been driven down.”

The Out Of Network Claims Filing Deadline Trap

Some may be asking “What are Out-of-Network Benefits?”  This is the coverage some get when they see a provider (usually a doctor) that is not part of their health care plan’s network.  Typically, they are covered at a significantly lower rate, but something is still better than nothing.  The tricky part is that, unlike in network benefit claims which are typically filed by your provider/doctor, you/the patient must file a request for reimbursement with the insurance company when seeking service by an out-of-network provider, and insurers are quite strict on the deadline for filing those claims.

A Claims Filing Deadline is a Hard Stop

“A claims filing deadline is just that – a hard stop – file the claim before the deadline or the Plan has the right to deny it altogether…most claim filing deadlines are 120 days, six months or a year. That might sound like a long time but when a family is reeling from the news of a serious diagnosis, it is typical that the entire focus is on the medical care for the person diagnosed and not on filing claims.”

REMINDER: send in information on your out-of-network services as soon as possible so that you avoid timely filing denials. It’s impossible for the insurance company to know about out-of-network services until a claim with a statement is filed.

Filing Deadline for Medicare is 1 Year

By the way, the filing deadline for Medicare  is one year.  “Of course, patients rarely file claims to Medicare but patients can get caught in the middle of disputes if, for example, someone who was on an active group plan becomes ill and ultimately is moved to the company’s long term disability benefits. At that time, according to the rules of insurance, Medicare becomes primary. Insurance companies have become much better at identifying when they paid as primary when Medicare should have and they want the money back.  These situations create a mess because the group plan insurer takes its payments back from in-network providers and seeks reimbursement for medical services from patients directly (and sometimes quite aggressively) for out-of-network providers.”

Have you had some experience with out-of-network claims and the filing deadlines?

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If you need help understanding your out-of-network benefits or the related claims deadline, please fill out the form below and one of our experts will be in touch with you right away!

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