Your Guide to Filing an Out-of-Network Claim: What You Need to Know
Summary
TLDRJohn from 'Friends With Your Benefits' guides viewers on filing an out-of-network claim with Aetna via iPhone, highlighting the higher deductibles and coinsurance compared to in-network rates. He explains the lower reimbursement rates for out-of-network providers and demonstrates the claim submission process in the Aetna app, emphasizing the importance of uploading itemized bills and accurate claim details for potential reimbursement.
Takeaways
- 📝 Out of network deductibles are likely to be significantly higher compared to in-network levels.
- 💰 If the out of network deductible is met, coinsurance rates are usually higher, ranging from 40% to 50% of the total bill.
- 🏥 In-network coinsurance is typically between 10% and 30%, which is lower than out-of-network rates.
- 💼 Out of network providers may receive lower reimbursement rates from insurance companies, often around 150% of Medicare rates.
- 💲 In contrast, in-network providers could receive up to 200% to 300% of Medicare rates from insurance companies.
- 🚫 Providers may not be satisfied with the lower out-of-network reimbursement rates and could bill the patient for the difference.
- 📲 The process of filing an out-of-network claim with Aetna can be done easily through the Aetna app on an iPhone.
- 🔍 When filing a claim, it's necessary to add claim and cost information, including the date of service and whether the provider was paid in full.
- 📄 An itemized bill must be uploaded to provide details about the provider, facility, services, and costs for potential reimbursement assessment.
- ✍️ After entering all required information, the claim must be reviewed and submitted, including confirming that state notices for claim submissions have been reviewed.
- 📬 If the claim is eligible for reimbursement, the patient will likely receive a check in the mail from the insurance company.
Q & A
What is the purpose of the video by John from Friends With Benefits?
-The purpose of the video is to help viewers understand how to file an out-of-network claim with Aetna using their iPhone.
What should one know before seeing an out-of-network provider according to the video?
-One should be aware that the out-of-network deductible is likely higher, coinsurance rates are higher, and the reimbursement rate from the health insurance company is significantly lower compared to in-network providers.
What is the typical coinsurance range for in-network providers?
-The typical in-network coinsurance range is between 10% and 30%.
What could be the coinsurance percentage when seeing an out-of-network provider?
-The coinsurance percentage for out-of-network providers can be between 40% and sometimes 50% of the overall bill.
How does the reimbursement rate for out-of-network providers compare to in-network providers?
-The out-of-network reimbursement rate is often around 150% of Medicare, whereas in-network providers might receive between 200% and 300% of Medicare.
What is the first step in filing an out-of-network claim using the Aetna app?
-The first step is to open the Aetna app, scroll down to 'manage,' and select 'submit a claim.'
What information is required when adding claim and cost information in the Aetna app?
-You need to provide the member for whom the claim is being filed, specify it's a medical claim, and enter the date the claim occurred.
Why is it important to upload an itemized bill when filing a claim?
-Uploading an itemized bill provides information about the provider, facility, services, and costs, which helps determine the potential reimbursement rate.
What should be done if the claim is not related to an accident or employment?
-In such cases, the relevant sections in the claim form should be left blank, indicating that the claim has no relation to an accident, employment, or other coverage plans.
What is the final step in submitting an out-of-network claim through the Aetna app?
-The final step is to review the information, check the box confirming that state notices for claim submissions have been reviewed, and then click 'submit.'
What can one expect after submitting an out-of-network claim?
-If the claim is eligible for reimbursement, Aetna will review it and the claimant will likely receive a check in the mail.
Outlines
📱 Filing Out of Network Claims with Aetna on iPhone
John from 'Friends With Your Benefits' introduces a tutorial on how to file an out of network claim with Aetna using an iPhone. He explains that out of network deductibles are typically higher and coinsurance rates can be between 40-50%, compared to the 10-30% range for in-network services. He also mentions that reimbursement rates for out of network providers are lower, often around 150% of Medicare, versus 200-300% for in-network providers. The video script guides viewers through the process of filing a claim in the Aetna app, starting with adding claim and cost information, selecting the member, specifying the claim type and date, and uploading an itemized bill. The tutorial also covers reviewing and submitting the claim, and what to expect in terms of reimbursement.
Mindmap
Keywords
💡Out of Network Claim
💡Deductible
💡Coinsurance
💡Reimbursement Rate
💡Aetna App
💡Itemized Bill
💡Claim Submission
💡In-Network Provider
💡Medicare
💡Health Insurance Plan
💡Claim Eligibility
Highlights
Introduction to the process of filing an out-of-network claim with Aetna.
The out-of-network deductible is likely to be significantly higher compared to in-network levels.
Higher coinsurance rates for out-of-network providers, potentially 40-50% of the bill.
Lower reimbursement rates for out-of-network providers, often 150% of Medicare.
In-network providers may receive 200-300% of Medicare reimbursement.
Out-of-network providers may bill for the difference between their charges and the insurance reimbursement.
Demonstration of filing an out-of-network claim using the Aetna app on an iPhone.
Navigating the Aetna app to the 'manage' section to file a claim.
Step-by-step guide on adding claim and cost information in the Aetna app.
Instructions on selecting the member for whom the claim is being filed.
Specifying the date of service and choosing to indicate payment in full to the provider.
Uploading an itemized bill for claim processing.
Entering the amount paid to the provider for the claim.
Reviewing accident, employment, and coverage details for the claim.
Clarification on when to indicate other health insurance coverage.
Final steps of signing and submitting the claim in the Aetna app.
Process of reviewing and submitting the claim, including acknowledging state notices.
Expectation of receiving reimbursement if the claim is eligible.
Invitation for audience interaction regarding their experiences with out-of-network claims.
Transcripts
Hey guys, what's going on? This is John from
Friends With your Benefits where we're here to
help you make healthier benefit choices for
you and your family. Today.
We're going to talk about how you actually
go about filing and out of network claim
with Aetna and we'll show you the very easy way.
You can do this from your own iPhone.
Now before you see an out of network
provider.
There's a few things that you want to know.
So number one the out of network deductible
is likely going to be significantly higher
compared to the in-network level on top of that.
If you happen to satisfy your out of
network deductible.
Your coinsurance is likely going to be
higher compared to the in-network levels.
It's very common for in network coinsurance
to be anywhere between 10 and 30% But if
you happen to see an out of network
provider the coinsurance that you're
responsible for paying can be anywhere
between 40 and sometimes 50% of the overall
bill on top of that.
If you happen to see the out of network
provider the reimbursement rate that the
health insurance company is going to
provide and reimburse either you or
Provider is going to be significantly lower
compared to seeing in a network provider.
For example, it's very common to see the
out of network reimbursement rate be a
hundred and fifty percent of Medicare, but
on the flip side health insurance companies
really love their networks and they're
likely going to pay that in network
provider anywhere between two and three
hundred percent of Medicare.
So if you see that network provider just
know and just be prepared that the out of
network provider might not be happy with
the overall reimbursement rate and they may
send you a bill for the difference and what
they actually want between their bill
charges and what the health insurance
companies going to reimburse them.
So let's go right to our iPhone and we'll
show you how to actually go about filing
the out of network claim.
So we open the Aetna app and then we scroll
down until we see manage and there's a
whole bunch categories here.
We can look at our ID cards Quick Care
Health and Wellness claims and these are
filed claims or what we're going to focus
on today is submit a claim so we click that.
And we're going to step one which says add
claim and cost information to get started.
So we click that.
It asked to populate which member we're
going to do this for so we're gonna click me.
We do that we say it's a medical claim and
then just for today's purpose.
We're going to put down the claim happened
on December 19th.
We go back.
And we have two options here.
We could put that I paid the provider in
full or leave this blank.
And what I did is I actually paid my
provider in full.
So we checked that off.
The next item is we're going to upload an
itemized bill which has information about
the provider facility services and costs
and payments.
And really they need this ultimately to
know what the potential reimbursement rate
could be.
So we click upload.
Has a picture of the image.
And then we're done.
We click upload.
We go back.
And then what I forgot to do here is
actually put in the amount paid and what we
will type in.
Will be
$500.
We go back step 2 review accident
employment and coverage details.
So we do that and this claim is not related
to an accident anything related to my
employment and the last category the claim
covered by another Health Group plan such
as Blue Cross no fault insurance Medicare
any federal state or local government plan?
We're going to leave this one blank as well.
And this is important because it basically
you would only check this off.
If you happen to have coverage through
another health insurance plan such as your
spouse's.
We go back and the last step is to click
sign and submit.
We do that.
We have to go down and there's an option to
view State notices.
We won't do this now.
And then we check off the box that says I
have reviewed the state notices for claim
submissions. And when we're ready we click submit once
we do that at now.
We'll review the information.
And if this claim is eligible for
reimbursement, they will reach out to me
and likely I'll receive a check in the mail
from them.
So we want to hear from you guys.
Have you happen to file an out of network
claim in the past? And it's so what was the
overall reimbursement process like?comment below!
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