Your Guide to Filing an Out-of-Network Claim: What You Need to Know

Friends With Your Benefits | John Coleman

26 Dec 202304:25

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

00:00

📱 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

An 'Out of Network Claim' refers to a request for reimbursement for medical services provided by a healthcare provider who is not part of the patient's insurance network. In the video, this concept is central as it explains the process of filing such a claim with Aetna, highlighting the higher deductibles and coinsurance typically associated with out-of-network care.

💡Deductible

A 'Deductible' is the amount of money a policyholder must pay out-of-pocket before the insurance coverage begins to pay its share. The script mentions that the out-of-network deductible is likely to be significantly higher compared to the in-network level, emphasizing the financial considerations when choosing an out-of-network provider.

💡Coinsurance

'Coinsurance' is the percentage of the cost of a covered healthcare service that the insured must pay after the deductible has been met. The video script explains that coinsurance for out-of-network providers can be higher, ranging from 40 to 50%, compared to the more common 10 to 30% for in-network services.

💡Reimbursement Rate

The 'Reimbursement Rate' is the amount that an insurance company will pay for a covered service. The script contrasts the lower reimbursement rates for out-of-network providers, often 150% of Medicare, with the potentially higher rates for in-network providers, which can be 200-300% of Medicare.

💡Aetna App

The 'Aetna App' is a mobile application used by Aetna insurance members to manage their health benefits. In the script, it is used as a tool to demonstrate how to file an out-of-network claim, showing the steps within the app to submit such a claim.

💡Itemized Bill

An 'Itemized Bill' is a detailed statement of charges for services rendered, which includes information about the provider, facility, services, and costs. The video script instructs viewers to upload an itemized bill when filing a claim to help determine the potential reimbursement rate.

💡Claim Submission

'Claim Submission' is the process of formally requesting payment from an insurance company for covered services. The script outlines the steps to submit a claim through the Aetna app, including adding claim and cost information, and uploading necessary documents.

💡In-Network Provider

An 'In-Network Provider' is a healthcare provider who has a contract with an insurance company to provide services at a predetermined rate. The video contrasts this with out-of-network providers, noting that in-network providers often receive higher reimbursement rates from insurance companies.

💡Medicare

Medicare is a federal health insurance program in the United States for individuals aged 65 and over. The script uses Medicare as a reference point for explaining the typical reimbursement rates for both in-network and out-of-network providers.

💡Health Insurance Plan

A 'Health Insurance Plan' is a contract between an individual and an insurance company to provide coverage for medical expenses in exchange for premiums. The video script mentions the possibility of having coverage through another health insurance plan, such as a spouse's plan, which could affect claim submission.

💡Claim Eligibility

'Claim Eligibility' refers to whether a claim meets the criteria set by an insurance company for reimbursement. The script indicates that if a claim is eligible for reimbursement, the insurance company will review the information and potentially send a check to the policyholder.

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.