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

  • πŸ“ Out of network deductibles are likely to be significantly higher compared to in-network levels.
  • πŸ’° If the out of network deductible is met, coinsurance rates are usually higher, ranging from 40% to 50% of the total bill.
  • πŸ₯ In-network coinsurance is typically between 10% and 30%, which is lower than out-of-network rates.
  • πŸ’Ό Out of network providers may receive lower reimbursement rates from insurance companies, often around 150% of Medicare rates.
  • πŸ’² 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.
  • πŸ“² The process of filing an out-of-network claim with Aetna can be done easily through the Aetna app on an iPhone.
  • πŸ” 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.
  • πŸ“„ 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.
  • πŸ“¬ 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.

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Related Tags
Health InsuranceOut-of-NetworkClaim FilingAetna AppDeductiblesCoinsuranceReimbursementMedical BillingiPhone GuideInsurance TipsClaim Process