How to Help Patients Get Out-of-Network Claims Paid

Many patients don’t realize the extra steps involved with out-of-network claims. Here are updated instructions you can provide to your patients:

Submit a complete and accurate claim

• Ensure the superbill from your facility shows all necessary details:
  
  • date of service
  • provider name 
  • codes
  • charge amounts
    
• Patient completes the insurer’s claim form (or uses an online portal) and includes the superbill and any required attachments.
  
• Encourage prompt submission to prevent delays.
  

Gather and keep all supporting documents

• Bills, superbills, receipts,  proof of payment, correspondence with the insurer(Make note of dates, times, names of insurance representatives when corresponding with the insurance company).
  
• These documents can help if follow-up or an appeal is needed.
  

Follow up on the claim

• Instruct patients to check status via insurer portal or by phone.
  
• Claims may take several weeks; missing information or billing code errors are common causes of delay.
  

Understand reimbursement limits

• Insurance may only reimburse up to an “allowed amount” (or “usual, customary, reasonable” rate) rather than what the provider billed for specific medical service.
  
• The provider may bill the patient directly for the difference.
  

Appeal if the claim is denied or paid less than expected

• Patient should request their detailed Explanation of Benefits (EOB).
  
• Then they may: submit a corrected claim, obtain a letter explaining medical necessity from their provider, include supporting records.
  
• Your office may offer to provide documentation to assist in the appeal.
  

Ask about pre-authorization when possible

• Some out­-of­-network services (especially specialists) may still require insurer approval.
  
• Getting prior approval before appointment will  increase chances of reimbursement.
  

Offer to help patients with claim submission

• Your facility can provide the superbill and instructions.
  
• Even if you don’t submit the claim directly, you can walk the patient through what the insurer will need.
  

Discuss fee negotiation or payment planning when needed

• If the provider is out-of-network, patients may ask for a discount for upfront payment or a payment plan.
  
• Encourage them to speak with your billing department about options.
  

Out-of-network claims can be complex, but clear instructions and proactive support make a meaningful difference. When front desk and billing teams educate patients on documentation, timelines, and follow-up, practices can reduce delays, improve reimbursement outcomes, and build patient trust from the start.