How to Check Your Out-of-Network Benefits
February 15, 2024
A guide to checking your out-of-network benefits
Have you ever asked a healthcare provider, “Do you accept my insurance?” If the answer is no, that means the provider or facility is “out-of-network”. And you might be discouraged from using their services. However, if you have out-of-network benefits (aka out-of-network coverage), don’t dismay! You should be able to get reimbursement from your health insurance for their services.
Which probably leads you to the question, “Do I have out-of-network benefits?” In this post we’ll cover how to check your out-of-network coverage for FREE.
What Are Out-of-Network Benefits?
“Out-of-network benefits” refers to your health insurance plan’s coverage for providers or facilities outside of the insurer’s network. These are called “out-of-network providers,” or providers that don’t accept your insurance. People abbreviate out-of-network as OON, so you might see the phrase written as “OON benefits” and “OON providers”
OON benefits tend to be more limited than in-network benefits. This is because OON providers do not have a contract with your insurer. (Read more about the difference between in-network and out-of-network.) This means that you have to pay OON providers up front for their services, and your OON benefits kick in after you’ve been billed, in the form of a reimbursement.
It helps to know your OON benefits before you see an OON provider. That way you won’t be surprised by your healthcare expenses. You are only entitled to reimbursement according to your plan. No more, but also no less (assuming you’re willing to wrestle with your insurer a bit).
Most insurers cover a smaller percentage of OON costs. But you might be surprised by how close these percentages can be. For instance, a basic dental plan may cover 100% of preventive care services in-network and 80% out-of-network. The 20% extra you pay to see the OON provider may well be worth it. Especially if it gets you a better dentist for an important preventative procedure.
Therefore, knowing your OON benefits before you make your next healthcare appointment will help in the decision-making process. To learn more about why going outside your network can be a smart healthcare choice, read The Case for Out-of-Network Reimbursement.
How to Verify Insurance Benefits
Some healthcare providers may be able to check your insurance benefits before your visit. Ask the healthcare provider if they can do this for you to see if they have a tool to verify your benefits. If not, they may tell you to call your insurance company. You’ll need to locate the customer support phone number on the back of your insurance card. When you get a hold of a support representative, ask them about your OON benefits for the specific type of healthcare service you are seeking.
Checking your insurer’s website
Another way to check your OON benefits is by visiting your health insurer’s website. Log in and view your plan details. Some health insurers make it easier than others to find this information. If you’re having trouble, try to use the search bar to find what you’re looking for.
Now let’s put our knowledge into practice! In this section, we’ll go over how to verify dental insurance benefits with a popular insurer, Delta Dental. We wanted to walk you through the process step-by-step with visual cues, so we decided to use this sample insurer in order to provide specific images of the process.
We chose Delta Dental as the sample insurer because their website is pretty standard. It’s representative of what you’ll likely encounter navigating your own insurer’s website. We also chose it because OON benefits are widely used for dental care, since dental procedures often require specialists and can cost a lot of money.
Here we go!
The first thing you need to do to check OON benefits is navigate to your insurer’s website and sign in. For Delta Dental, the Sign In button is in the top right corner of the page.
After you sign in, head to your patient portal. Insurers use various names for this (Delta Dental calls it the Member Dashboard) but you should be able to find something that refers to members or patients on the home page. Some insurers’ sites will take you straight there after you sign in.
From your patient portal, you can look up providers in Delta’s network, check your OON benefits, and sometimes estimate the cost for services. Delta Dental’s OON coverage depends on your plan, so we don’t dive into the specifics here. Just make sure you’re looking at your plan’s details when checking your OON benefits.
The next step is where it can get a little complicated. Since most insurers only list a few general services on their site itself, if you’re seeking a more specialized service you’ll need to find the actual plan document to see your entire list of OON benefits.
For instance, say you need to visit an endodontist for an evaluation. Delta Dental’s plan doesn’t mention anything about endodontists, since they’re specialists who often work outside of networks.
With Delta Dental, you need to locate your plan, then scroll down to the bottom where they have a document called Policy and Benefit Details, download an 83 page pdf file, and scan that until you find the service you’re considering.
This is where we advise you to proceed with caution. Getting all of your information from the insurer’s website is a bit one-sided. Because they have a contract with their in-network providers, they have a strong incentive for you to stay in-network. It seems they make it intentionally difficult to find your specific OON benefits, even though it may be in your best interest to use them.
Remember that promotional content (like the short version of a plan’s description) is essentially an advertisement. The real contract you’ve signed with your insurer is that 83 page document. All your actual benefits are detailed there.
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