Clarus Imaging currently accepts self-pay patients and can provide patients with out-of-network insurance benefits with the necessary documentation to make out-of-network claims.
What does out-of-network (OON) mean?
An out-of-network provider is a service provider which is not part of your insurance provider’s network or does not accept your insurance plan.
Some health insurance plans only cover in-network services, while other plans may cover both in-network and out-of-network services. Assuming you have met your out-of-network deductible, insurance plans that cover out-of-network services, will typically reimburse for between 50-80% of the costs of out-of-network services.
Out-of-network providers generally cannot submit claims on your behalf, and you will have to submit this claim on your own.
What is a Deductible?
A deductible is a specific amount of money that you, as an insurance policy holder, are responsible for paying out-of-pocket before your insurance coverage begins to cover eligible expenses.
For example, if your health insurance policy has an out-of-network deductible of $1,000, you will need to pay for the first $1,000 of covered medical expenses in a given year. After you have met the $1,000 deductible, your insurance typically begins to pay a portion of the remaining eligible expenses (usually a percentage) until you reach your out-of-pocket maximum.
Please check with your insurance provider whether you need to submit out-of-network claims before you have met your deductible. In many cases, when you have not met your deductible, you will still need to submit out-of-network claims, but your insurance provider may not reimburse you for any expenses until you reach your deductible.
What is an Allowed Amount?
An allowed amount is the maximum cost your insurer agrees to cover for certain out-of-network services.
You will need to contact your insurer’s Member Services to assist you in determining your plan’s maximum allowed amount for a particular service from an out-of-network provider. Ask your referring physician for the specific CPT codes to provide to your insurance provider.
How do I know what procedures are covered?
You can always find a list of approved services and providers on your health insurer’s website and a comparison of coverage for in-network vs. out-of-network providers for your specific plan.
How Do I submit an out-of-network claim?
- Check your out-of-network benefits including your:
- out-of-network benefits (if any)
- out-of-network deductible and if you have met your deductible
- allowed amount for the service (ask your referring physician for the CPT codes)
- out-of-network co-insurance (usually a percentage of allowed amount)
- Ask the provider for a superbill, a document that details the service a healthcare provider performed for you and includes diagnosis and procedure codes needed for insurance payers to reimburse you for the services after you’ve paid.
- Submit an out-of-network medical claim with your insurance provider. Please follow your specific insurance provider’s instructions on how to submit the claim.