My claim was denied because the provider was out of network. What now?

Why was my claim denied as out of network?

Your insurer keeps a list of doctors, hospitals, and other providers it has contracted with. That list is your network. If the provider was not on it, the plan may deny the claim or pay less.

What the plan does with out-of-network care depends on the plan type. HealthCare.gov says an HMO generally won't cover out-of-network care except in an emergency, and an EPO covers services only in the plan's network, except in an emergency. A PPO lets you use providers outside the network for an additional cost. You are not alone, and a letter like this is a reason to look closer, not a final answer.

My claim was for an emergency. Can they still deny it for being out of network?

HealthCare.gov says an insurer can't charge you more for emergency room services at an out-of-network hospital, and can't require prior approval before emergency room care. If your denial says out of network for a true emergency, that is worth questioning.

You may still owe your normal deductible, so a bill is not always zero. If you think the plan got it wrong, appeal and say plainly that it was an emergency.

I got a surprise bill from a provider I didn't choose at an in-network hospital. Is that allowed?

The federal No Surprises Act is meant to protect you from unexpected out-of-network bills for emergency room visits, for non-emergency care related to a visit to an in-network hospital, hospital outpatient department, or ambulatory surgical center, and for air ambulance services, according to CMS.

If you think your provider or insurer is not following these rules, you can call the CMS No Surprises Help Desk at 1-800-985-3059, which CMS says has phone support 7 days a week, or submit a complaint through the CMS medical bill rights pages. Details and exceptions depend on your plan and the situation. A separate dental-only plan, Medicare, or Medicaid may follow different rules, so ask your plan which apply to you.

There was no in-network option. Can I ask them to treat the claim as in-network?

Yes, you can ask. We did not find a federal consumer page that guarantees this, so we won't promise it. Insurers and state rules differ, and your plan type matters.

Put the request in writing. Explain that you looked for an in-network provider, name who you contacted, and say none was available or none could treat you in time. Ask the plan to process the claim at the in-network level. Keep copies of everything. Your state insurance department can tell you what your state requires.

How do I appeal an out-of-network denial?

HealthCare.gov explains the internal appeal process for health plans. Here are the steps. If you have Medicare or Medicaid, your denial notice will list that program's own appeal steps, so follow those.

HealthCare.gov says you must file within 180 days of the denial notice. It also says the Consumer Assistance Program in your state can file an appeal for you.

• Step 1: Read the denial letter. Find the claim number, the reason given, and the appeal deadline. Note the date on the letter.
• Step 2: Gather proof. Collect the bill, the explanation of benefits, any letter from your doctor, and notes on who you called and when.
• Step 3: File the internal appeal. Complete the forms your insurer requires, or write with your name, claim number, and insurance ID. Say what happened, and ask for the claim to be reconsidered. Keep copies.
• Step 4: Ask for outside review if denied again. If the insurer still denies the claim, HealthCare.gov says you can file for an external review.

How long do I have, and how long will they take?

HealthCare.gov says you have 180 days (6 months) from the denial notice to file an internal appeal. The insurer should finish within 30 days if the service has not been received yet, or 60 days if you already got the care. Urgent cases are faster.

These are the rules HealthCare.gov describes for health plans. Employer plans, Medicare, Medicaid, and dental-only plans may follow different timelines, so the deadline printed on your own letter is the one to trust.

Your checklist

• Find the claim number and reason on the denial letter
• Write down your plan type: HMO, PPO, EPO, or POS, and whether it is through work, the Marketplace, Medicare, Medicaid, or a dental plan
• Note whether it was an emergency
• Note any in-network options you tried, with dates
• Gather the bill, explanation of benefits, and doctor letter
• Mark the appeal deadline on your calendar
• Text a photo of the letter to (213) 606-6303

A letter you can copy

[Your name] [Your address] [Date] [Insurance company name] Appeals Department [Insurer address] Re: Appeal of denied claim Claim number: [claim number] Member ID: [insurance ID] Date of service: [date] Provider: [provider name] To whom it may concern: I am appealing the denial of the claim above, which was denied as out of network. [Choose one: This was emergency care. / I was treated at an in-network facility by a provider I did not choose. / I could not find an in-network provider who could treat me.] Here is what happened: [short description]. I contacted [in-network providers or the plan] on [dates] and [what you were told]. I ask that you reconsider and process this claim at the in-network level. Please send me your decision in writing, and the specific plan language you relied on. Enclosed: [denial letter, bill, explanation of benefits, doctor letter]. Sincerely, [Your name] [Phone]

Which rules apply to you?

The steps and deadlines on this page can differ by the kind of plan you have. Your own denial letter always comes first.

• Coverage through a job:ask your HR team whether the plan is “self-funded” or “fully insured.” It can change who you can ask for help. Most private-sector job plans fall under a federal law called ERISA, and the U.S. Department of Labor’s EBSA takes health plan questions at Ask EBSA or 1-866-444-3272.
• Marketplace plan: follow the appeal steps at HealthCare.gov.
• Medicare or Medicaid: each has its own appeal process, listed on your notice.
• Dental-only plan: your plan contract sets the appeal rights, so read it and your letter.

Related answers

• My prior authorization was denied. What now?
• Denied as "experimental or investigational"? Here is what it means and how to push back.
• How to read an insurance denial letter
• How to write an insurance appeal letter
• All answers

Free tools for the next step

Keep your appeal papers in one place. Take a photo of your denial letter, EOBs and insurance cards with GetPreCare, so they are on your phone when the insurer or the office asks. Free. Open GetPreCare. Helping a parent or partner? Set it up for them.