Navigating Out-of-Network Insurance

Out-of-network insurance can significantly offset the cost of care at Ember Health. On average, our clients who submit claims receive 70% reimbursement for our services. With that said, out-of-network reimbursement is notoriously confusing. See here and here a couple of helpful guides on how it works. Read below our recommendations for how to get started.

Step One: Verify your out-of-network benefits

Call the member services phone number listed on your insurance card, and ask the following:

• Do I have out of network coverage with my plan?

• If so, how much can I expect to be reimbursed for a bill with the following CPT codes:

• 99215 with “modifier 25” (Established Patient Office Visit with modifier for additional service)

• 96365 (Injections and Infusions) 

• What is my deductible, and how much have I already hit this year?

Depending on what you learn:

• You can only expect to be reimbursed if you have out-of-network coverage.

• Add up expected reimbursement rates from the above codes to gain a sense of how much you may be reimbursed for each treatment at Ember Health.

• This amount will go towards your deductible after each treatment until your deductible is met. After you reach your deductible, your insurance company should reimburse you this amount directly after each visit.

Step Two: Determine how you want to pursue reimbursement

Because 30-40% of claims for out-of-network services are denied upon first review by insurance companies, we strongly recommend working with a third-party service to manage your claims. Ember Health is not able to provide assistance with issues that come up during your insurance reimbursement process. A few options you may consider:

Option 1: Engage concierge-level help to file your claims and support denials

• SJ Health Insurance Advocates (SJHIA) is a small business that provides hands-on support to help you file each claim, answer any questions your insurance has, and advocate for you if your claims are denied. 

  • SJHIA charges a 10% commission for any reimbursement you receive, but they handle everything on your behalf from start to finish.

  • Click here to send a pre-generated email to SJHIA to signal your interest in learning more.

    • Alternatively, you can email them directly at info@sjhealthinsuranceadvocates.com.

  • Click here for a detailed FAQ on SJHIA.

Option 2: Automatically file your claims 

• Reimbursify is a technology company that helps you auto-submit claims to your insurance provider and track reimbursements along the way. 

• Users download a free app and submit claims from their phone. 

• Reimbursify does not offer any assistance if your insurer denies the claim or requests more information.

• Click here for an FAQ on Reimbursify.

Option 3: File your claims yourself

• If you’re confident you have the time and know-how to submit bills on your own and navigate denials, Ember Health can send you a superbill after each treatment.

• This article outlines step-by-step guidance for how to submit your claims on your own.

If you choose options 2 or 3, and your claim is denied by your insurance company, you may contact SJHIA or a similar service such as Community Health Advocates for assistance. Some large employers include healthcare advocacy groups as a part of their benefits package. You may contact your employer’s HR department to learn more. Alternatively, you can escalate your insurance denials to the Attorney General Office of New York.