Trying to manage insurance coverage for your child’s care?
Undivided can help ensure you are getting the most out of your health plan.
How it works
1. Chat with us
Get a free consult call to understand if insurance advocacy is needed.
2. Perform an audit
Receive a personalized audit of your coverage, benefits, and processes.
3. Get access to ongoing support
Undivided claims support can file your claims for you and monitor them for correct processing.
Trusted by parents in California
“To have someone who listens and understands, validates fears, and finds solutions is so helpful.”
– The Smith Family
Understanding out-of-network reimbursement
Decipher your health plan’s coverage, exclusions, and lingo.
Research requirements for pre-authorization of services.
File timely and accurate claims.
What does out-of-network mean?
Out-of-network simply means that a provider has not contracted with your specific (or often any) health plan. To work with this provider, you will access out-of-network levels of coverage on your plan, and will most likely submit your own claims for processing. Learn all about handling insurance claims in our Insurance decoder.
Why would a provider choose not to contract with a health plan?
- Network contract rates have been trending lower in recent years.
- Network contracts may impose limitations on what services are covered by diagnosis.
- Low contract rates may limit the length of sessions that the provider can offer.
Why would I see or be referred to an out-of-network therapy provider?
- Not all of your child’s needs are covered by in-network therapy providers.
- Your child’s primary care physician or specialist may recommend a therapy provider who is out-of-network.
- It’s not uncommon for out-of-network providers to spend more time on clinical discussion with you and other members of your care team.
What do I need to understand when choosing an out-of-network provider?
- You should understand your health plan’s out-of-network benefits, coverage, and deductible. Coverage can vary dramatically depending on the benefit levels of your plan.
- You should know whether pre-authorization is required from your health plan for the service. (Pre-authorization will require a prescription and a written evaluation.) You will most likely need to file claims directly with your health plan.
- You will often not know the exact amount of reimbursement you’re entitled to prior to submitting a claim for a service or visit.
- You will often need to pay your provider prior to receiving reimbursement (if you do receive reimbursement) from your health plan.
Are there other factors I should consider?
- Is the service or care considered medically necessary by a physician?
- At what point will you meet the plan’s out-of-network deductible and see reimbursement begin?
Is it possible for an out-of-network provider to be covered as in-network?
In some cases, out-of-network providers can be covered at the in-network benefit level if you can prove that your out-of-network provider is uniquely qualified to provide a service that is medically essential.
See if insurance advocacy is right for you.
Jason Lehmbeck, CEO, Undivided, with his family
The Undivided team has 100+ combined years of experience parenting kids with disabilities and supporting parents of out-of-the-box kids in California. We are tenacious in our fight for access and support, both for our kids and yours.