No in-network provider
Sometimes it can be difficult (or seemingly impossible) to find an in-network mental health clinician nearby and with a short wait-time for an appointment. It’s not right.
When no in-network provider is available, insurers may be obligated to cover the cost of out-of-network clinicians as if they were in-network.
Action Plan
Below are reasonable expectations for your accessing in-network providers:
- Medical expertise you need – you should have access to an in-network provider suited to your needs; that may be for out-patient care (in office or by telehealth) or for higher levels of care such as intensive outpatient, partial hospitalization, or residential
- Within 30 – 45 minutes travel time (or by telehealth)
- Soon:
- Within 10 – 14 days for non-urgent care
- Within 2 -3 days for urgent care
- After a search of no more than 10 providers who are in-network.
If no in-network provider is available, you should pursue having an out-of-network provider covered as if they were in-network. That may be the law in your state. It is, in any case, a reasonable expectation.
Your insurance company should provide you with names of in-network providers:
- In an online directory
- From a customer service rep
Your insurance company customer service rep should also tell you how soon and how nearby you should expect to find an in-network provider. Ask!
Two tips:
- Take a screen shot or picture of on-line directory showing “available” providers; this evidence may be helpful later.
- Some states require insurers to have network providers near you and available soon. To learn more, visit https://www.ncsl.org/health/health-insurance-network-adequacy-requirements and select your state
Your insurance company should provide you with names of in-network providers:
- In an online directory
- From a customer service rep
Your insurance company customer service rep should also tell you how soon and how nearby you should expect to find an in-network provider. Ask!
Two tips:
- Take a screen shot or picture of on-line directory showing “available” providers; this evidence may be helpful later.
- Some states require insurers to have network providers near you and available soon. To learn more, visit https://www.ncsl.org/health/health-insurance-network-adequacy-requirements and select your state
Getting Going
If you do not find a suitable, in-network provider, ask an insurance company customer service rep for help, using these talking points:
- “I’ve tried to contact [how many?] potential providers and none are available to see me (soon enough).”
- “Please schedule an appointment for me by tomorrow.” OR
- “Please approve my use of an out-of-network provider at in-network rates.”
Your request for coverage of an out-of-network provider at in-network rates should be put in writing. AND, your insurer’s response to that request should also be sent to you in writing.
Insurer request for in-network coverage for out-of-network provider
If this does not result in a timely appointment with an in-network providers, then see “Filing a formal complaint with your insurer” for a next step.
Why file a complaint?
- The goal of filing a “formal complaint” is to escalate an issue towards overcoming whatever obstacle is blocking access to care.
- Filing a formal complaint with your insurer may be helpful (even required) before additional actions, such as filing a complaint with a state insurance regulator.
What a complaint is not?
- A “formal complaint” is NOT an appeal.
- If you are asked whether you want to file an appeal, your response should be: “No, I want to file a formal complaint. This is not an appeal.”
