Off-Network or OON Benefits under an insurance plan

Off-Network or OON Benefits under an insurance plan are known as out-of-network (OON) in medical coding services. An out-of-network provider does not have an agreement with the patient's insurance provider. As a result, they are not required to accept the reduced payment the insurance provider was able to arrange with their in-network providers. The benefit level for members is specified in every commercial insurance plan. Benefits are typically lower when a patient is treated by a non-contracted provider. A copay for an in-network provider may be relatively low for your patient, whereas a copay for an out-of-network provider may be significantly higher. Some providers may not be at all covered by certain carriers. i.e., in-network

An in-network (INN) provider is a healthcare professional who has an agreement with the payer's insurance provider or the network. Patients who visit in-network providers typically pay lower deductibles and co-insurance. Additionally, a copayment may be required for INN office visits from the patient at the time of the visit. Healthcare Maintenance Organization A health maintenance organization (HMO) is a form of insurance or health plan that limits a patient's options for receiving care from a specialist. When a patient has an HMO, they are given a primary care doctor who acts as the plan's gatekeeper and typically refers them to other in-network providers when a specialist is required. If the patient's primary care doctor determines that the patient needs to see an OON provider, then either a referral, a prior authorization, or possibly both are needed. If an in-network option is not available, patients with only HMO coverage typically do not receive any benefits when they see an out-of-network provider, unless their primary care physician makes a referral. HMOs are discussed in greater detail in Chapter 6. preferred provider organization (PPO) A preferred provider organization (PPO) is a type of health insurance that gives members the freedom to pick any doctor or specialist within the network of the payer or insurance provider. Although it's not necessary, the patient may select a primary care physician. Referrals are not necessary if the patient decides to use a PCP. For more information on the advantages offered by preferred provider organizations, see Chapter 6. Pay-at-Stand Health Insurance The point-of-service (POS) health insurance option is a kind of PPO/HMO hybrid plan. For patients who opt to only see in-network HMO providers, it offers affordable HMOs. Members can also visit non-network providers, though. Higher deductibles and copayments apply to patients who select the out-of-network option. On POS plans, see Chapter 6.

Benefits Explanation: EOB

The insurance provider responds to a claim submission by explaining benefits (EOB). The EOB reflects how the claim was handled and displays the charges that were billed, any discounts that were applied (either by a contract, fee schedule, negotiation, or arbitrarily assigned), the amount that was permitted, and, finally, any outstanding patient liabilities. Patients are billed by the EOB of the dental billing company, so providers cannot charge them more to offset any discounts that may have been applied to the claim. Information on the EOB and what you, as a biller or coder, should do with it is provided in Chapter 13. Workers' Compensation (WC) Employees injured at work are covered by workers' compensation (WC) insurance. There are filing requirements for each Workers' Compensation carrier, so make sure you are aware of them. Additionally, Worker's Compensation claims must be specific to the body part and condition being treated; therefore, you must confirm that the injury and body part being treated match the course of action authorized by Worker's Compensation before filing a claim. There are fee schedules or payment laws in some states that carriers must abide by and providers must accept. To price their claims, carriers typically turn to PPO networks (which are occasionally silent). Workers' compensation claims and how to handle them are covered in more detail in Chapters 6 and 16. Electronic Data Interchange (EDI) Medical claims can be electronically transferred from the provider to the payer using the electronic data interchange (EDI) system. The transfer can go directly from the provider to the payer or it can go to a clearinghouse first and then be forwarded to the payer. Patient demographic and clinical data are protected by EDI, which enables secure information transmission. Because EDI eliminates the need for paper, it moves more quickly and produces more.