These are typically in the Summary of Benefits, included in a member information packet or on your insurance company website. Keep an eye out for these terms:
Out-of-network deductible: This is the amount of money you have to pay before you are eligible for reimbursement.
Let’s say your out-of-network deductible is $1,000, and your insurance company pays for 100% of services after you meet that amount. That means you’ll have to pay $1,000 out of pocket, after which you’ll have “met your deductible.”
In this scenario, if you spend $1,500 on chiropractic services, you’ll have to pay $1,000 out of pocket (e.g. $100 at each session for 10 sessions), but the remaining $500 will be reimbursed to you in the form of a check (mailed to you after you submit your claim).
Deductibles typically reset every calendar year, and any health expense you pay out-of-pocket contributes to meeting it–so submit it, even if you will not be reimbursed as it will help with other health expenses.
Coinsurance: This is the percentage of the service fee that you’re ultimately responsible for paying.
Let’s say your chiropractic office charges $100 per session. If your coinsurance is 25%, you’re only responsible for paying $25. (Note: You’ll need to pay the full $100 upfront. Your insurance will send you a check for $75 per session after the care plan is over, and once you’ve met the deductible and submitted a claim.)
Some insurance companies determine an “allowed amount,” which caps the office fee that they’ll cover. If your insurance has determined $100 is their “allowed amount” per session, at a 25% coinsurance rate, your insurance company will still only reimburse you up to $75, no matter what the chiropractic office fees are.
In other words, if your insurance has an allowed amount of $100 but your chiropractic office fees are $200 per session, you won’t get reimbursed more; you’ll still be reimbursed $75, and will be ultimately responsible for $125.
2. Call your insurance company to verify your benefits
The best way to be absolutely sure of your benefits is to clarify with your insurance company member services line. You can find this phone number on the back of your insurance card.
Ask these questions when speaking to your insurance company about benefits:
How much of my deductible has been met this year?
What is my out-of-network deductible for chiropractic adjustments, exams, and xrays?
What is my out-of-network coinsurance for chiropractic adjustments, exams, and xrays?
How do I submit a claim form for reimbursement?
Could you please send me the claims form needed to receive reimbursement for sessions paid out of pocket?
3. Ask your chiropractic office for a “Superbill”
Your chiropractic office will provide you a document called a Superbill that you send directly to your insurance company at the end of your corrective care plan. The Superbill details how many sessions you’ve had, the total fee, and what you’ve paid out of pocket.
4. Receive out-of-network reimbursement!
You’ll need to pay your chiropractor the total fees for services before services are rendered, but depending on your specific plan, your insurance company will mail you a check to reimburse a portion of that cost.
There are many reasons to see an out-of-network chiropractor. By following these steps, you’ll be able to expand your search to find the best QUALITY OF CARE for you and your family, not just the office who is in-network.
