Out-of-network denials happen when your insurer won't cover (or fully cover) care from a provider not in their network. But several laws and strategies can help you get coverage, especially if the network doesn't have adequate providers.
Grounds for Appealing OON Denials
1. Network Inadequacy
If your plan doesn't have an adequate in-network provider for your condition:
- The plan may be required to cover out-of-network care at in-network rates
- Document that you searched for in-network providers and none were available
- Check your state's network adequacy standards
2. Continuity of Care
If your provider left the network during active treatment:
- Many states require a transition period
- You may be entitled to continue at in-network rates for a defined period
- Some plans have internal continuity of care policies
3. No Surprises Act
Emergency care and certain non-emergency out-of-network services at in-network facilities are protected:
- You only pay in-network cost-sharing
- No balance billing allowed
- See our No Surprises Act guide for details
4. Referral from In-Network Provider
If an in-network provider referred you to an out-of-network specialist:
- Some plans cover OON referrals at in-network rates
- Check your plan's referral policies
Appeal Strategy
- Document your search for in-network providers
- Get a letter from your doctor explaining why this specific provider is needed
- Cite network inadequacy laws and regulations
- Request a single case agreement (SCA) — an individual contract for OON coverage
- If emergency: cite the No Surprises Act