What do I do if there are no in-network providers close to my house?

Choosing an in-network provider is often the easiest way to get your child's care covered by your insurance plan, but what if all the in-network providers live far away from you?

Undivided's Director of Health Plan Advocacy, Leslie Lobel, says that it's not easy, but if no one is within a reasonable driving range, you may have a case. Obtain your health plan’s network contracted provider list and make calls to those within a 20-mile radius or one-hour drive time of your home zip code to confirm that none of these contracted providers are able to deliver the care your child requires. The law requires the insurance company to provide access to care authorization.

You can then either have the provider agree to set up as a single case agreement (an agreement to take the insurance with this one client, which a lot of offices are hesitant to do) or ask for in-network level reimbursement, rather than out-of-network level, to get reimbursement at whatever level it would have been if the provider was in-network. Make sure the coverage is worth the effort as it is a lot, but it can absolutely be worth the hassle.

Know that if you're approved at in-network level reimbursement, it will be a constant state of requesting the reimbursement, resubmitting for it, and reminding insurance that it needs to be paid. It will also take re-authorization every certain amount of time.

Lobel says you can make the geography argument if a specialist is needed. For example, a child needs oral motor feeding or a specialist in apraxia, and that specialty isn't offered by their in-network providers. So if no one in the area is versed in oral motor or not trained appropriately, the insurance is required to give your child the medical support they need (assuming it is in your insurance plan).

Plan to pay out of pocket for at least three months before you are reimbursed. Getting insurance to agree is a victory, but know that it may take several times of having the claim reprocessed. If the claim comes back as applied to the out-of-network deductible, you have to call and have them reprocess it. Make sure to write the authorization number on the superbill that you turn in; it may still be overlooked the first time, but you can ask for expedited reimbursement because you put the information on there, and the mistake was on their end. Expedited reimbursement is 7-10 days instead of 30 days. It's also good to submit the authorization letter when you submit the superbill so that no one can say they don't see the authorization.

See our step-by-step guidance to help you advocate for network-level reimbursement from your health plan.