What if my child needs a specialist who is out-of-network?

Undivided's Director of Health Plan Advocacy Leslie Lobel says that if the specialist you absolutely want is not in-network with your plan (learn more about in-network specialists here), you can appeal and request for an authorization for the out-of-network provider to be reimbursed at a higher rate. “But it’s not a matter of preference,” Lobel says. “The plan is really not going to give you someone out of network at a higher rate of reimbursement because you prefer them. You have to show that it is medically necessary, that it's the plan’s obligation, because there is no one in-network who is qualified and available to provide that service. If you call every OT or every developmental pediatrician or every person on your child's plan, and either they are not doing peds or they're booked out for a year, or they don't have the specific subspecialty or the specific training that your child needs in their team member, you can advocate for increased reimbursement” for someone out-of-network.

You can also speak to the provider where you're seeking treatment and see if they’re willing to do a single case agreement with your health plan. You can help them by documenting conversations with all network providers that they exclude the particular modality that your child requires. Get your child’s physician, developmental pediatrician, or neurologist to write a letter to support the need for a provider to be trained in that modality to have access to that care.

For more tips, see our article How to Build a Care Team.