How to handle out-of-network claims

Figuring out the right steps for processing out-of-network claims can be confusing.

Some payers require provider registration. Others make you submit a claim before enrolling for Electronic Remittance Advice (ERAs). Some have few requirements at all.

If you’ve run into questions or hurdles, you’re not alone.

While requirements vary between payers, there are common patterns you can use to reliably submit out-of-network claims and – when possible – get back ERAs. 

This guide aims to answer your questions about out-of-network claims. It also covers patterns we’ve seen work.

Provider network status

A provider’s network status indicates whether a provider is in-network or out-of-network for a specific payer. If a provider is out-of-network, any claim they submit is also out-of-network.

Network status is determined by credentialing and payer enrollment, which are handled directly with the payer.

They’re separate from transaction enrollment, which determines what transactions you can exchange with a payer. Your clearinghouse only handles transaction enrollment.

For help with credentialing or payer enrollment, contact the payer or use a credentialing service like CAQH, Assured, or Medallion.

Checking a provider’s network status
You can’t reliably determine whether a provider is in-network or out-of-network using an eligibility check or other pre-claim clearinghouse transaction. However, there are options for checking this programmatically. For a rundown, see our Provider network status docs.

Out-of-network benefits
Even if a payer accepts out-of-network claims, not all patients have out-of-network benefits. You can determine if a patient has out-of-network benefits –and whether they’re eligible for reimbursement – using an eligibility check. See the In Plan Network Indicator docs

Requirements for out-of-network claims

Most payers accept out-of-network claims, but requirements can vary. The two main things to check are:

• Whether the payer requires registration for out-of-network providers

• Whether they require transaction enrollment for claims submission

Provider registration
Some payers require any out-of-network provider to register as a “non-participating” provider before they’ll accept claims. This registration is separate from transaction enrollment and happens outside of Stedi. 

You’ll need to contact the payer to confirm what’s needed and set up your provider if required.

Transaction enrollment for claims submission
Most payers don’t require transaction enrollment for claims submission – but some do. If a payer does and enrollment isn’t completed, the claim will be rejected.

Before submitting claims, check the payer’s enrollment requirements using the Payer API or Payer Network. You can filter payers by supported transaction type and enrollment requirements.

Once any needed provider registration or transaction enrollment is complete, the provider can submit out-of-network claims for the payer.

Submit an out-of-network claim

You submit out-of-network claims using the Claims API, the Stedi portal, or SFTP.

There are no special fields or requirements for out-of-network claims. Just submit them as you would an in-network claim. A provider doesn’t have to be enrolled for ERAs with a payer to submit claims.

You’ll receive claim acknowledgments for out-of-network claims. You can also run real-time status checks.

ERAs for out-of-network claims

Unlike claims, all payers require transaction enrollment for ERAs. Providers can only be enrolled for ERAs with one clearinghouse per payer at a time.

Transaction enrollment for ERAs
ERA enrollment for out-of-network providers varies by payer. Some payers treat ERA enrollment the same for all providers. Others require out-of-network providers to be "on-file" first, meaning the payer already has a record of the provider.

“On-file” requirements
To become "on-file," out-of-network providers typically need to either:

• Submit a claim to the payer.

• Register as a “non-participating” provider with the payer.

Many payers require a submitted claim before ERA enrollment. However, claims submitted before or during enrollment won't generate ERAs. 

Rejected ERA enrollment requests
Under HIPAA, payers are required to accept ERA enrollment requests from out-of-network providers. However, some payers still reject them.

Many payers send Explanations of Benefits (EOBs) – typically snail mailed – for out-of-network claims or when no ERA enrollment is on file. EOBs contain the same information as ERAs, but if you and your providers rely on ERAs for reconciliation, this can create issues.

If the provider receives paper EOBs, you can use Stedi Lockbox. Stedi receives the provider's payer mail, deposits any paper checks, and makes each EOB available as a PDF with OCR text.

The out-of-network claims runbook

There are several ways to handle out-of-network claims with Stedi. Here's practical steps you can follow based on what we’ve seen work.

Step 1. Check the payer’s requirements for out-of-network claims and ERAs.
Contact the payer to see if they require registration for “non-participating” for out-of-network claim submissions and ERAs. If so, complete any registration steps for the provider.

Step 2. Check if the payer requires transaction enrollment for claim submission.
Check the payer’s transaction enrollment requirements for claim submission using the Payer API or Payer Network.

If transaction enrollment is required, use the Enrollments API or the Stedi portal to submit a related enrollment request. Wait for enrollment to complete before submitting claims to the payer.

Step 3. Start submitting out-of-network claims.
Submit out-of-network claims using the Claims API, the Stedi portal, or SFTP.

Many payers require a claim on file before processing ERA enrollment. While these initial claims won't get ERAs, waiting risks cash flow delays and missed timely filing deadlines. We'll address this gap in step 5 below.

Step 4. Submit an ERA enrollment request for the payer.
Use the Enrollments API or the Stedi portal to submit an ERA enrollment request for the payer.

Most enrollment requests complete in 1-2 business days, but it varies by payer. You can monitor the enrollment status using the API or the portal.

Step 5. Monitor for ERAs from the payer.
Once enrollment completes, you can listen for and fetch ERAs using our APIs or SFTP.

ERA enrollment isn't retroactive. You'll only receive ERAs for claims submitted after enrollment completes. For claims submitted before or during the enrollment process, use real-time claim status checks and your provider’s actual payments for reconciliation. If you use Stedi Lockbox, you can also review the payer's paper EOBs as PDFs in Stedi.

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