Out of Network Claim Form for Members - Penn Behavioral Health: Fill out & sign online

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Click ‘Get Form’ to open the Out of Network Claim Form in the editor.
Begin by filling in the Employee’s Name, Date of Birth, and Sex. Ensure that you provide the correct mailing address and daytime phone number.
Indicate if there is a new address by selecting Yes or No. Provide an alternative phone number if applicable.
Enter the Social Security Number and ID Number, along with the Plan Name and your employer's name by circling either UPHS or University of Pennsylvania.
Fill in the Patient’s details including their name, date of birth, relationship to employee, and daytime phone number.
List the Provider’s information including their name, contact details, and degree/license. Document all services received with corresponding dates and diagnoses.
Complete the CPT codes and charges for each service provided. Ensure that you are using the updated CPT codes as required.
Both Employee and Patient must sign at the bottom of the form to authorize release of information and certify accuracy.

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We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

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Can you submit out of network claims to insurance?

Yes! In general, PPO (preferred provider organization) insurance plans do cover OON services, although at a somewhat higher cost than in-network. In contrast, HMO (health maintenance organization) and EPO (exclusive provider organization) plans usually only cover in-network services.

Can I get reimbursed for out of network therapy?

If the therapist youre seeing is not in-network with your insurance, then you will have to pay the full price of the session upfront. Fortunately, depending on your health insurance plan, your insurance company may help reimburse a portion of the cost by mailing you a check or depositing money into your account.

Can I submit an out of network claim?

Your plan allows you to use out of network providers. To submit claims for reimbursement, you must fill out the Health Claim Form and return it along with an itemized statement and proof of payment.

Can insurance still cover out of network?

Insurance companies usually cover less of the cost of an out-of-network provider. For example, you might have to pay a $25 copay if you see an in-network provider but a $35 copay if you see an out-of-network provider. Insurance companies do not usually reimburse you based on the amount you actually paid your provider.

What is an example of out of network reimbursement?

So, for example, if your insurer agrees to pay 130 percent of Medicares fee schedule for an out-of-network doctors visit, and Medicares rate is $100, your insurer will pay up to $130. But, if the provider charges $200 for that visit, you may need to pay the remaining $70 yourself.