This information may also be found in your insurance policy or you can call the customer service number on your membership identification card to ask how to request approval. When you talk to your insurance company, you need to make it clear that it is medically necessary for you to see an out-of-network specialist and that there is no in-network specialist available. If you are in a health plan that requires referrals, your primary care physician may be able to help you.
Your health plan must decide on your request in a timely manner, usually no more than 2 working days after the plan receives the information necessary to decide. (Some decisions must be made sooner).
If your request is denied, you have the right to appeal the denial. The Office of the Attorney General's Health Education and Advocacy Unit (HEAU) can help you appeal the denial or with the request process.
IMPORTANT: You must use the company process. If you do not and you choose to see an out-of-network specialist, and in-network specialists were available, the services will be covered only if you have out-of-network benefits and only for the amount allowed for out-of-network coverage. If you are not getting the assistance you need fast enough, the Maryland Insurance Administration can help you. Contact us at (800) 492-6116.
Will I have to pay more to see an out-of-network specialist?
Maybe - Even if your health plan has to cover the services that you receive from the out-of-network specialist under Maryland law, and your claims has to be processed based on your in-network deductible, coinsurance, or copayment, because an out-of-network specialist does not have a contract with your health plan, the specialist's charges may be higher than the amount the health plan would pay an in-network provider. When an out-of-network provider bills you for the difference between their charge and the total amount your insurance company has to pay, this is called “balance billing."
You can be balanced billed by the out-of-network specialist even when your health plan approves your request to see an out-of-network specialist, except in two situations. If you are covered under an HMO and the out-of-network provider is subject to Maryland law, the provider is not allowed to balance bill you. Additionally, because of a new law that will apply to health plans beginning on January 1, 2023, if you are approved to see an out-of-network specialist for mental health or substance use disorder services, your health plan must pay the costs of the out-of-network specialist's services other than your cost-sharing amount (deductible, copay, coinsurance), which you must pay. Your health plan must ensure that the approved out-of-network services cost you no more than you would have paid if you received the services from a provider on the plan's provider panel. This means there will be no balance bill.
Additional balance billing protections apply to Maryland regulated plans in emergency circumstances and for services you receive in certain in-network facilities. See https://insurance.maryland.gov/Consumer/Pages/Federal-No-Surprises-Act.aspx.