Commercial Carrier Process to Request a Referral to a Specialist or Non-Physician Specialist

Sometimes, you may not be able to get the health care that you need from a specialist who is in your insurance company’s network. The in-network specialist may be unreasonably far away, or might not have an appointment for an unreasonably long time, or may not be able to treat your condition. When that happens, and you have to go to a specialist that is out-of-network, your insurance company may have to cover the out-of-network specialist the same as they would an in-network specialist. Your health insurance company has to have a process that you can use to find out how to get in-network coverage for care by an out-of-network specialist. And when you make your request, they have to respond quickly. You can use the links below to find out the process to use for your insurance company. Keep in mind that the specialist might charge more than the insurance company has to pay. Read all of the information below about what is called “balance billing.” If you have any questions or are not receiving the help that you need from your insurance company, you can contact the Maryland Insurance Administration at (800) 492-6116 for help.

Under Maryland law, if your health insurance plan does not have an in-network specialist who can provide medically necessary services to treat your condition or disease without requiring you to travel an unreasonable distance or wait an unreasonable amount of time, you can ask for approval from the health plan to see an out-of-network specialist. If certain conditions are met, your health plan will be required to cover the services you receive from the out-of-network specialist and process your claims applying your in-network deductible, coinsurance, or copayment.

The information at these links explains the health plans' processes for you to use when seeking approval to go out of network.

Aetna Health and Life Insurance Co.
Aetna Health, Inc.
Aetna Life Insurance Co.
CareFirst BlueChoice, Inc.
CareFirst of Maryland, Inc.
CIGNA
Freedom Life Insurance Co.
Golden Rule Insurance Co.
Group Hospitilization and Medical Services, Inc.
Kaiser Foundation Health Plan of the Mid-Atlantic
MAMSI Life and Health Insurance Co.
Optimum Choice, Inc.
United Healthcare Insurance Co.
United Healthcare of the Mid-Atlantic, Inc.
Wellfleet Insurance Co.

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.

The information provided on this webpage has been collected by the MIA from the carriers and has not yet been reviewed for compliance purposes. This is not an endorsement by the MIA of any particular carrier or the procedures employed by the carrier nor should the posting of these procedures be considered an acknowledgment that they are consistent with applicable regulatory requirements. The MIA welcomes information about noncompliant processes.