Reservation of Rights: Out-of-Network Provider Notice
This letter notifies the member that a service was performed by an out-of-network provider and that the plan is investigating the claim while reserving its right to limit payment to the allowed network rate.
Letter Template
Date: {{current_date}}
Member Name: {{member_name}} Member ID: {{member_id}} Claim Number: {{claim_number}} Date of Service: {{date_of_service}} Provider: {{provider_name}}
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1. The Decision
We have received your claim for services provided by {{provider_name}}. At this time, we are processing this claim under a Reservation of Rights, as we investigate whether these services were performed by a provider within your plan's network.2. Clinical/Factual Basis
Our initial review indicates that {{provider_name}} does not have a current participating provider agreement with our network for the location where services were rendered. As an out-of-network provider, their charges may not be fully covered at the same level as an in-network provider.3. Plan Provision / Clinical Guideline
Your plan's Summary Plan Description (SPD), Section {{network_provision_section}}, states that benefits for out-of-network services are subject to higher co-insurance and deductibles, and are limited to the Allowed Amount determined by the plan. We are also reviewing this claim under the No Surprises Act provisions to determine if "surprise billing" protections apply to this specific date of service.4. Rationale (The "Why")
Because the provider's network status is still being verified for the specific date of service, we are reserving our right to:- Deny coverage for the amount exceeding the Allowed Amount.
- Apply out-of-network cost-sharing to your claim.
- Seek additional information from {{provider_name}} regarding their affiliation status.
This reservation allows us to process the claim preliminarily without waiving our right to enforce network limitations once the investigation is complete.