Out-of-Network Claims, Actually Handled — Not Just Submitted

If you've ever submitted an out-of-network claim, you know that hitting "submit" is often the easy part.

The real work can come afterward.

Your superbill might be missing information. Your insurer might deny the claim. Your reimbursement might be lower than expected. Or you might receive an explanation of benefits (EOB) that makes no sense—and have no idea whether your insurer processed the claim correctly.

Submitting an out-of-network claim is only one step in getting reimbursed.

That's where Sheer Health is different.

We don't just help you send a claim to your insurance company. We help you navigate the entire out-of-network claims process—from understanding your benefits and reviewing your documentation to submitting and tracking your claim, understanding your EOB, investigating denials, and navigating what happens next.

What Is an Out-of-Network Claim?

An out-of-network claim is a request you submit to your health insurance company for reimbursement after receiving care from a provider who isn't part of your plan's network.

Unlike in-network care, where your provider typically submits the claim directly to your insurer, out-of-network care often means you pay the provider upfront and then submit a claim to your insurance company for reimbursement.

If your plan includes out-of-network benefits, you may be able to get some of that money back.

The amount you receive depends on your specific plan, including factors such as your out-of-network deductible, coinsurance, allowed amount, and the type of care you received.

The challenge? Your insurance company doesn't always make the process easy to navigate.

That's why getting an out-of-network claim submitted correctly is important—but submission is just the beginning.

Why Out-of-Network Claims Are So Difficult

An out-of-network claim can involve much more than filling out a form.

You may need to:

• Understand whether your health plan includes out-of-network benefits
• Figure out how your deductible, coinsurance, and allowed amount affect reimbursement
• Get a complete and accurate superbill and other claim documentation
• Submit the correct claim documentation
• Meet your insurer’s filing deadline
• Track your claim after submission
• Understand your explanation of benefits (EOB)
• Figure out why a claim was denied or underpaid
• Correct or resubmit the claim
• Appeal a denial when appropriate

That's the gap Sheer Health is built to fill.

Sheer Health Doesn't Just Submit Your Claim

Most claim-submission tools are built around one moment: filing the claim. Sheer is built around everything that happens before and after it.

1. We Review Your Claim Before It's Submitted

A missing piece of information can turn a straightforward claim into weeks of back-and-forth with your insurer.

Sheer reviews your superbill and claim documentation before submission to help catch potential issues that could lead to delays or denials.

The goal isn't just to get a claim out the door. It's to give it the best chance of being processed correctly the first time.

2. We Help You Understand Your Out-of-Network Benefits

Getting reimbursed starts with knowing what your plan actually covers.

Sheer helps you understand your out-of-network benefits, including the coverage and cost-sharing details that can affect how much you get back.

That means you can have a clearer picture of your potential reimbursement before you submit a claim, rather than submitting a claim and hoping for the best.

3. We Submit Your Out-of-Network Claim

Once your claim is ready, Sheer handles the submission to your insurance company.

You don't have to figure out which forms to complete, where to send them, or how to navigate your insurer's submission process on your own.

We handle the administrative work so you don't have to.

4. We Make the Claims Process Transparent

Submitting a claim is only the beginning. What happens after that can feel like a black box—with processing, insurer decisions, requests for information, and other activity happening behind the scenes.

Sheer keeps you informed as your claim moves through the process, explaining what's happening and what it means in plain language. You can understand where your claim stands, what your insurer is doing, and whether anything is needed from you.

You shouldn't have to wonder whether your claim was received or what's happening with it. We give you visibility from submission through resolution.

5. We Investigate Denied Claims

A denial doesn't always mean you're out of options.

Claims can be denied because of missing information, coding issues, eligibility questions, filing requirements, or other reasons.

Sheer helps investigate why a claim was denied and identify what can be done next.

That may mean correcting documentation, resubmitting a claim, or pursuing an appeal, depending on the circumstances.

6. We Review Your EOB

Getting an EOB doesn't necessarily mean your claim was processed correctly.

Sheer helps review how your claim was processed so you can understand what your insurer paid, what they didn't pay, and why.

Because “your claim was processed” isn’t the same as “your claim was processed correctly.”

7. We Help You Navigate the Path to Reimbursement

The goal of an OON claim isn't simply to get a claim number.

It's to receive the reimbursement your plan provides for eligible care.

Sheer helps you navigate the process when the reimbursement you receive doesn't align with your plan's benefits or when you believe your claim may not have been processed correctly.

We don't just help you submit a claim and leave you to figure out the rest. We stay with you through the process, helping you understand what happened and what you can do next.

What Makes Sheer Different?

The difference is what happens after you hit submit.

A traditional claim-submission tool may help you send paperwork to your insurance company. But an OON claim doesn’t end when the paperwork is filed.

Sheer is built around the full claims journey—not just the moment a claim gets submitted.

Why Sheer Health for Out-of-Network Claims?

We've built our process around what happens after the claim is submitted—not just the submission itself.

Sheer Health has:

• Submitted 100,000+ out-of-network claims
• Helped members recover over $20 million in reimbursements and savings
• Achieved a 95% first-submission claim approval rate

Those results come from treating an OON claim as more than a form.

We look at the full process: your benefits, your documentation, your claim, your insurer's response, your EOB, and what happens when something doesn't go according to plan.

The Difference Between Submitting a Claim and Getting Reimbursed

Submitting an out-of-network claim is important.

But submission isn't the outcome you're looking for. Reimbursement is.

A claim-submission tool can help you send paperwork to your insurer. But if the claim is denied, underpaid, delayed, or processed incorrectly, you still have an insurance problem to solve.

Sheer Health helps take that problem off your plate.

We handle the insurance. You focus on getting the care you need.

How to Get Help With an Out-of-Network Claim

If you've already paid for out-of-network care, you don't have to figure out the reimbursement process alone.

Sheer Health can help you understand your coverage, prepare and submit your claim, and navigate what happens after submission.

Have an out-of-network claim? Let Sheer handle the insurance work.

→ Get help with your out-of-network claim

Frequently Asked Questions About Out-of-Network Claims

How do I file an out-of-network insurance claim?

An out-of-network claim is typically submitted to your health insurance company after you receive care from a provider who isn't in your plan's network. Depending on your insurer and plan, you may need a claim form, superbill, receipt, and other supporting documentation. Sheer Health can help prepare and submit your claim and manage what happens afterward.

How long does an out-of-network insurance claim take to be processed?

The time it takes to process an out-of-network claim varies by insurance company, plan, and claim. Some claims may be processed relatively quickly, while others can take longer if the insurer requests additional information or identifies an issue with the claim.

How much will insurance reimburse for an out-of-network claim?

Your reimbursement depends on your specific health plan and factors such as your out-of-network deductible, coinsurance, allowed amount, and the type of care you received.

Reviewing your out-of-network benefits before submitting a claim can give you a better understanding of what reimbursement to expect.

What is an explanation of benefits (EOB)?

An explanation of benefits, or EOB, is a document from your health insurance company explaining how a claim was processed.

It typically shows the amount billed, allowed amount, what your insurer paid, and what you may owe. An EOB is not a bill.

Why was my out-of-network claim denied?

Out-of-network claims can be denied for several reasons, including missing information, eligibility issues, filing deadlines, coding or documentation problems, or plan-specific requirements.

A denial does not necessarily mean you have no options. Depending on the reason for the denial, you may be able to correct the issue, resubmit the claim, or appeal the decision.

Can I appeal a denied out-of-network claim?

In many cases, yes. Your options depend on the reason for the denial and the terms of your health plan. Correcting missing information, resubmitting documentation, or filing an appeal may be appropriate depending on the situation.

Can Sheer Health track my out-of-network claim?

Yes. Sheer Health helps members understand what is happening with their out-of-network claims after submission, including claim status, insurer decisions, EOBs, and next steps when something goes wrong.

What's the difference between submitting an OON claim and managing an OON claim?

Submitting a claim is just the first step. Managing a claim can include tracking its status, responding to requests for information, understanding the insurer's decision, reviewing the EOB, addressing denials or underpayments, and determining what to do next.

Sheer Health helps with the process beyond simply submitting the claim.