What if I have an Out-of-Network plan?

To avoid higher out-of-pocket costs for your child's services, it is best to seek treatment with health care providers approved by your insurance plan or specific coverage network. To do this, call your insurance plan and ask what providers are available in your coverage network. 

Determine which in-network provider is best for your child’s healthcare needs and proceed with scheduling an appointment at an in-network facility.

If your insurance plan says there are no providers in your network that can treat your child, OR if you would prefer that your child be seen at Children’s Mercy regardless of providers available in your network, go to the next step below.

If you are unable to find in-network care for your child OR prefer that your child be seen at Children’s Mercy regardless of in-network status with your insurance plan, you will call Children’s Mercy to schedule an appointment. At the time of scheduling, you will provide information on your child’s insurance plan. Because your insurance plan is OON with Children’s Mercy, appointments will be offered 30-45 days in advance to allow Children’s Mercy staff to advocate for and obtain an approved prior authorization, and in some cases a signed Single Case Agreement (SCA) with your insurance plan. These approvals must be approved with your insurance plan before the appointment date.

The Children’s Mercy Financial Clearance team will contact your insurance plan and request prior authorization approval. Once the prior authorization has been approved, Children’s Mercy Payor Relations will initiate a Single Case Agreement (SCA) request with your insurance plan. This process can take up to 30-45 days to complete.

If approved, you may proceed with your child’s appointment.

If not approved, you can:

1. Cancel your child’s appointment at Children’s Mercy and seek in-network care, OR

2. Keep your child’s appointment at Children’s Mercy and choose to be self-pay (your insurance plan will not be billed for services received at Children’s Mercy, and you will pay out-of-pocket).

*If a determination is not reached before appointment date, you can:

1. Reschedule appointment to a later date, allowing more time for prior authorization and/or SCA processes to be completed and approved, OR

2. Keep your child’s appointment at Children’s Mercy and choose to be self-pay (your insurance plan will not be billed for services received at Children’s Mercy, and you will pay out-of-pocket).

Prior-Authorization: Requirement for pre-approval from an insurance plan to evaluate the medical necessity of services and/or determine benefit coverage prior to services. If prior authorization is not obtained or approved, this could result in a reduction or denial of benefit coverage. 

Single Case Agreement (SCA): A contract between Children’s Mercy and your insurance plan for a single visit or period of care required by your insurance plan for services provided by OON providers.

OON Exception: An approval by a payor that services at Children’s Mercy are medically necessary for a patient and will be paid at in-network benefit levels.

Out-of-State (OOS) Medicaid: Any Medicaid plan through a state other than Kansas or Missouri. Please refer to the full list of OON plans at www.ChooseChildrensMercy.org to identify other states that may have special agreements with Children’s Mercy.