Out-of-Network Benefits, Explained
Freedom to see any provider — and a clear picture of how your claims are processed.
Your Solo plan lets you see virtually any provider in the country, in-network or out. When you go out-of-network, your claim is still covered. The key thing to understand is the allowed amount — and how it shapes your deductible credit and any reimbursement. Questions about a specific claim? Contact Solo Concierge.
Your Solo plan gives you the flexibility to see virtually any provider in the country — in-network or out-of-network. When you go out-of-network, your claim is still covered.
All PPO health plans, including Solo, use an allowed amount for out-of-network services. The allowed amount is what the plan considers a fair and reasonable cost for that service in your area. Your deductible credit and any reimbursement are based on that allowed amount — not the provider's full billed charge.
Claim is submitted
Your provider's office can submit directly to Vault Admin Services, or you can self-submit using the Medical Claim Form in your member account.
Allowed amount is determined
Vault reviews the claim and establishes the allowed amount — a fair and reasonable cost for that service in your geographic area. This is the figure used for all plan calculations.
Applied to your deductible
The allowed amount is applied toward your deductible. Only the allowed amount counts — not the full amount billed by the provider.
Plan pays after your deductible
Once your deductible is met, the plan reimburses you by check for the allowed amount or pays the provider directly — depending on who submitted the claim and whether you paid upfront.
Balance beyond the allowed amount
Any difference between the provider's charge and the allowed amount is not covered by the plan and does not count toward your deductible or out-of-pocket maximum.
Solo is an open-network plan — you may see any provider willing to submit claims to Vault Admin Services. If a provider won't bill Vault directly, you can submit the claim yourself.
- Where to submit. Log in to your Member Portal and follow the claims submission guidance — it walks you through the process step by step.
- What to attach. An itemized bill with patient name, provider name / address / tax ID, date of service, ICD-10 diagnosis codes, CPT procedure codes, and total charge.
- Proof of payment. If you've already paid the provider, include proof of payment to be eligible for reimbursement.
- Questions along the way? Vault Admin Services can help at 888-211-5706.
- Timely filing. Submit within the window specified in your SPD — late submissions will be denied.
Here's how a $2,400 provider bill gets processed under the plan's allowed amount:
| Item | Amount |
|---|---|
| Provider's billed charge | $2,400 |
| Plan's allowed amount | $1,150 |
| Applied to your deductible | $1,150 |
| Balance — not covered by the plan | $1,250 |
For illustration only. Actual allowed amounts vary by service and location.