What is the difference between in and out-of network?
When a doctor, hospital or other provider accepts your health insurance plan we say they’re in network. We also call them participating providers.
When you go to a doctor or provider who doesn’t take your plan, we say they’re out of network.
The two main differences between them are cost and whether your plan helps pay for care you get from out-of-network providers.
When a provider joins our network, they agree to accept our approved amount for their services. For example, a doctor may charge $150 for a service. Our approved amount is $90. So as a member, you save $60.
On your claims and explanation of benefits statements, you’ll see these savings listed as a discount or an adjusted amount (depending on what the EOB says).
Doctors or hospitals who aren’t in your network don’t accept the approved amount. You’ll be responsible for paying the difference between the provider’s full charge and your plan’s approved amount. That’s called balance billing and you would be responsible for that cost as a member.
How to find in-network providers
Before you go to a doctor or hospital, it’s always a good idea to call and ask if they take your plan. Sometimes we aren’t notified right away when things change.