The short answer is to confirm the exact provider, location and health plan with your insurer before receiving nonemergency care. A provider directory is the right place to start, but do not rely only on the name of the insurance company or a statement that the office "accepts" your insurance.
Network basics
In network means the provider contracts with your exact plan
An in-network provider or facility has an agreement with the health plan to provide covered services at negotiated rates. An out-of-network provider does not participate in that network.
The insurance company name is not enough. One insurer can offer several employer networks, Marketplace networks and plan types. A doctor may participate in one and not another. Participation can also differ by practice location or billing entity.
The provider or facility contracts with your plan. Covered services generally use negotiated rates and the plan's in-network cost-sharing rules.
The provider or facility does not participate in your plan's network. The plan may charge more, apply separate limits, or provide no nonemergency coverage.
Plan type matters. A PPO generally allows out-of-network care at an additional cost. An HMO or EPO generally covers only network care except in an emergency. Your plan documents control.
Verify the provider
Start with the insurer and document the answer
CMS recommends checking the provider directory on the health plan's website. If the provider is not listed or the information is unclear, call the insurer using the member-services number on the insurance card. Use this process before a scheduled appointment or procedure.
- 1Identify the exact plan and network.
Use the full plan name from the insurance card or member portal, including any network name, employer group or plan identifier shown.
- 2Search for the exact provider and location.
Match the clinician's full name, specialty and office address. Use the National Provider Identifier when the office or insurer can provide it.
- 3Ask the insurer for direct confirmation.
Ask whether that provider at that address is in network for the planned date of service under your exact plan. Request a call-reference number or save the secure message.
- 4Confirm the billing entity with the office.
Give the office the exact plan and network name, and ask which medical group or organization will submit the claim.
- 5Check the facility and supporting services.
Confirm the hospital, clinic, laboratory, imaging center and other clinicians that may bill separately.
Save a screenshot of the directory listing with the date. Keep any chat transcript, secure message, confirmation number and the name of the representative who answered. This record can matter if the claim is later processed as out of network.
The whole visit
An in-network doctor does not make every charge in network
A medical visit can involve more than one provider or facility, and each can have its own network status.
For planned care, verify the parts that are reasonably known in advance:
- Facility. Confirm the hospital, outpatient department, clinic or surgery center.
- Laboratory. Ask where bloodwork, pathology or other samples will be processed.
- Imaging. Verify the location and the professional who interprets the scan when possible.
- Procedure team. Ask about anesthesia, assistant surgeons, pathology and radiology.
- Medical equipment. Confirm the supplier for braces, devices or other equipment.
You may not be able to identify every clinician before receiving care. Federal surprise-billing rules protect some situations, but they do not replace a network check for services you can choose in advance.
Cost difference
Out-of-network care can change more than the coinsurance rate
The difference is not always a simple change from one percentage to another. Out-of-network care can affect the price used for the claim, the coinsurance rate, the deductible, and whether the spending counts toward your out-of-pocket maximum.
How network status can change the bill
| Cost feature | In network | Out of network |
|---|---|---|
| Starting price | Contracted allowed amount | Plan's out-of-network allowed amount, or the provider's charge |
| Deductible | In-network deductible | A separate, often higher deductible may apply |
| Coinsurance | In-network percentage | A higher percentage may apply |
| Balance billing | Network contract generally prevents it | Provider may bill above the allowed amount unless prohibited |
| Out-of-pocket limit | Covered cost sharing generally counts | Some or all spending may not count toward the in-network limit |
| Coverage | Covered when other plan rules are met | PPO may cover less; HMO or EPO may cover nothing except where required |
This table describes common plan structures. Your Summary of Benefits and Coverage and plan document control.
A simple coinsurance comparison
HealthCare.gov uses 20% as an example of in-network coinsurance and 40% as an example of out-of-network coinsurance. Using its $100 allowed-amount example only to isolate the percentage difference:
The actual out-of-network allowed amount may be different, and the provider may also be permitted to balance bill you. CMS gives this example: if a provider charges $200 and the plan's allowed amount is $110, the provider may bill the remaining $90 when balance billing is permitted. That $90 can be added to the plan's required cost sharing.
These are illustrations of the mechanics, not price estimates. For the complete copay, deductible and coinsurance calculation, read how much a doctor visit costs with health insurance.
Directory errors
Incorrect network information can trigger protections
Provider directories can be wrong or become outdated. A clinician may leave a network, change locations, join a different medical group, or stop accepting new patients.
If you relied on incorrect provider-directory information and received out-of-network care as a result, federal rules can limit your cost sharing to the in-network amount. The plan may also have to count that amount toward the in-network deductible and out-of-pocket maximum. If you paid more than the permitted in-network amount, reimbursement protections may apply.
Coverage type and circumstances matter. Contact the insurer first, provide the saved directory listing or confirmation, and ask it to reprocess the claim using the applicable in-network terms. If the issue is not resolved, use the appeal instructions on the explanation of benefits or contact the No Surprises Help Desk.
Surprise bills
Federal protections cover specific out-of-network situations
The No Surprises Act generally limits out-of-network cost sharing and balance billing for most covered emergency services, certain nonemergency services from out-of-network providers during a visit to an in-network hospital, hospital outpatient department or ambulatory surgical center, and covered services from an out-of-network air ambulance provider.
The protections do not make every out-of-network service subject to in-network pricing. They generally do not cover a voluntary visit to an out-of-network doctor when an in-network option was available, and they generally do not cover ground ambulance services, although state law may provide additional rights.
Before care
Ask these questions when the answer is unclear
Use the insurer's secure message or member-services number and ask:
- 1Is this exact clinician in network at this exact address?
Give the provider's full name and NPI, the office address, and the full plan and network name.
- 2Is the facility separately in network?
Name the hospital, clinic or surgery center where care will happen.
- 3What deductible amounts remain?
Ask for both the in-network and out-of-network balances.
- 4What copay or coinsurance applies?
Ask about the specific service you expect to receive.
- 5Does out-of-network spending count toward any limit?
Confirm whether it counts toward an out-of-pocket maximum at all.
If the office and insurer give different answers, pause nonemergency care until the insurer confirms the network status in writing or through a documented call.
The bottom line
Confirm the provider, location, facility and exact plan
Start with the insurer's provider directory, then confirm the exact provider and address under the full plan and network name. For planned care, check the facility and any supporting services that may submit separate claims.
Out-of-network care can involve a higher allowed amount, a separate deductible, higher coinsurance, balance billing, and spending that does not count toward the in-network out-of-pocket maximum. Federal protections can help in specific situations, but verifying the network before nonemergency care remains the safest way to avoid an unexpected bill.
