When Out-of-Network Care Can be Covered In Network
Receiving care from a provider in your health plan’s network usually costs you much less than going to an out-of-network provider. (See In-Network and Out-of-Network Care). But, you may need to go out of network for certain types of care, especially if you or a member of your family has a rare illness, such as a genetic disorder. Suppose no provider in your network has the training or experience to treat it the right way. With prior approval from your insurer, you may be able to receive the care you need out-of-network and still pay only the lower, in-network rate.
Different insurers take different approaches to requests for out-of-network care at in-network rates. You may have to make a formal request to your insurer, sometimes called an “appeal,” or send in a request for prior authorization. Information about the process to follow should be available from your insurer’s website, plan documents or customer service representative.
Your primary care physician (PCP) or in-network specialist typically send the initial request to the insurer. The insurer may deny your first request. But, usually you have more than one chance to get your case reviewed. You may appeal the decision “internally,” which means you can ask the insurer to reconsider your benefits denial. If your request is still denied, federal or state law may require your insurer to allow you to start an “external” appeal. That means you appeal to an independent, outside group.
If your insurer agrees to let you go out of network at the in-network rate, your out-of-network referral will usually be to a specific doctor. But, typically, any doctor managing your care will work with other providers who perform related procedures. The claim from the original doctor will be processed at the in-network rate. But, the claims from the other providers may be processed as out of network and you will have to appeal the insurer’s decision. To avoid that, it’s best that you work out those details with the insurer in advance.
Your health insurer contracts with doctors, hospitals and other providers who agree to accept the insurer’s rate as payment for their services. These are the providers in your “network.” Staying in your network usually costs you much less than going to an out-of-network provider, as you benefit from the lower rates your insurer has negotiated with network providers.