While we make efforts to ensure that our lists of doctors and hospitals (i.e. providers) are up-to-date and accurate, it is important to understand that sometimes health care providers leave our networks without letting us know, or they switch networks, or they change employment with provider groups and hospitals. Depending on your plan, these changes may impact how much you pay out of your own pocket for services.
Not all providers are included in every plan’s network of doctors and hospitals. In order to avoid higher costs, it is important to understand whether your provider participates in your plan’s network and if your plan’s network includes Tiered providers. If you visit a provider who is not in your plan’s network or who is a Tier 2 provider for applicable Tiered plans, you may be required to pay a greater percentage of the deductible and/or co-insurance (your percentage of the cost). (Tiered benefit plans enable you to pay lower cost share amounts by using providers in a plan network who are assigned to benefit Tier 1 or Tier 2. Although both Tiers represent in-network providers, you will generally be responsible for lower copayments, deductibles and coinsurance – and, therefore, pay less – if you use a Tier 1 provider.)
If you are a member, logging in is the most accurate way to search for providers in your plan network. You may also enter the first three letters of your member ID number (found on your ID card) to search for in-network health care providers based on your plan prefix.
Your doctor may refer you to another provider or facility for treatment. In-network providers are required to make best efforts to refer you to other in-network providers when possible. However, it is important to remind your doctor to refer you to in-network providers in order to avoid out-of-network costs and additional charges from the doctor by non-participating providers (also known as balance billing).
If you receive services from an in-network hospital, the hospital may have arrangements with emergency room physicians, anesthesiologists, radiologists, and/or other providers to assist in your care. These providers may not participate in your plan’s network. To avoid out-of-network costs and balance billing by non-participating providers, when you choose a hospital in your network be sure to look for messages within the hospital’s displayed information in the search results that identifies hospital-based providers not in your plan’s network.
If your health plan has out-of-network benefits, we may reimburse you up to the maximum allowed amount for covered services if you see a non-participating provider. The process and method used by us to determine reimbursement for non-participating providers depends on your health plan. However, because we do not have a contract with non-participating providers, they can bill you for services up to their full billed charges regardless of your insurance coverage of benefits, unless prohibited from doing so by your state.
Health plans vary. We recommend that you consult your benefit plan document and/or contact the member services number listed on the back of your ID card to confirm in advance that the desired service is covered. Keep in mind that most HMO plans do not have out-of-network benefits and therefore may not reimburse for any out-of-network services except in limited circumstances.