Definition of an Out-of-Network Provider

There May be Times Where an Out-of-Network Provider is Necessary

A patient presents a health insurance card.
A patient presents a health insurance card.. Petrol/Getty Images

An out-of-network provider is one which has not contracted with your insurance company for reimbursement at a negotiated rate. Some health plans, like HMOs, do not reimburse out-of-network providers at all, which means that as the patient, you would be responsible for the full amount charged by your doctor. Other health plans offer coverage for out-of-network providers, but your patient responsibility would be higher than it would be if you were seeing an in-network provider.

Reasons for Choosing Out-of-Network Health Care

Although it may initially cost you more money, there may be times when you might find it necessary, or even advisable, to use an out-of-network provider.

Sometimes you have no choice, or it just makes sense to choose a non-network healthcare provider. Below is a list of the scenarios in which you may be automatically eligible for or you can appeal for in-network coverage:

Emergencies: In an urgent situation, you must seek the closest available help. Many plans make exceptions for out-of-network coverage during an emergency, according to the Health Rights Hotline. It's imperative that you or someone else contact your primary-care physician or your insurance company within 48 hours of your emergency treatment to improve your chances of getting coverage. If it's not truly an emergency, your visit will not be processed as in-network treatment; you should go to a covered provider instead.

  • Specialized care: If you have a rare ailment for which no specialist is included in your plan, out-of-network care may be crucial.
  • Changing providers would jeopardize your health: If you're in the middle of treatment for serious or end-of-life issues, and your provider leaves the network, it may be in your best interest to continue that care by going out of network. You can appeal for continued in-network coverage, if only for a period of time or a set number of visits.
  • Out-of-town care: If you need medical care while away from home, you may have to go out of network, but some insurers will handle your visit to a non-participating provider as if it were in network. However, in-network providers may be available. If it's not an emergency, it's best to contact your insurer first to find out.
  • Proximity issues: If you live in a rural area and there is no primary-care provider within a short drive or if you require a specialist and none is nearby, your continued health may depend upon using a non-participating doctor. In these cases, many companies will cover the cost at an in-network rate.
  • Natural disasters: Floods, widespread fires, hurricanes, and tornadoes can destroy medical facilities and force people to evacuate to other areas in which they must seek health care. Sometimes, these patients may be eligible for in-network rates as part of a declaration of emergency by the state or federal government.

More information: When Should I Obtain Out-of-Network Health Care?

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