What Happens if I Go To an Out-of-Network Provider?

There may be times when you decide to receive care from an out-of-network doctor, hospital or other health care provider. Many health plans offer some level of out-of-network coverage, but many do not including most HMO plans except for emergencies. If you are going out-of-network to get care, here are a few things to keep in mind.

Avoid going out-of-network unintentionally. If your in-network primary care physician (PCP) referred you to a specialist, don't assume they are also in-network. Ask your PCP to suggest a specialist who is part of your plan's network if cost is important to you. You can also your plan's Provider Finder to search for a specialist in your network that is located on the insurance company's website.

Double-check your choices. Perhaps you have a rare health issue or are suffering from an illness that calls for a hard-to-find doctor or specialist. Most plans are required to offer a broad network of doctors and hospitals within your plan's service area that cover specific conditions and specialties. So before you decide to go out-of-network, you may want to check the Provider Finder or call the number on the back of your ID card for help.

Research your potential costs. First, try to find out what the costs of services will be from your out-of-network doctor or other health care provider. As long as these costs can be estimated ahead of time (which may not always be possible), you can check your policy to find out what your share of the cost will be. In some cases, there may be an added deductible, so check your policy carefully to estimate your costs.

Know your payment terms and options. If you think your share of the cost will be high, or if your out-of-network doctor requires you to pay in full, you should find out about their payment terms. Most doctors and other health care providers take credit cards and many offer financing or flexible payment terms.

Find out who will process the claim. Most in-network doctors, hospitals and other health care providers will file a claim directly with us on your behalf. Out-of-network doctors may or may not do so. Be sure to check with their billing staff if you have questions. If you will need to file a claim yourself, download a claim form and follow the instructions.