Make it make sense: even if you’re in-network, you might only be eligible for payment at out-of-network rates.
As it turns out, network status is a small piece of a complicated puzzle. We’ll clarify the difference between network status and contracting below.
What is a network?
Simply put, a network is a group of health care providers who have credentialed and contracted with an insurance company. This includes doctors, specialists, dentists, hospitals, surgical centers, and other facility types.
What is the difference between In-network and Out-of-network providers?
An in-network provider has credentialed with an insurance company, and is contracted to provide services to plan members for pre-negotiated rates. (Some companies use a tiered system, listing providers as Preferred or Participating with separate rates for each.)
An out-of-network provider is not contracted with the health insurance plan. Out-of-network providers may be described as “non-participating”.
How It Works
After you have:
- Submitted all application materials and received contracts,
- Signed and returned your contracts to the insurance company, and
- Been given an effective date,
You’re considered to be in-network.
However, to be eligible for in-network payment rates, you must be both in-network with the insurance company and contracted for your patient’s plan.
If you’re in-network with Cigna, but not contracted for a patient’s Cigna plan, your claims will process as out-of-network. Confusingly, carrier representatives describe [in-network but non-contracted] as “out-of-network”.
There are many reasons why you may be ineligible to treat patients or participate in a plan. Manage your expectations, and verify benefits carefully before services are rendered.
Looking for help getting in-network? Check out our sister company, Alchemy Credentialing, and turn your practice into gold!