Being in-network does not necessarily mean a provider is contracted with every single insurance plan the company manages. Understanding the following differences between In-Network, Out-of-network and being contracted with a particular plan will save you time and headaches, trust us!
What is a network?
Simply put, a network is a group of health care providers who have been credentialed and contracted with a given insurance company. This includes doctors, specialists, dentists, hospitals, surgical centers & other facility types.
What is the difference between In-network and Out-of-network providers?
An in-network provider is contracted with the health insurance company to provide services to plan members for specific pre-negotiated rates. (Some companies may also 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. This may also be called Non-Participating.
How It Works
After a provider has:
- Submitted all application materials and received contracts,
- Signed and returned their contracts to the insurance company, and
- Been given an effective date,
They are considered to be In-Network.
However, being in-network does not mean that they are contracted with every single insurance plan the company manages. Providers may only be eligible for contracts with select plans, and may still be considered as non-participating or non-contracted for others. This means that even though a provider is still technically “in-network” with Aetna or Cigna, they may also have claims processed at out-of-network or non-participating rates for some patients’ plans.
There are many reasons why providers may be ineligible to participate in a plan, so it is important that both providers and patients have realistic expectations, and that benefits are carefully verified before services are rendered.
Looking for help getting in-network? Check out our sister company, Alchemy Credentialing, and turn your practice into gold!