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.
About Network Status
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. Network status describes your relationship to an insurance company, and your participation in their networks.
What is the difference between In-network and Out-of-network providers?
Network status is not as straightforward as it seems. An insurance company may manage hundreds or thousands of policies. When you credential with that company, it will contract you for all eligible plans. You will not be eligible for every policy the insurer manages.
In-network providers are credentialed with an insurance company, and contracted to provide services to plan members for pre-negotiated rates. Some companies use a tiered system, and pay separate rates for Preferred vs. Participating providers.
Out-of-network providers are not contracted with the health insurance plan. Insurance companies may describe out-of-network providers as “non-participating”.
How It Works
You’re considered to be in-network once you:
- Submit all application materials and receive contracts,
- Sign and return your contracts to the insurance company, and
- Receive an effective date
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”.
You may be ineligible to treat patients or participate in a plan for a variety of reasons. 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!