Getting care from a provider in your health plan’s network generally costs much less than going to an out-of-network provider. (see care in and out of network). But you may need to go out-of-network for certain types of care, especially if you or a family member has a rare disease, such as a genetic disorder. assume that no provider in your network has the training or experience to treat you the right way. With prior approval from your insurer, you may be able to get the care you need out of network and still pay only the lowest in-network rate.
Different insurers take different approaches to requests for out-of-network care at in-network rates. You may need to make a formal request to your insurer, sometimes called an “appeal,” or submit a request for prior authorization. Information about the process to follow should be available on your insurer’s website, plan documents, or customer service representative.
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Your in-network primary care physician (PCP) or specialist usually submits the initial request to the insurer. the insurer may deny her first request. but usually she gets more than one chance to get her case reviewed. she can appeal the decision “internally,” which means she can ask the insurer to reconsider the denial of her benefits. If your request is still denied, federal or state law may require your insurer to allow you to initiate an “external” appeal. that means you appeal to an outside, independent group.
If your insurer agrees to let you go out-of-network at the in-network rate, your out-of-network referral will usually be to a specific doctor. but, typically, any physician managing your care will work with other providers who perform related procedures. the original physician’s claim will be processed at the in-network rate. but, claims from the other providers may be processed as out-of-network and you will have to appeal the insurer’s decision. To avoid this, it is best to arrange these details with the insurer in advance.