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Insurance Network: Understanding In-network and Out-of-network

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Dental insurance plans are generally designed to provide dental coverage from a specific network of providers. Although patients can always visit an out-of-network dental provider, going for a treatment from an in-network provider usually costs much less than going to an out-of-network provider. Now, the question here is whether an insurance plan pays for an out-of-network treatment or not. Does an insurance plan allow patients to visit an out-of-network provider and pay for the treatment they receive? Does it pay partially or fully or pay nothing? The article will address all these questions in detail.

Understanding In-network and Out-of-network

  • In-network: Every insurance plan has a set of providers associated with it known as in-network providers. These providers agree to the terms & conditions of the insurer and provide their services to the patients who have taken that insurer’s plan. 

As per the conditions of the plan that they have enrolled, patients pay a certain amount for the treatment they receive and the rest, the plan covers. This is typically the process when they visit an in-network provider. It keeps their dental treatment costs at bay and this is precisely the purpose of taking a health insurance plan.

  • Out-of-network: Dental providers who are not associated with the insurer are simply considered as out-of-network providers. At times, a patient may need to visit an out-of-network provider for certain types of treatments that are not provided by any of the plan’s in-network dental providers. Although the terms & conditions of payment may change when a patient visits a provider that is not in the network, s/he may be able to receive the required treatment with prior approval from the insurer and still pays the lower amount similar to the in-network rate.

Availing out-of-network benefits

A lot of patients are unaware of the benefits their dental insurance plan has to offer even after taking one. Awareness about the type of plan is important to avail the benefits. Let’s take a look at some of the points worth knowing when it comes to out-of-network coverage.

  • Know all about the plan – Patients are advised to read and understand their plan to maximize insurance benefits. They should know all the benefits and limitations of their plan. They can get in touch with their insurer directly to know all about their plan, especially the process for receiving out-of-network care.
  • Dental emergency – Usually, all dental insurance plans cover the cases of a dental emergency or urgent care services. So, if a patient needs to visit an out-of-network provider in case of an emergency, s/he is likely to receive it at in-network rates. The plan-specific terms & conditions would be applied though.
  • Prior authorization- Every insurer has a different approach to address out-of-network care requests. If a patient’s insurer does not offer or allow its patients to go out-of-network, s/he may need to send a formal request to his/her insurer, also known as an appeal, or send in a formal request for prior authorization. A primary care provider (PCP) or an in-network specialist is likely to help patients with submitting the prior authorization requests. After getting approval from the insurer to go out-of-network for treatment, patients are advised to understand cost-sharing (Copays, deductibles, and other charges) to keep the costs at a minimum level.

When do patients need an out-of-network provider?

Let’s take a look at some instances when a patient may need to see an out-of-network healthcare provider.

  • In case of a rare dental problem that is not covered by an in-network provider
  • Patients living in a remote area where no in-network provider is available
  • In case of a dental emergency, patients may need to visit the nearest provider either in-network or out-of-network
  • When a patient is receiving treatment from an in-network provider and the provider leaves the network
  • When a patient has a rare dental condition and no in-network provider has the specialization to treat it

So, a dental insurance plan can pay for out-of-network care. However, the cost of the treatment may either go up or similar to in-network rates, depending on the terms & conditions of the plan. Patients need to consider learning all about their plan and maintain regular communication with their insurer to understand all the charges in case of out-of-network care.