One of the biggest assets of your health insurance plan is the provider network that is associated with it. It’s important to know what it is, how it works and what you are entitled within your provider network, as this will determine the kind of health care will receive.

What is a Provider Network?

The provider network includes physicians, hospitals, clinics, laboratory services, and sometimes even pharmacy and external or outpatient care facilities.
Usually, a provider network is made up by suppliers who have partnered with your health insurance company, and have affiliated to provide care for them. Your Health Insurance Company could have one, or several provider networks, depending on their coverage range. Most, if not all health insurance plans have accessibility to a Provider Network, and because of this you should abide to your network and policy’s rules.

When you signed up for your insurance plan, you agreed to its coverage rules. You were probably given a packet that describes the kind of coverage you have. To avoid misunderstandings about your coverage, you need to read the rules of your insurance plan.

What is included in my Provider Network?

Well, this question has a specific answer, depending on who your Insurance Company is, but usually, they offer the following services:

Doctors and hospitals
Managed care plans sign contracts with certain doctors and hospitals to care for their plan members. Your plan may refer to them as providers. This group of providers is often called the plan's network. Like you, they have agreed to follow the plan's rules. Your insurance company might not pay for you to go to a provider who is not in its network. If it does pay for you to use a provider outside your network, it may pay less than it would for a network provider. In either case, you are responsible for the part of the bill that the plan doesn't pay.

Extended Services
If your doctor decides that you need to go to the hospital, have surgery or have certain tests, your network should give you access to either a hospital laboratory, or a testing facility for exams such as X-Rays, CAT scans, etc. Mental institution, nursing homes and outpatient care facilities could also be part of the extended services of your plan.

Pharmacy
Almost every managed care plan has a drug formulary. A formulary is a list of prescription medicines that your health plan has approved. If a drug isn't on the formulary, you'll probably have to pay more for it. Your insurance company can give you a list of drugs that are on the formulary. If necessary, show the list to your doctor when the doctor writes you a prescription.

Most policies include a list of hospital services that are covered by a basic plan. These services include what you might expect: room and board for the duration of your stay, general nursing care and diagnostic exams. Generally, oxygen services, the administration of blood and plasma, and use of the operating room and the intensive care unit are covered. Inpatient benefits are the same whether you have an HMO plan or a fee-for-service plan, but in some cases preapproval is required. However, in emergency situations, preauthorization is usually waived.

As with any other benefit, most insurance carriers have specific guidelines for the payment of inpatient services. As mentioned above, most plans require preapproval and often a referral from your primary care physician for a medically necessary treatment. Once you're in the hospital, there is a limit to the number of days within a calendar year that your inpatient benefits will cover. Some plans even include a lifetime limit on inpatient treatment.

Using your Provider Network

If you need to use your Health Insurance and any of your Provider Network services, you should ALWAYS double check that the facility you plan to attend is part of your network. This can save you great financial distress, as using out-of-network facilities or services usually come with either a deductible, co-pay or no reimbursement at all.

A good way to check your network is either by contacting your insurance company to request a paper Provider Network Directory, or by going to their website. Most health insurance companies offer now an online provider network search service, that lets you look and check for a physician or clinic if you don’t have one, or confirm that the one you plan to attend is part of the network.

Use the resources your health insurance plan gives you. This ensures the best usage of your health insurance policy, and the least additional cost for you.