What is Out-of-Network?
The use of health care providers who have not contracted with the health plan to provide services. Members enrolled in preferred provider organizations (PPO) and point-of-service (POS) health plans can go to out-of-network providers and still obtain reimbursement for covered expenses, but they typically pay additional costs in the form of higher deductibles and coinsurance and may be subject to maximum caps on benefits. Because fees are not contractually negotiated with out-of-network providers, health plans typically calculate reimbursement amounts for these providers based on the lower of the actual charge or the “usual, customary and reasonable” (UCR) charge as determined by the plan. Members are typically responsible for any charges that exceed the UCR amount in addition to any applicable deductible or coinsurance.
