How does the process work for using the provider out of network?
When you go to the providers outside the network, you can present the insurance card. The insurance card has all the information the provider's office will need to bill the insurance company directly such as the certificate number, claims filing address in the U.S., and toll-free number to call and verify the coverage.
It still depends upon the provider whether to bill the insurance company directly or not. Even if the provider accepts the card, there is no network negotiated fee. If you have to first pay, you can get reimbursement by filing a Claim Form. You can either use the claim form you receive in the mail along with the insurance card or you can download it from our Client Center.
What is the disadvantage of using the provider out of network?
As described in the previous FAQ, when you go to the provider out of the network, the provider may not recognize the insurance, and you may have to first pay out of your pocket and file for reimbursement. There are no network negotiated fees.
If I go to the hospital that is in network, does it mean all the providers there are in the network too?
No. When you go to the hospital, you get a bill from the hospital. Several service providers who work there such as the doctor, radiologist for x-ray, anesthetist etc. generally do not work for the hospital, but they work independently there. It is an unfortunate fact of the U.S. healthcare system or the fault of the hospital that some of those providers do not participate in a PPO network, even if the hospital itself participates in a PPO network. If any of the providers are out of network, the claim will be processed as out of the network.
All I can do is find a hospital in the PPO network. I don't have control over all the people who provide services to me. How am I supposed to find who is in the network and who is not?
Unfortunately, you don't always have control over who provides you service in the hospital. The best thing you can do is ask each service provider whether they are in the network or not. But you may not always have that choice. In any case, out of network benefits would be applied in case any provider happens not to be participating in the network.
If I have a life threatening emergency, how am I supposed to know which hospital is in the network or who is not? When I call 911, I can't control where the ambulance is going to take me. How does it work in such cases?
Soon after you buy the insurance, but before some emergency happens, it is best to search the providers in the PPO network and remember a few hospitals in your area or take a print out. If you have a choice (and sometimes even the emergency paramedics or ambulance people give you that choice, if medically appropriate), you can direct which facility to go to.
If you are traveling to various places, it might be wise to search for the hospitals within the PPO network in those cities or areas in advance and keep the list handy.
However, you don't always have that kind of choice and you should always give the highest priority to the health of the person and use your own judgment. In any case, if you incur expenses outside the PPO network, they would be processed as out of network.
When my parents visit me, we are planning to visit various places throughout the U.S. Will my visitors insurance have providers in various states?
Most of the visitors insurance plans participate in the PPO network that have a good number of providers all across the country. As visitors are expected to travel to various places, it would not be practical to have a PPO network that is restricted only to a certain area. You generally don't have to worry about being able to find the provider within the PPO network.
In any case, if I decide to go out of the network, am I still covered or not?
If you go to the providers outside the network, you are still covered according to the terms of the policy. In some cases, out of network coverage is less than in-network coverage. However, the difference is not huge in most cases.
I don't see a PPO network logo on my card or phone number. How do I find out what network my insurance uses? Or if it even has a network?
Most insurance plans that use a PPO network will have some way to indicate that on the insurance card. If it does not specify, then you can always look the information up in the Client Center. If the plan uses a PPO network, you'll be able to look up providers that are in the PPO network; if the plan does not have a PPO network, it will tell you that you're able to visit any provider you choose.