Out-of-network
A provider or facility that has no contracted agreement with a patient's health plan, typically resulting in higher patient cost.
Updated
An out-of-network provider is one that has not contracted with a patient's health plan. Without a negotiated allowed amount, the provider may bill the patient for the difference between the charged amount and what the plan pays, a practice known as balance billing.
Out-of-network services generally carry higher cost-sharing, and some plans do not cover out-of-network care at all except in emergencies.
In practice
Claims for out-of-network providers often process at lower benefit levels or are denied entirely. Billing teams must verify whether the plan includes out-of-network benefits and apply No Surprises Act protections where applicable before collecting from the patient.
Commonly confused with
- In-network: In-network providers have a contract with the plan and accept a negotiated allowed amount, resulting in lower patient cost.