What You're Responsible for If You Stay In Network
- Your provider (doctor's office, hospital, laboratory, etc.) files the claim. You may receive a bill after the claim has been processed if you have any patient responsibility. If your service was routine preventive care, you pay nothing.
- You pay your deductible and coinsurance/copay.
- Your costs for services are less because the network providers generally discount services between 40%-50% of the total costs.
- Check your Explanation of Benefits (EOB) to make sure it's accurate, and keep it for future planning.
What You're Responsible for If You Go Out of Network
- You may need to file a medical claim. It's likely that your provider (doctor's office, hospital, laboratory, etc.) will bill you for the entire cost of the service. Some out-of-network providers may require you to pay for the charges up front.
- You pay more of the costs, higher deductibles, coinsurance, and out-of-pocket maximum, plus there are no network discounts.
- There is a Reasonable & Customary (R&C) limit set by your medical claims administrator. It's based on the amount that 90% of doctors and other providers in the area charge for a given service. You pay all costs over R&C each time you use an out-of-network doctor or service. You'll receive a separate bill for these costs.
What You're Responsible for While You're Traveling
- If you become ill or injured while traveling, contact your medical claims administrator (find telephone number on back of medical ID card) to find if there is a network doctor or hospital in the area. If so, charges will be covered at the in-network level. If not, you'll be charged at the out-of-network level.
- If you have an emergency while traveling, go to the nearest emergency room. If it's a true emergency, the charges will be paid at the in-network level. If it's not a true emergency, the charges will be paid at the out-of-network level. Some examples of true emergencies are: fractures, lacerations, motor vehicle accidents, hemorrhage, shock, or other conditions associated with deterioration of vital life functions.