Before you book with a specialist, it helps to know more than whether the office “takes your insurance.” A practice can accept a company’s insurance and still not be in network for your specific plan. This guide explains the terms, the questions to ask and a quick checklist. It is general information, not medical, legal or financial advice. Your plan documents and your insurer have the final word on your coverage.
Key takeaways
- “We accept your insurance” is not the same as “we are in network with your plan.” Ask about your exact plan name.
- Network status can differ by doctor and by location within the same practice, so confirm the doctor and the address.
- A referral and a prior authorization are different things. Your plan may require one, both or neither.
- Check with your insurer as well as the office, and write down who you spoke with and when.
“Accepts insurance” vs. “in network”
HealthCare.gov defines a network as the facilities, providers and suppliers your health insurer or plan has contracted with to provide health care services. Being in network means the provider has a contract with your plan, not just with the insurance company in general. One insurer often sells several plans, and each can have its own network.
An office that “accepts” an insurer may only be in network for some of that company’s plans. Ask using the full plan name printed on your insurance card.
Why the doctor and the location both matter
A large practice may have several doctors and offices, and their contracts are not always identical. When you check, give the name of the specific doctor you want to see and the address of the office you plan to visit, not just the practice name.
Imaging, lab work or a procedure at a separate facility may be billed by a different provider. If one is planned, ask who will bill for it and whether they are also in network.
Your plan type changes the rules
HealthCare.gov’s guide to plan and network types describes the common ones:
- HMO: usually limits coverage to doctors who work for or contract with the HMO, and generally won’t cover out-of-network care except in an emergency.
- EPO: covers services only if you use doctors, specialists or hospitals in the plan’s network, except in an emergency.
- POS: you pay less in network, and you need a referral from your primary care doctor to see a specialist.
- PPO: you pay less in network, and you can see providers outside the network without a referral for an additional cost.
Referral vs. prior authorization
A referral is a written order from your primary care doctor for you to see a specialist or get certain services. HealthCare.gov notes that in many HMOs you need a referral before you get care from anyone except your primary care doctor, and that if you don’t get one first, the plan may not pay.
Preauthorization, also called prior authorization, is a decision by your insurer or plan that a service, treatment plan, drug or piece of equipment is medically necessary. A plan may require it for certain services before you get them, except in an emergency. HealthCare.gov also points out that preauthorization isn’t a promise the plan will cover the cost.
A referral and a prior authorization are separate requirements, and your plan may require one, both or neither. Before you book, ask your plan which of them apply to the first consultation and to any tests or treatments that may be planned.
Medically necessary vs. cosmetic care
HealthCare.gov defines medically necessary care as services or supplies needed to diagnose or treat an illness, injury, condition, disease or its symptoms that meet accepted standards of medicine. Medical necessity is only one part of coverage. A plan can still exclude a service, and covered care may still depend on network status, your plan’s benefits and any prior authorization rules. Services done mainly to change appearance may not meet that definition. If a dermatology or plastic surgery treatment could fall on either side, ask your plan whether it is covered before you schedule.
How to confirm network status before booking
- Read your plan’s summary. Insurers and job-based plans must give you a plain-language Summary of Benefits and Coverage, and you can ask for a copy at any time. It shows your costs for specialist visits and whether referrals are needed.
- Check your insurer’s provider directory. Search for the doctor’s name and the office address under your exact plan.
- Call the number on your insurance card. Ask whether this doctor, at this location, is in network for your plan. Ask whether you need a referral for the visit.
- Call the specialist’s office. Give your plan name and member details, and ask the same questions. Ask whether any planned tests or procedures need prior authorization and who requests it.
- Write it down. Note the date, the name of the person you spoke with and any reference number.
If you have Medicare
Original Medicare works a little differently. Medicare.gov explains that you can get the lowest cost if your provider accepts assignment, meaning they accept the Medicare-approved amount as payment in full for covered services. You may still owe your Medicare deductible and coinsurance; Medicare.gov says these providers agree to charge you only those amounts. Most doctors accept assignment, but Medicare.gov recommends checking. If you have a Medicare Advantage plan instead, network and referral rules depend on the plan type. Medicare.gov’s comparison of Medicare Advantage plan types shows, for example, that HMO plans generally require in-network care and a referral to see a specialist, while PPO and Private Fee-for-Service plans don’t require specialist referrals. Ask about your exact plan by name.
What federal billing protections do and don’t cover
The No Surprises Act protects people with most private health insurance from certain unexpected out-of-network bills. According to CMS’s guide to medical bill rights when using insurance, this includes emergency room care and non-emergency care related to a visit to an in-network hospital, hospital outpatient department or ambulatory surgical center. CMS notes that these protections don’t apply at other settings, like a doctor’s office that isn’t a hospital outpatient department, or if you go to an out-of-network facility. In certain situations, such as when you are scheduled for some types of care from an out-of-network provider at an in-network facility, a provider may ask you to sign a notice and consent form. Signing it means you agree to out-of-network care and give up those protections for that care. CMS notes that signing is your choice.
So a standard specialist office visit depends on your own network check. CMS also notes that if your provider leaves your plan’s network, some patients in ongoing treatment may qualify for up to 90 days of continued in-network coverage.
Quick checklist before your specialist visit
- Exact plan name and member ID from your insurance card
- The specific doctor’s name and the office address
- Network status confirmed with your insurer and with the office
- Whether you need a referral, and whether it is on file
- Whether any planned test or procedure needs prior authorization
- Names, dates and reference numbers from each call
Frequently asked questions
If a specialist accepts my insurance company, am I covered?
Not necessarily. An office may work with an insurance company but only be in network for some of its plans. Ask whether the doctor is in network for your exact plan name, and confirm with your insurer.
Do I need a referral to see a specialist?
It depends on your plan. POS plans and many HMOs require one; PPOs generally don’t. Check your plan summary or call your insurer.
Is prior authorization the same as approval to pay?
No. Preauthorization is your plan’s decision that a service is medically necessary, and HealthCare.gov says it isn’t a promise your plan will cover the cost. Your deductible, copays and other plan rules still apply.
What if my insurer and the office give me different answers?
Your plan decides what it covers, so go back to your insurer, give them the doctor’s name and office address, and ask them to confirm. Keep notes on each call in case you need them later.
Find a specialist and prepare for your visit
Once you know what your plan requires, you can compare practices by city on our All Locations page and then call the office to confirm network status. If you’re seeing a pain specialist or an ear, nose and throat doctor, our guides to your first pain management appointment and your first ENT appointment explain what to bring.