Some PEHP plans pay benefits for out-of-network providers. However, PEHP doesn’t pay for any services from certain providers, regardless if you have an out-of network benefit.
Check your Benefits Summary to see if your plan has out-of-network benefits.
If it does, keep in mind you’ll usually pay a greater portion of the cost (co-insurance) for out-of-network providers. You may also be subject to balance billing. Balance billing happens when a provider not contracted in your network bills more than the allowed amount. For example, if the provider’s charge is $100 and the allowed amount is $70, the provider may bill you for the remaining $30.
To be covered, all out-of-network services must meet the same standard as if they were in-network. This means you must get preauthorization for certain services. All services must be medically necessary to be covered. For example, unnecessary labs and tests won’t be covered.
If a provider is not in your network, you will not be able to take advantage of PEHP’s discounts with the provider, and you may not know exactly how much the provider will bill. To avoid paying the full billed charges, PEHP encourages you to negotiate with the provider prior to services being rendered so that you will know exactly how much you will pay, and may even receive an additional discount.
If you reach an agreement for the price of services with a provider, you may want to memorialize that in writing. PEHP has provided a sample agreement below that you may want to modify to fit your needs in such a scenario. PEHP provides this sample agreement as is, without representation or warranty of any kind. PEHP provides this sample agreement as information only. This information does not create an attorney/client relationship, and is not intended to convey or constitute any legal advice. For legal advice, please consult a lawyer.