Depending on your policy, a provider/doctor is IN NETWORK if he has a contract with that insurance company and agrees to accept whatever $$$ the insurance contract allows for the bill and not bill you for the difference between the allowed amount and his amount. You are only responsible for the amount between the ALLOWED amount and what the insurance paid. An OUT OF NETWORK doctor can bill for the difference between the allowed amount and what he charges.

On my current policy, charges that are not covered at 100%, are covered either at 90% if IN NETWORK, or 70% OUT OF NETWORK. The other policy available at my company pays 80% or 60%. If for instance you go for a chest Xray at an IN NETWORK facility and they have a OUT OF NETWORK radiologist read it, it will be paid at the OUT OF NETWORK rate. Since you has no control as to who read the film, the insurance will normally reprocess this as IN NETWORK and pay the radiologist the higher rate. You should not be responsible for the difference betweeen the two rates, only the amount above the IN NETWORK rate when at an IN NETWORK facility. A telephone call to the insurance company is usually all it takes to get it reprocessed correctly. If your policy doesn't differentiate this way, you don't have to worry about it.

Hope that explains it better.

Eileen