What services are considered out-of-network and how are they billed?

Out-of-network services typically refer to medical care provided by healthcare providers or facilities that do not have a contractual agreement with an individual’s health insurance plan, such as Anthem Blue Cross & Blue Shield. When a member receives care from an out-of-network provider, it is important to understand that the billing and reimbursement process differs from in-network services. Out-of-network services may include visits to specialists, surgeries, emergency care, or any other type of treatment rendered by providers who are not part of the insurer's preferred network. Because these providers do not participate in the contract negotiated with the insurer, they may charge higher fees than in-network providers. Anticipating higher out-of-pocket costs is essential, as plans often provide lower coverage levels for out-of-network care, resulting in higher deductibles, co-pays, and coinsurance rates. When billing occurs, out-of-network providers typically bill the patient directly. After the patient submits a claim to Anthem Blue Cross & Blue Shield, the insurer processes the claim according to the plan's out-of-network coverage terms. Members may receive a percentage of the total billed amount or face balance billing, where the provider bills them for the difference between the billed amount and the insurer's payment. To understand specific out-of-network coverage, it is advisable to refer to the plan documents or visit the official Anthem website for detailed information.