Non-Participating Provider

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Non-Participating Provider


A non-participating provider usually refers to a provider that does not accept Medicare.

Some insurance plans also used the term to refer to a provider who doesn’t have a contract with the health insurer or plan to provide services to you.

These providers would be considered out-of-network. You’ll pay more to see these providers. In some cases, you must pay all costs.

Check your policy to see if it will pay for out-of-network providers.

♦ Medicare beneficiary — a non-participating provider does not have to accept people with Medicare.

If a non-participating provider sees people with Medicare, they are allowed to charge them more.

They may require payment in full at the time of service.

If you are in this situation, you would have to submit a claim to Medicare and wait for reimbursement.

♦ Some insurance plans refer to non-participating providers as non-preferred providers.

This is misleading because they are not the same. A network consists of participating providers.

♦ The network may include some the insurer considers "preferred," which means the other participating providers are "non-preferred."

You may see either provider but if you see the "preferred" provider your costs usually are lower. Prescription drug benefits have gone this route also.

Related content

Networks - In & Out

• Why you should use in-network ?

• Why you might use out-of-network ?