A healthcare professional, facility, or service provider that has entered into an agreement with an insurance company or managed care organization to offer services at discounted rates to plan members.

In-Network Provider:

A healthcare provider who is part of a preferred network and has agreed to accept negotiated rates for services, resulting in lower out-of-pocket costs for the insured individual.

Out-of-Network Provider:

A healthcare provider who does not have a contract with a specific insurance plan or managed care organization, often resulting in higher costs for the insured individual.

Network:

The collective term for all preferred providers, including doctors, hospitals, clinics, and other healthcare professionals, who have agreements with an insurance company or managed care organization.

Provider Directory:

A listing or database of preferred providers within a network, helping insured individuals locate healthcare services covered by their insurance plan.

Referral:

Authorization from a primary care physician or healthcare provider for a plan member to receive services from a specialist or another healthcare professional within the preferred network.

Primary Care Provider (PCP):

A designated healthcare professional, often a family doctor or internist, who serves as the main point of contact for the insured individual and coordinates their healthcare services.

Specialist:

A healthcare provider with expertise in a specific area of medicine, such as a cardiologist, orthopedist, or dermatologist, often requiring a referral for services.

Co-payment (Co-pay):

A fixed amount that insured individuals pay for covered services, such as doctor visits or prescription medications, at the time of service.

Deductible:

The amount an insured individual must pay out of pocket for covered services before the insurance plan begins to cover costs.

Coinsurance:

A cost-sharing arrangement where the insured individual pays a percentage of the total cost of covered services, with the insurance plan covering the remaining percentage.

Preferred Provider Organization (PPO):

A type of managed care health insurance plan that allows members to receive healthcare services from both in-network and out-of-network providers, with financial incentives for using in-network providers.