In Network and Out of Network Benefits
The purpose of this webpage is to provide you with information that will help you understand the differences between In-Network benefits and Out-of-Network benefits.
Each certified WCNet has an approved service area (a geographical area within which services from network providers is available and accessible). Each certified WCNet has been formed as a health care provider network to arrange or provide services to injured employees. During the certification process, each network must demonstrate to the Department that they have enough contracted and credentialed physicians and providers of a variety of specialties to meet the needs of the injured employees.
In-network benefits are provided by a physician or provider who is listed in the network's provider directory. The providers listed in a network directory have contracted with the network to provide services. If an injured employee lives within the approved geographical service area of the certified network, the injured employee must seek services from providers contracted with the network in order to receive in-network benefits.
Any services, other than emergency services, provided to an injured employee from physicians or providers not contracted with the certified network, unless pre-authorized by the network, would be out-of-network benefits. If an injured employee who is required to seek services from a network provider and does not meet the emergency or pre-authorized requirement, continues to seek care from an out-of-network, non-contracted provider, they may be liable for the medical charges. Out-of-network services are those services provided by physicians or providers that are not listed in the network's provider directory, or have not made a specific agreement with the network to provide services for the network.
In order for injured employees to be required to use a certified network, they must live within the certified network's approved geographical service area. The definition of where an employee lives includes the following:
- The employee's principal residence for legal purposes, including the physical address which the employee provided the employer as the employee's address;
- A temporary residence necessitated by employment; or
- A temporary residence taken by the employee primarily for the purpose of receiving necessary assistance with routine daily activities because of a compensable injury.
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Last updated: 09/06/2014