You have a few options for determining whether the requesting provider is in- or out-of-network for the patient. The most reliable method is contacting the payer or provider directly. You can also use the benefitsInformation objects in the eligibility response to determine whether prior authorization or a referral is required for requested services.

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Is the provider in- or out-of-network?

Unfortunately, you can’t reliably answer this question from a standard eligibility response. Payers typically don’t explicitly indicate whether the requesting provider is in- or out-of-network for the patient (though there are some exceptions). You also can’t use the inPlanNetworkIndicatorCode property for this purpose. The inPlanNetworkIndictorCode indicates whether the specific benefit type applies to in- versus out-of-network, not the requesting provider. The most reliable way to determine network status is to check directly with the payer or the provider. Note that payers may have different networks for different health plans, such as employer-sponsored plans versus Medicare Advantage, and these networks may have different contact paths.

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Payer FHIR APIs

Some payers have implemented the HL7 Da Vinci PDEX Plan Net (FHIR) API, which allows you to query directly for provider network status. Here are links to these APIs for a few large, commercial payers: This is not an exhaustive list, and we provide these links for convenience and reference only. Stedi can’t give any additional support on how to use third-party APIs.

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Additional network status details

Some payers do provide additional information about whether the requesting provider is in- or out-of-network. They may do this through either selective inclusion of benefits in the response or through freeform messages.

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Selective inclusion of benefits

A small subset of payers selectively include portions of the eligibility response according to the provider’s network status. For example, some payers only return out-of-network benefits if the requesting provider is out-of-network. Likewise, if the provider is in-network, they only provide in-network benefits. One example is Blue Cross and Blue Shield of New Mexico (BCBSNM). Their 270/271 Transaction Standard Companion Guide states in section 5.3:
“When local transactions are submitted, BCBSNM uses the provider type and/or provider specialty along with the providers contracting network status to determine the applicable benefits.”
Stedi doesn’t have a complete list of payers that selectively include or exclude benefits based on the provider’s network status. The most reliable way to determine network status is to reach out to the provider or payer directly.

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Freeform messages

While uncommon, some payers communicate information about the requesting provider’s network status using freeform messages. For example, Cigna’s 270/271 Companion Guide states:
“When the requestor’s network participation status can be determined, Cigna will send a Message on the EB1*30 Row that indicates either the Health Care Professional (or facility) is in or out of the customer’s medical network.”
In Stedi’s eligibility response, these types of freeform messages are typically included in the benefitsInformation.additionalInformation.description property. For example:
  • PROVIDER IS OUT NETWORK FOR MEMBER
  • BENEFITS RETURNED BASED ON NON-AFFILIATED PROVIDER STATUS
This description property may also contain information about network tier levels, since some plans have more complex benefit structures with reduced patient responsibility for higher-tier providers. These freeform messages are not standardized across payers and may even differ across plans for the same payer. Again, the most reliable way to determine network status is to reach out to the provider or payer directly.

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In Plan Network Indicator

The X12 EDI 271 eligibility response includes a data element called EB12 (In Plan Network Indicator). Stedi represents this field as the benefitsInformation.inPlanNetworkIndicatorCode property in the eligibility benefits response. Counterintuitively, this value doesn’t indicate whether the provider is in- or -out-of-network for the patient’s health plan. Instead, the InPlanNetworkIndicatorCode specifies whether the specific benefit type applies to in- vs. out-of-network. Most payers include information about both the patient’s in- and out-of-network coverage and benefits in the response, regardless of the requesting provider’s network status. Payers can send the following inPlanNetworkIndicatorCode values:
  • Y - Yes
  • N - No
  • W - Not Applicable | This indicates that the benefit applies to both in and out-of-network providers.
  • U - Unknown | This indicates that it is unknown whether the benefits apply to in- or out-of-network providers.
The example benefitsInformation object below shows the patient’s out-of-network deductible for the calendar year, which is $7,500 dollars. The inPlanNetworkIndicatorCode is N, indicating that the deductible is applicable to services performed by providers outside the patient’s network. 
{
  "code": "C",
  "name": "Deductible",
  "coverageLevelCode": "IND",
  "coverageLevel": "Individual",
  "serviceTypeCodes": ["30"],
  "serviceTypes": ["Health Benefit Plan Coverage"],
  "timeQualifierCode": "23",
  "timeQualifier": "Calendar Year",
  "benefitAmount": "7500",
  "inPlanNetworkIndicatorCode": "N",
  "inPlanNetworkIndicator": "No"
}

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Is prior authorization required?

Prior authorization (also called pre-authorization or pre-certification) is a requirement that the patient or their provider must get approval before a payer will cover specific services, procedures, medications, or devices. Without it, the payer may deny claims. Payers use the benefitsInformation.authOrCertIndicator property to indicate whether prior authorization is required for the service type code in the eligibility check. It can have the following values:
  • Y indicates that prior authorization is required.
  • N indicates that prior authorization is not required.
  • U indicates that the payer is unable to confirm whether or not prior authorization is required.
If you don’t receive the benefitsInformation.authOrCertIndicator property in the response, you can assume that prior authorization is not required. Some payers may send additional notes about prior authorization rules in the benefitsInformation.additionalInformation.description property.

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Is a referral required?

A referral is a written or electronic authorization from a primary care physician (PCP) to see a specialist or receive certain services. Some health plans won’t cover specialty care without a referral. Payers aren’t required to provide information about whether referrals are required for benefits, and we can’t provide a definitive list of payers who do. When this information is included, you can find it in the benefitsInformation.additionalInformation.description property. You’re more likely to receive referral information for members with HMO plans.