Your Choices for Receiving Care
Each time you need care, you choose between:
  • In-network services received from participating providers
  • Out-of-network services received from non-participating providers
The Plans pay benefits either way, but at a higher level for in-network care. In addition, participating providers file claims and generally handle prior authorization requirements for you.
In-network benefits are based on negotiated fees paid to participating providers. When covered health services are received from out-of-network providers, eligible expenses are based on fees that are negotiated with the provider, a percentage of the published rates allowed by Medicare for the same or similar service, or in rare circumstances, 50% of the billed charge or a fee schedule that is determined at the time of service. When reasonable and customary fee guidelines apply, you are responsible for paying the provider for any difference between the reasonable and customary fee and the provider's actual charge.
Out-of-Network Benefit Exception
Most of the healthcare services you need are available within the network. However, if there is no in-network provider within a 20-mile radius of your home ZIP code, you may be eligible for in-network benefits in connection with specific covered health services. UnitedHealthcare must approve any benefits that fall under this exception prior to receipt of care. These benefits are subject to any plan limitations or exclusions outlined in this Benefits Summary.