Tell me which specialists are in network for this patient, and provide this service or CPT code

One problem that primary care providers often face, is that when they are seeing a patient who needs a referral to a specialist for something exotic, while they know which specialists can provide that service (and already have a relationship with that specialist) they often don't know whether that particular service provided by that specialist will be covered by the patient's insurance.

This leads to multiple problems

• First, they might refer a patient to a specialist who is not covered by that patient's plan, which could lead either to the specialist rejecting the patient, or the patient paying a huge out of pocket bill
• Second, even if the specialist is covered by the patient's plan, the specific service being provided might not be (this is rare, but can happen)
• Finally, if there are multiple specialists covered by that patient's plan, there might be a huge disparity in how much the plan reimburses those specialists, and the primary care provided wouldn't know which would be the most cost effective. This could be particularly impactful for patients on high deductible plans, who would be footing a portion of the bill out of pocket.

Here's how to find which specialists are in network for a patient, or covered by a patient's plan, and provide a specific service with Health Plan Explorer:

1. Find the plan you're looking for. This example utilizes a plan administered by United Health Care. United Health Care's Machine Readable Files (MRFs) are hosted here. Copy the link for the in network file for the patient's plan.
2. Head over to healthplanexplorer.com, Select "URL" and paste the link into the text field. Hit "Add" to add the Health Plan you're looking for. In this step, you can add as many health plans as you want - for example if you frequently deal with a few core plans and a few core services, you can do this search once. One nit - health insurers only host the most recent month's data for their plans (this should mean that most plans are up to date). Hit "Next".
3. Now enter the NPI(s) of the specialist you're looking for, and the CPT code(s) for the service(s) you're referring the patient(s) for. Hit "Next".
4. At this step, hit "Checkout".
5. Once you're done checking out and paying, we'll notify you by email when your file is ready. Once it's ready, you'll receive a report letting you know if the specialists you're seeking are in network with that patient's plan. If the specialists are not in network, you'll receive a full report of every specialist in network with that plan. Bear in mind that that these files are huge, so you might be working with a large file