NON-PARTICIPATING PROVIDER

A provider that does not sign a contract to participate in a
health plan and refuses to accept insurance allowable as
payment in full.

In commercial plans, non-participating providers are also
called “Out-of-Network Providers” or “Out of Plan
Providers”.

If a beneficiary receives service from an out of network
provider, the health plan will pay for the service at a
reduced rate or will not pay at all. In Medicare Program,
this refers to providers who are therefore not obliged to
accept assignment on all Medicare claims.

Non-Participating Provider also referred to as “Non-Par”
elects not to participate with given health care plan. In
some instances, provider bills patient for the difference
between the allowed amount and fee for the service
provided.
Some health plans have limitations on how much patient
can be billed for. The health plan will send payment to the
patient and the patient will be responsible for paying the
provider.