Claims In Network And Non-Network Hospitals: Difference, Procedure, And Formalities

All to know about what happens to claims when you decide to opt for network or non-network hospital
Team Loop Health
June 10, 2021

For health insurance policyholders, the most important aspect is to get timely medical aid with a smooth claims process. Therefore, terms such as ‘cashless claims’ and ‘network hospitals’ are crucial factors while purchasing the insurance cover or zeroing down on the policy provider.

It’s a proven fact that availing cashless benefits with health insurance is always better. It allows you to simply walk into a network hospital and get treatment without shelling out a single penny from your pocket. But, what happens in case you are not eligible for a cashless claim, or you need to visit a non-network hospital due to an emergency?

Let’s find out by analyzing the differences in formalities and the process to file a claim between network and non-network hospitals below.

Difference Between Network Hospitals And Non-Network Hospitals

Network Hospitals are the ones stated in the agreement you have with the insurance provider. Hospitals not covered in the said agreement are termed non-network hospitals.

More often than not, well-known hospitals are listed under the network of most insurance providers. This makes it not only timesaving but also more secure to get treatment at a network hospital in case of a health emergency. But, this does not in any way discount the credibility of non-network hospitals.

Claim Processing, Formalities, And Waiting Time

Generally speaking, the claim process is faster, smoother, and hassle-free at network hospitals. This is because policyholders need not go through the ordeal of collecting and submitting documents for reimbursement. The patient can simply walk into a network hospital, submit a form with the Third-Party Administrator or TPA for cashless Mediclaim with zero waiting time and receive timely treatment.

However, since a non-network hospital is not registered with the insurance provider, it requires the policyholder to pay for the whole treatment upfront, gather documents, proof, and bills of the treatment, and submit them to the policy provider for reimbursement. This increases the waiting period for claim processing, requires the policyholder to dispense urgent cash, and go through the arduous process of gathering documents and submitting them as proof.

While cashless claims at network hospitals are approved almost instantaneously, the reimbursement process for treatment at non-network hospitals takes 10-15 days as there is a waiting period for verification before which one can receive the claim amount.

In the case of non-network hospitals, there is also a higher chance of expenses not being approved beyond a certain threshold as the insurance provider may not find them justified as per market standards. Simply put, the scrutiny is always higher for hospitalization claims at non-network hospitals, thereby jeopardizing the policyholder’s overall position.

When To Visit A Non-Network Hospital

In the case of both cashless as well as non-cashless claims, it is undoubtedly better to visit a network hospital for treatment. Without the cashless benefit, the policyholder will still be required to collate proof for reimbursement and pay cash upfront for treatment. But even then, the claim processing can be smoother and less time-consuming.

In case of unavoidable health emergencies, it is better to visit the nearest hospital facility, even if the same is not registered with the insurance provider. It would be unwise to travel all the way up to the network hospital in such cases, as even a few minutes could make a big difference amid a health contingency.

Health Is Wealth

Cashless claim at a network hospital comes with its own benefits. It allows policyholders to capitalize on their health insurance plan and make the most of it.

Even without the cashless benefit, it’s advisable to visit a network hospital for faster reimbursement claim processing. It’s also best to keep the network hospitals list in handy for quick reference. However, in case of unavoidable health emergencies, you can rely on non-network hospitals.

After all, you can’t control the wind, but you can adjust the sails.

Interested in learning more about Claims in Group Health Insurance? Click here

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