Will insurance cover labs ordered by an out-of-network doctor if I get them done at an in-network lab?

Plan Benefits
1

Hello everyone,
I have Health Net Bronze 60 Ambetter PPO and want to start treatment with Defy Medical (HRT telehealth clinic). They said they could send a script for lab work at LabCorp. LabCorp is in-network for my plan, but I’m concerned if my insurance will cover it since the ordering doctor isn’t in-network.

Here’s what my EOB says about diagnostic tests (bloodwork):

Preferred Provider:

  • Lab: $40 copay per visit, deductible does not apply

Out-of-Network Provider:

  • 50% coinsurance

Limitations, Exceptions, & Other Information:

  • None

I’ve had labs done at LabCorp before with no issues and was charged the $40 copay as stated, but those tests were ordered by in-network doctors. Thanks for any insight.

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2

It would depend on the plan/carrier I would recommend checking with your plans customer service since you are on a PPO.

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3

Yes if you have a PPO and the lab is in network.

Probably not if you have an HMO.

Definitely not if you have Kaiser.

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4

Generally speaking, I have seen this work.

With the major exception being Medicare if the tests are not ordered by specific taxonomy.

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5

I have a epo with Serra health my doctor is out of network, but any place he sends me to for test and blood work as long as their in network they will cover it

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6

Yes, it’ll be covered at the in-network rate. Participation status of a referring/ordering provider doesn’t affect another provider’s contracted rate or their ability to fulfill the order.

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7

I know in a HMO it would it would if you do not have a referral on file of the ordering provider. Might be a good idea for OP to check with customer service.

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8

Getting your labs done at an in-network location like LabCorp will use your in-network benefits. Insurance companies bill based on where the service is performed and the type of service (CPT codes), not who ordered the test. LabCorp will submit the claim to your insurance company, and they’ll adjust it to the allowed amount (a contracted rate) and send payment, minus your lab copay. It’s always a good idea to call your insurance company first to verify. I hope this helps!

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Thanks for explaining! I plan to call and verify, but my trust in reps is low since I’ve been given wrong info before. Just wanted to see if others interpret the EOB the same way I do before I call.

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I work in the health insurance world, so I completely understand why you might not trust reps. I can’t speak for your specific company, but I’m glad I could offer some helpful insight. Good luck!