Understanding networks, primary care and specialists

July 2016

If you have health insurance and want to use your care, the first step is understanding which doctors are covered by your plan.

In the world of health insurance, a network is the group of doctors, nurses, specialists, hospitals and clinics that work with your insurance company. You need to use the medical professionals in this group.

Your insurance company can let you know which medical professionals are in this group. You will then choose a primary care provider or PCP. A primary care provider is the doctor, nurse or health care professional you see for most of your health care needs. Think of your PCP as your first point of contact who helps you with your health needs.

On the other hand, a spebless-you-1175296_640cialist is a doctor who only treats specific problems, like those in your heart, your skin or other areas. Often, a referral from your primary care provider is required that shows you need to see specialist. Some insurance companies also require you to get approval before you get the care your specialist recommends.  Many insurance companies will not pay for a specialist if you do not have both a referral from your doctor and approval from the insurance company for the care.

If you see a specialist, it’s important to tell your primary care provider about it. Additionally, let him or her know if you visit urgent care, or go to the emergency room. Your primary care provider helps you stay healthy and understands how all your medicines and treatments interact with each other.

Covering Wisconsin has created a how-to sheet titled Understanding Networks, Primary Care, and Specialists available online at coveringwi.org that defines these terms and explains how to find a specialist who is covered in your network.

Still unsure who to call when you need care? No worries, contact your insurance company for help.

Contact: Stephanie Severs, 608-261-1455, ssevers@wisc.edu, Nancy Crevier, 715-732-7510, ncrevier@marinettecounty.com








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