Learning Center . Learning Insurance . Understanding Networks

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Health Insurance Networks

Learn about health insurance networks, primary care providers, and how to find a specialist:

What is a Primary Care Provider (PCP)?

A primary care provider (PCP) is the doctor, nurse, or health care professional you see for most of your health care needs.

Talk to your Primary Care Provider about:

  • New symptoms

  • How your medicines interact with each other

  • Your treatments and if they need to be changed

  • Follow-up exams, tests, or visits

  • Referrals to see specialists

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What is a Network?

A network is the group of doctors, nurses, specialists, hospitals, and clinics that works with your insurance company or HMO. Call your insurance company or HMO to find out who is in your network.

If you have BadgerCare Plus and get a bill in the mail or have questions, call your insurance company or HMO and ask for the BadgerCare Plus advocate. If they can’t help, call the HMO ombudsman at 1-800-760-0001.

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What is Out-of-Network?

Out-of-network is the doctors, nurses, specialists, hospitals, and clinics that don’t work with your insurance company or HMO. You need approval for out-of-network care before you make an appointment.

If you have BadgerCare Plus and get a bill in the mail or have questions, call your insurance company or HMO and ask for the BadgerCare Plus advocate.

Illustration of a doctor with a stethoscope, surrounded by a dotted circle, with the text 'Out-of-Network Care needs approval'.

How to find a specialist in your network:

A specialist is a doctor who only treats specific problems, like those in your heart, your skin, or other areas.

To see a specialist, follow the steps below:

  1. Call your doctor and tell them about your symptoms

  2. Ask your doctor if you need a referral to see a specialist. Some health insurance companies require approval to see a specialist.

    • A referral is a doctor’s note that shows you need more care. Many insurance companies won’t pay for a specialist without a referral.

    • If you have BadgerCare Plus and are having problems getting approval for needed care, call 1-800-760-0001

  3. Call and ask your insurance company or HMO for a list of specialists who are accepting new patients. Ask if you need approval to see a specialist.

  4. Call and make an appointment with a specialist who works with your insurance company or HMO.

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You can download a printable PDF of this information

Click the image to download a copy in English and Spanish.

Diagram illustrating healthcare networks, including primary care, specialists, urgent care, eye care, mental health, doctors, emergency room, and hospital, with a note to call your insurance company for out-of-network coverage.