Provider Network Verification & Open Network Education Protocol

By Mishe · Member Concierge

Provider Network Verification & Open Network Education Protocol

One of the most common questions members ask is whether a specific provider is "in-network." For traditional PPO plans, the answer is binary: the provider either participates in the network or they don't. But for Open Network plans — like San Patricio County Medical and Dental Plan — the answer requires a different framework entirely. There is no restricted network. Members can see any provider they choose. The question isn't can I see this provider — it's what will it cost me .

This protocol establishes standardized procedures for Member Services representatives to verify whether a provider has a contracted rate with a member's plan, educate members about how Open Network benefits work, and set accurate expectations regarding coverage, reimbursement, and potential member responsibility — all before the member receives care.

Section 1: Verifying Provider Contract Status

For Open Network plans, there is no traditional PPO network. However, some providers have contracted rates with specific employer groups. These contracted rates are stored in the plan's Fee Schedule within Sync. When a member asks whether a provider is "in-network," what they're really asking is: does this provider have a pre-negotiated rate with my plan, and will my visit be fully covered?

Step-by-Step Verification Process

Step 1: Access the Fee Schedule. Navigate to Sync → Plans → [Select Plan] → Fee Schedule. The direct path follows this pattern: sync.mishe.com/plans/[PLAN_ID]/fee-schedule . The Fee Schedule module is synced to Algolia and powers the Member Portal search, so the data you see here is the same data members can access.

Step 2: Search for the Provider. Use the search bar within the Fee Schedule module. Enter the provider's name — this can be a clinic name, practice name, or individual provider name. Results will display based on provider and procedure matches. Contracted providers will appear with associated procedure codes and reimbursement rates.

Step 3: Review Search Results. If the provider appears in the Fee Schedule, they have a contracted rate with the plan. Note the specific procedures and rates listed — these define what the plan will reimburse for that provider. If the provider does not appear, proceed to Step 4.

Step 4: If Provider Is Not Found. Perform a Google search to verify the provider's official business name. Check for alternate names, DBAs, or parent organizations. Search using the individual physician's name if the practice name yields no results. Document your search attempts in the member's file for reference.

In the example below, we received a call from a member inquiring whether Coastal Bend Retinal Specialists is in network with her San Patricio County Health Plan. We don't have any contracts for a provider with "Retinal Specialists" in their name, but we do have contract pricing on file with Coastal Bend Eye Center.

If we have contract pricing listed in the Plan>Fee Schedule module for this plan, that provider is technically in-network and treatment will be covered in full when coordinated through the Mishe Concierge.

Handling Ambiguous Results

Provider naming conventions vary, and similar names do not guarantee the same entity. For example, "Coastal Bend Eye Center" appearing in the Fee Schedule does not confirm that "Coastal Bend Retinal Specialists" is contracted — these may be entirely separate practices with different ownership, tax IDs, and contract status.

When a similar but not exact match appears: do not assume two similarly-named providers are the same entity. Verify with the provider directly if needed. Inform the member that you will confirm and follow up. Document the discrepancy and your verification steps.

Section 2: Educating Members About the Open Network Benefit

The Open Network model inverts the traditional insurance paradigm. Instead of restricting members to a defined panel of providers, the plan allows access to any provider — with cost transparency provided upfront. This requires a different conversation than the binary "in-network or out-of-network" framing members may expect from prior insurance experience.

Key Concepts to Communicate

Recommended Member Script

When explaining the Open Network benefit to members, use language similar to the following:

"You have an Open Network plan, which means all providers are in-network in the sense that you can see anyone you choose. Since you've coordinated this visit with us, you are covered in full up to your plan's maximum allowed reimbursement, which is set by your employer.

If the pricing for your chosen provider is above that maximum allowed amount, you would be responsible for paying the difference between what the provider expects and what your plan reimburses.

Here's the important part: we will tell you well ahead of your appointment whether the visit will be covered in full, or if you'll have any out-of-pocket responsibility. We'll also tell you exactly what that amount will be upfront, so there are no surprises if you choose to proceed with that provider.

That's part of the Mishe Guarantee."

Common Follow-Up Questions

"So any doctor is in-network?" — "Yes, you can see any provider. We'll help you understand the costs before your appointment so you can make the best decision for your situation."

"What if my provider charges more than the plan covers?" — "We'll source a few options for you to choose from. Some may be fully covered, and some may have a balance you'd be responsible for. We give you that information upfront so you can decide."

"How do I know if a provider is contracted?" — "We can check that for you. Contracted providers have pre-negotiated rates with your plan, which often means full coverage. Let me look that up and get back to you with options."

"What is the Mishe Guarantee?" — "It's our commitment to transparency. We tell you exactly what your visit will cost before you go — no surprise bills, no hidden fees. You'll know your responsibility upfront."

Section 3: Workflow Summary

The following workflow summarizes the end-to-end process when a member inquires about provider network status:

1. Receive Inquiry: Member asks "Is [Provider] in-network?" or similar question about provider coverage.

2. Access Fee Schedule: Navigate to Sync → Plans → [Plan Name] → Fee Schedule.

3. Search Provider Name: Enter provider name in search bar and review results.

4a. If Found: Confirm with member and provide contracted rates. Explain any potential member responsibility based on procedure and plan maximums.

4b. If Not Found: Search alternate names, verify provider exists via Google, and explain the Open Network benefit. Offer to source alternative provider options that may offer full coverage.

5. Document & Follow Up: Record the interaction in the member's file and follow up with sourced provider options as needed.

Section 4: Documentation Requirements

For each provider verification inquiry, document the following in the Treatment Request record:

• Member name and plan • Provider name(s) searched • Search results (found / not found / ambiguous match) • Information provided to member • Any follow-up actions required • Date and representative name

Thorough documentation ensures continuity if the member calls back, provides an audit trail for quality assurance, and helps identify patterns (e.g., frequent requests for a specific provider may indicate an opportunity to pursue a contract).

Section 5: Escalation Guidelines

Escalate to a supervisor or the Provider Relations team in the following situations:

• Member disputes the reimbursement amount or believes they were quoted incorrectly • Provider refuses to accept the plan's maximum allowed reimbursement and member wants to proceed • There is confusion about whether two provider entities are the same (e.g., similar names, unclear affiliation) • Member requests exceptions to standard coverage or reimbursement policies • Member expresses dissatisfaction with available provider options

Appendix: Quick Reference

For questions about this protocol or to suggest improvements based on member interactions, contact your Case Manager or Client Manager.