What factor determines whether a claim is considered in-network or out-of-network for a patient?

• A. The CPT code used
• B. The provider's contract status with the payer
• C. The patient's deductible
• D. The facility location

Answer: (B)

The determining factor is whether the provider has a contract with the payer. If there’s a contract, the provider is in-network and the payer uses negotiated rates, usually resulting in lower patient costs. If there’s no contract, the provider is out-of-network, which can lead to higher charges and potential balance billing. The CPT code, patient deductible, or facility location don’t set network status; they influence pricing and patient responsibility, but not whether a claim is considered in-network.