NCN - Out of Network

Payors and groups may purchase out-of-network claim services from HealthLink/National Capital PPO. National Care Network provides the services that include savings-based networks, professional fee negotiation services and related services designated to contain costs on non-participating provider claims.

To successfully implement NCN services for out-of-network claims:

• The payor?s ID card should identify that the par and non-par provider claims be routed to HealthLink (EDI #90001) with the standard P.O. Box address in St. Louis. (An NCN logo is not placed on payor-produced ID cards).


• The payor's methodology for U & C (usual and customary cut-backs) should be reported to NCN in order to set the baseline for the savings reports (Examples: 85% HIAA or 80% Ingenix (percentile and source)).


• Verify the payor will pay the NCN claims at the ?out of network? benefit tier.


• HealthLink system is set with NCN in the network ?hierarchy?. Claims repriced using the HealthLink-NCN services will have specific repricing organization identifiers in the range of 90001 0059 to 90001 0152.


• NCN claims will be sent to the payors in the standard (not a separate) EDI file.


• Payors need to set their system to:
  • Read the special NCN repricing organization identifiers , sending the correct corresponding EOB remark code on their EOBs to providers; or suspend claims received with codes in that range, for manual intervention on the payor's part to enter the specific EOB remarks in the payor's system.
  • If the EOB doesn't reflect the correct NCN repricing comment (method of discounting), providers may not honor the discounts.


• The EOB remark code table is provided to payors with HealthLink-NCN access.


• The EOB remark codes are available in the Outbound EDI Companion Guide.


• In the early phases of this program, HealthLink will suspend the EDI claims, send them to NCN, and enter the claim repricing detail (allowables and NCN codes) into the HealthLink system; like affiliated network repricing. The EDI claim will be identified as ?par? by using 12 (PPO) in SBR09 .


• Payors (groups) will be billed for NCN services at a percentage of savings rate of 25% savings, with savings calculated from the baseline U & C. This monthly bill is separate from the access fee billing/payment process.

National Capital Preferred Provider Organization, Inc. ("NCPPO") is a Maryland corporation. HealthLink®, Inc., is an Illinois corporation. Both are organizers of independently contracted provider networks, which are made available by contract to a variety of payors of health benefits, including insurers, third party administrators or employers. Neither has control nor right of control over the professional, medical judgment of contracted providers, nor are they liable for any acts or failures to act, by contracted providers. Neither is an insurance company and neither has liability for benefits under benefit plans offered or administered by payors. HealthLink® is a registered trademark of HealthLink, Inc. Both companies are subsidiaries of WellPoint, Inc.