POS

A Point of Service plan is a managed care plan that combines features of HMOs and PPOs, requiring a primary care referral for specialists but allowing out-of-network use at higher out-of-pocket costs.

A Point of Service plan combines features of both HMO and PPO plans. Members choose a primary care physician and need referrals for specialists (like an HMO), but they also have some coverage for out-of-network services at a higher cost (like a PPO). POS plans are less common than PPOs and HMOs but still exist in certain markets, particularly in employer-sponsored group plans. For credentialing purposes, POS plan enrollment is typically bundled with the payer's other products. When you credential with a payer that offers HMO, PPO, and POS plans, you may be enrolled in all three or you may need to specify which products you want to participate in. The practical difference for you as a provider is how the patient's benefits work. A POS member who comes to you through a PCP referral will be treated as in-network with standard in-network cost sharing. The same patient coming to you without a referral might face higher cost sharing, similar to out-of-network levels. If you are a specialist in a POS network, referral management matters. Make sure the referring PCP has submitted the referral authorization before the patient's visit, or the claim may be denied or paid at a lower rate.