---
title: Providers and Provider Networks Terminology
description: Explore provider network terminology, including in-network care, referrals, provider directories, and access, for interpreted member services calls.
---
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# Providers and Provider Networks Terminology
## A quick-reference glossary for interpreting conversations about finding providers, checking network participation, and arranging care.
Health plans may contract with specific professionals, facilities, pharmacies, and suppliers. Network participation and availability should be checked for the member’s exact plan, service, and location.
### Providers and roles
- Provider: A healthcare professional, facility, or organization delivering health services.
- Primary care provider (PCP): A professional who provides routine care and helps coordinate other services.
- Specialist: A healthcare professional focused on a particular clinical field, condition, or group of patients.
- Facility: A location or organization providing care, such as a hospital or outpatient center.
- Supplier: An individual or organization supplying equipment or other healthcare items.
- Referring provider: A professional requesting care or assessment from another provider.
### Network participation
- Provider network: The professionals, facilities, and suppliers contracted with a plan to deliver specified services.
- In-network provider: A provider contracted with the member’s particular plan network.
- Out-of-network provider: A provider not contracted with the member’s particular plan network.
- Participating provider: A provider participating under a stated contract or program; the precise meaning should be confirmed in context.
- Accepting new patients: Willing and able to register additional patients under the relevant practice and plan arrangements.
- Provider directory: A plan’s listing of providers and related details.
- Network status: A provider’s participation status for a specified plan and service.
- Network adequacy: Whether a plan’s network meets applicable access standards.
- Continuity of care: Arrangements supporting ongoing treatment during certain provider, plan, or care changes, subject to applicable rules.
### Plan structures and access
- Health Maintenance Organization (HMO): A plan type that generally requires use of its network for routine care, with exceptions under applicable rules.
- Preferred Provider Organization (PPO): A plan type generally allowing covered out-of-network care at different member costs and conditions.
- Referral: A provider’s direction or order for another service or specialist assessment, as required by the plan.
- Network exception: Permission under applicable rules to obtain specified care outside the usual network arrangements.
- Service location: The address or setting at which a provider delivers a service.
- Medicare assignment: A provider’s or supplier’s agreement, or obligation, to accept the Medicare-approved amount as full payment for a covered service, with applicable member cost sharing.
Network rules, referral requirements, and provider availability vary by plan and may change. A provider accepting Medicare or an insurer’s name does not automatically participate in every Medicare Advantage or other plan offered by that insurer. The plan and provider can confirm the exact participation and appointment arrangements.
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