International health insurance isn’t just about buying cover — it’s about knowing how to use it when you need treatment abroad. Direct billing and reimbursement work differently, and provider networks often determine whether a hospital will accept your membership card or ask for payment up front. This guide explains networks, cashless treatment, pre-authorisation and out-of-network claims so you can reduce the risk of costly surprises and focus on getting well.
Before treatment, make sure you have these essentials to hand:
- Your insurer’s contact details and emergency helpline saved on your phone, plus a written copy.
- Access to the insurer’s provider directory (or app) so you can check hospitals and clinics in your area.
- Your policy number and membership card (physical or digital) to present at the provider.
- Sufficient funds or available credit to cover any excess (deductible), co-payments or deposits.
- Copies of relevant medical notes or referral letters if you have ongoing conditions or planned treatment.
- Know your network: In-network hospitals have agreements with your insurer and may offer cashless treatment. Out-of-network providers usually require payment up front and can be more expensive.
- Direct billing isn’t universal: Direct billing typically works only where a provider has the right billing arrangement and your treatment meets the insurer’s requirements (often including pre-authorisation). Always check before you rely on it.
- Pre-authorisation matters: Admissions, surgery and other high-cost treatments often need approval in advance. Missing pre-authorisation can result in delays and may affect how much is paid.
- Reimbursement is still common: For many outpatient appointments — and for out-of-network care — you’ll pay first, then submit a claim with itemised invoices and receipts.
- Prepare before treatment: Use provider directories, call your insurer and speak to the hospital billing team to confirm network status, pre-authorisation and deposits. Get written confirmation and keep copies.
- Expect nuances: An excess and/or co-payments can still apply under direct billing. Not all services qualify, and telemedicine may have different billing rules. If you’re unsure, ask your insurer or broker.
What is a provider network?
A provider network is a group of doctors, hospitals and healthcare facilities that have agreements with your insurer to provide services at negotiated rates. When you use an in-network provider, they agree to the insurer’s standards and pricing terms. If you use an out-of-network provider, you may have to pay the full cost up front and then claim back from your insurer.
Understanding which hospitals are in your plan’s network matters because it can affect whether you can access cashless treatment and how much you may pay out of pocket.
- Network / in-network provider: a hospital, clinic or doctor with an agreement to treat members under the insurer’s terms, often including cashless options.
- Out-of-network provider: a provider without an agreement. They can set their own fees and usually require payment in full at the point of treatment.
- Direct billing: sometimes called direct settlement; the insurer pays the provider directly (you may still pay an excess and/or co-payment).
- Reimbursement: you pay up front and then submit a claim to be reimbursed for eligible costs.
- Pre-authorisation / pre-approval: the insurer’s advance approval for certain treatments (often admissions, surgery or other high-cost care), confirming that cover checks have been completed.
- Guarantee of payment (GOP): a written confirmation to the provider setting out what the insurer agrees to pay for a specific course of treatment.
- Excess (deductible), co-payment and co-insurance: the portion of the cost you pay under your policy. These can apply even when the provider bills the insurer directly.
- Reasonable and customary costs: the maximum amount the insurer will reimburse for a service based on typical charges in your region; you pay any shortfall.
- Membership card: your insurance card (physical or digital) used to confirm your cover and support billing arrangements at participating providers.
Large networks are often advertised as a selling point, but what matters most is whether there’s a suitable hospital near you that will accept your insurer’s billing process for the treatment you need. In practice, some hospitals offer direct billing for in-patient care but not for outpatient consultations — or only for certain procedures.
Before you rely on cashless treatment, check the provider directory (or app) and then confirm with both the insurer and the hospital billing team. Even within a network, hospitals may ask for a deposit or require forms to be signed.
Out-of-network providers usually won’t offer direct billing. In that case, you’ll typically pay in full and submit a claim. If the provider’s charges are higher than the insurer’s usual allowance for the area, you may be responsible for the difference.
Below is an abstract illustration of a global healthcare network to visualise how providers may connect across countries:
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Direct billing explained
Direct billing means the healthcare provider invoices your insurer directly for covered services. If everything is in place, you present your membership card, complete any required forms, and the insurer settles the provider’s bill. You may still need to pay an excess and/or co-payments, plus any non-covered items.
Direct billing is often used for planned admissions, surgery and higher-cost procedures, but it isn’t automatic. You typically need to confirm the provider is in network and follow any pre-authorisation requirements.
Why insurers use pre-authorisation
Pre-authorisation (sometimes called pre-approval or a treatment guarantee) is commonly required for admissions and major procedures. It allows the insurer to check eligibility under the policy, review clinical information where needed, and confirm billing arrangements. Without pre-authorisation, the provider may ask for a deposit and/or refuse direct billing, and it can affect how the claim is handled.
You develop symptoms or a clinician recommends treatment
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Check your policy and the provider directory for in-network options
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Contact your insurer for guidance and request pre-authorisation (if required)
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Provide any requested documents (e.g., diagnosis, estimate, provider contact details)
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The insurer reviews the request and may issue a guarantee of payment
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Present the guarantee (if issued) and your membership card at the hospital
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The hospital invoices the insurer directly; you pay any excess/co-payments
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The insurer and hospital settle the account in line with the policy terms.
Benefits of direct billing
You may not have to pay the full hospital bill at admission. That can reduce cash-flow pressure while you focus on treatment.
The provider submits invoices directly. You may still need to provide documents for pre-authorisation and keep records for your files.
Network pricing and insurer review can help manage costs, although exclusions, limits and co-payments can still apply.
Limitations and risks
- Network dependence: direct billing is usually limited to providers with the right agreement in place.
- Cost sharing still applies: you may still pay an excess, co-insurance or co-payments (and any excluded items), even when the insurer pays the provider.
- Cover limitations: direct billing applies only to services covered under your policy and within any limits or sub-limits.
- Provider practice varies: some hospitals may still request a deposit, particularly where pre-authorisation is incomplete or the scope of treatment changes.
Guarantee of payment (GOP)
A guarantee of payment is a written confirmation from your insurer setting out what they agree to pay for a specific treatment at a specific provider. It’s often requested for elective treatment and/or higher-cost care. Insurers typically ask for patient details, clinical information, the provider’s billing contact details and an estimate of costs before issuing a GOP. It’s usually treatment-specific, so if the procedure changes you may need an updated confirmation.
Reimbursement claims explained
Reimbursement is the traditional route: you pay the provider first and then submit a claim to recover eligible costs. This is common for routine outpatient appointments, for out-of-network providers, or where there isn’t time to arrange direct billing.
To help the claim progress smoothly, you’ll normally need clear documentation and to meet any policy time limits for claim submission.
Process
- Pay the provider: settle the bill and obtain an itemised invoice and receipt.
- Collect documents: ask for itemised invoices showing dates of service and a breakdown of charges. Keep proof of payment. For anything beyond a straightforward consultation, medical notes or a referral letter may help.
- Submit the claim: use the insurer’s portal/app (where available) or follow their email/post process. Include your policy details and all supporting documents.
- Assessment: the insurer reviews the claim against the policy terms and may request further information.
- Payment: if approved, the insurer reimburses eligible costs, less any excess and/or co-payments/coinsurance.
When reimbursement can make sense
Reimbursement is sometimes unavoidable (for example, where direct billing isn’t available), and some policyholders choose it to see a preferred clinician. If you expect to claim by reimbursement, it helps to plan for the up-front cost and to keep records organised from the outset.
Pros and cons of each method
| Method | When it works best | Typical requirements | Friction points | What can go wrong |
|---|---|---|---|---|
| Direct billing | Planned admissions, surgery and higher-cost diagnostics at participating (in-network) hospitals | Provider must accept the insurer’s billing; pre-authorisation (often); a guarantee of payment for some treatments; membership card | Obtaining approvals; coordinating with the hospital billing team; deposits; scope changes mid-treatment | Provider may not accept direct billing for your plan/treatment; some charges excluded; shortfalls where limits apply; delays if information is missing |
| Reimbursement | Outpatient appointments, smaller claims, and out-of-network treatment | You pay up front; itemised invoices/receipts; correct claim submission route; meet any time limits | Cash-flow impact; documentation requirements; claims follow-up | Claim reduced/declined if documents are incomplete; reimbursement limited to “reasonable and customary”; you may be liable for shortfalls |
The right approach depends on the treatment, where you are, and what your insurer can arrange. For higher-cost treatment, direct billing can reduce financial exposure, but it often requires planning. For routine care, reimbursement can be practical — as long as you’re prepared for the up-front cost and the claims process.
Checking hospital networks before treatment
One of the most effective ways to avoid billing surprises is to confirm network status before you attend. Use this step-by-step checklist:
- Check the provider directory: search by location and specialty and look for “direct billing”/cashless indicators where shown.
- Confirm the detail: a provider may be in network for one service line but not another (e.g., in-patient vs outpatient).
- Call the insurer: confirm network status for your plan, whether pre-authorisation is required, and whether a GOP is needed.
- Speak to the hospital billing team: confirm they will accept direct billing for your insurer and your treatment type, and ask where to send the GOP.
- Get it in writing: keep written confirmation and/or the GOP for your records and take a copy with you.
- Confirm the excess/co-payments: ask how these are collected and be ready to pay them if applicable.
- Reconfirm near the appointment: network arrangements can change, so recheck shortly before treatment.
Hello, I’m booked for [procedure] at [hospital] on [date]. My insurer is [insurer name] and my policy number is [number]. Please can you confirm whether this hospital is in your network for my plan and whether direct billing is available for this treatment?
Does this treatment require pre-authorisation? If so, what information do you need from my clinician, and can you arrange a guarantee of payment?
Are there any excesses or co-payments I should expect? If possible, please confirm these details in writing.
Using network cards and telemedicine
Keep your membership card with you. Many insurers provide a digital card in their app (for example, a QR code or downloadable PDF). Depending on the insurer and the provider, you may also see payment solutions such as virtual cards or pre-funded cards for approved treatment — but these arrangements vary, so it’s worth checking the process before you attend.
Telemedicine is now common in many international plans. It can be helpful when you need advice quickly, you’re unsure whether you need in-person care, or you want guidance on the right provider pathway. Whether telemedicine is billed cashlessly or on a reimbursement basis depends on the policy and the service.
When using apps and online portals, you may be sharing sensitive personal data. Data protection requirements vary by jurisdiction. As a general rule, use secure connections, share only what is necessary, and follow your insurer’s guidance on how to submit medical information.
Steps to handle out-of-network care
Sometimes you can’t use an in-network hospital — for example, in an emergency or where there’s no suitable network provider. In that situation you may still be covered, but you’ll often need to pay first and claim back. These steps can help reduce costs and minimise friction:
- Get medical help first: in an emergency, attend the nearest appropriate facility.
- Notify the insurer: contact the emergency helpline as soon as practical and ask whether they can support a guarantee of payment.
- Request a GOP if possible: provide patient details, clinical information and the hospital billing contact details, plus any cost estimate available.
- Expect a deposit: even with a GOP, some hospitals may ask for a deposit or part-payment. Ask whether any deposit is refundable once the insurer settles.
- Collect paperwork: itemised invoices, receipts, discharge notes and test results where relevant.
- Submit the claim promptly: follow the insurer’s process and include proof of payment.
- Follow up: monitor progress and respond quickly to requests for more information.
- Plan for shortfalls: out-of-network reimbursement may be limited, and you can be liable for the difference.
- Review next steps: for follow-up care, ask whether a network provider can take over where appropriate.
Get Started
Understanding how provider networks, direct billing and reimbursement work can make a real difference when you need treatment abroad. If you’d like personalised guidance, we can help you understand the process and the questions to ask.
Visit our Individuals & Families page to learn more about our advisory services. If you already have a policy and need help reviewing an ongoing case, see Already insured?. For quick answers to common questions, explore our FAQ. Ready to compare options? You can request a quote.
For further reading, see: Choosing the Right Insurer for International Health Insurance and IPMI Abroad: Getting Health Cover Right Before You Move.
Points to verify
Policy terms and network arrangements vary across insurers and countries. Before relying on direct billing or reimbursement, verify the following with your insurer:
- Services that qualify for direct billing: does direct settlement apply only to in-patient care, or also to outpatient, maternity and mental health? Any exclusions for drugs or specific procedures?
- Pre-authorisation requirements: which treatments require approval and how far in advance must you request it? What information is needed?
- Excess and co-payments: how are these collected under direct billing? Will the provider request a deposit at admission?
- Emergency rules: what counts as an emergency and how quickly must you notify the insurer?
- In-patient vs outpatient networks: confirm whether the provider offers direct billing for both, where relevant.
- Telemedicine billing: is telemedicine included and how is it billed? Are there limits on the number of consults?
- Claim documents and time limits: what documents are required for reimbursement (invoices, receipts, medical reports) and how long after treatment do you have to submit?
- Reasonable and customary limits: how are out-of-network reimbursements calculated, and can you be liable for shortfalls?
- Validity of pre-authorisation and GOPs: how long do approvals last, and what happens if dates or treatment details change?
- Network changes: providers can enter or leave networks — reconfirm status before each treatment.
Clarifying these points in advance will help you plan more confidently and reduce the risk of unexpected costs.
