Common use of Member Payment Liability Clause in Contracts

Member Payment Liability. In accordance with 42 CFR 438.106, which relates to liability for payment, the Contractor and its subcontractors shall provide that members are not held liable for any of the following:  Any payments for covered services furnished under a contract, referral or other arrangement, to the extent that those payments are in excess of the amount that the member would owe if the Contractor provided the services directly;  Covered services provided to the member for which OMPP does not pay the Contractor;  Covered services provided to the member for which OMPP or the Contractor does not pay the provider that furnishes the services under a contractual, referral or other arrangement; and  The Contractor’s debts or subcontractor’s debts, in the event of the entity’s insolvency. The Contractor shall ensure that its providers do not balance xxxx its members, i.e., charge the member for covered services above the amount paid to the provider by the Contractor. If the Contractor is aware that an out-of-network, non-IHCP provider, such as an out-of- state emergency services provider, is balance billing a member, the Contractor shall instruct the provider to stop billing the member and to enroll in the IHCP in order to receive reimbursement from the Contractor. The Contractor shall also contact the member to help resolve issues related to the billing. IHCP providers are prohibited from charging a member, or the family of the member, for any amount not paid as billed for a covered IHCP service. Provider acceptance of payment from the Contractor as payment in full is a condition of participation in the IHCP. An IHCP provider can xxxx a member only when the following conditions have been met:  The service rendered must be determined to be non-covered by the IHCP;  The member has exceeded the program limitations for a particular service;  The member must understand, before receiving the service, that the service is not covered under the IHCP, and that the member is responsible for the charges associated with the service; and  The provider must maintain documentation that the member voluntarily chose to receive the service, knowing that the IHCP did not cover the service. A generic consent form is not acceptable unless it identifies the specific procedure to be performed, and the member signs the consent before receiving the service. See the IHCP Provider Manual for more information. In cases where prior authorization is denied, a provider can xxxx a member for covered services if certain safeguards are in place and followed by the provider. The Contractor shall establish, communicate and monitor compliance with these procedures, which shall include at least the following:  The provider must establish that authorization has been requested and denied prior to rendering the service;  The provider has an opportunity to request review of the authorization decision by the Contractor. The Contractor must inform providers of the contact person, the means for contact, the information required to complete the review and the procedures for expedited review if necessary;  If the Contractor maintains the decision to deny authorization, the provider must inform the member that the service requires authorization, and that authorization has been denied—if the provider is an out-of-network provider, the provider must also explain that covered services may be available without cost in-network if authorization is provided;  The member must be informed of the right to contact the Contractor to file an appeal if the member disagrees with the decision to deny authorization;  The provider must inform the member of member responsibility for payment if the member chooses to or insists on receiving the services without authorization;  If the provider chooses to use a waiver to establish member responsibility for payment, use of such a waiver shall meet the following requirements:  The waiver is signed only after the member receives the appropriate notification.  The waiver does not contain any language or condition to the effect that if authorization is denied, the member is responsible for payment.  Providers must not use non-specific patient waivers. A waiver must be obtained for each encounter or patient visit that falls under the scenario of non-covered services.  The waiver must specify the date the services are provided and the services that fall under the waiver’s application.  The provider must have the right to appeal any denial of payment by the Contractor for denial of authorization.

Member Payment Liability. In accordance with 42 CFR 438.106, which relates to liability for payment, the Contractor and its subcontractors shall provide that members are not held liable for any of the following:  Any payments for covered services furnished under a contract, referral or other arrangement, to the extent that those payments are in excess of the amount that the member would owe if the Contractor provided the services directly;  Covered services provided to the member for which OMPP does not pay the Contractor;  Covered services provided to the member for which OMPP or the Contractor does not pay the provider that furnishes the services under a contractual, referral or other arrangement; and  The Contractor’s debts or subcontractor’s debts, in the event of the entity’s insolvency. The Contractor shall ensure that its providers do not balance xxxx its members, i.e., charge the member for covered services above the amount paid to the provider by the Contractor. If the Contractor is aware that an out-of-network, non-IHCP provider, such as an out-of- of-state emergency services provider, is balance billing a member, the Contractor shall instruct the provider to stop billing the member and to enroll in the IHCP in order to receive reimbursement from the Contractor. The Contractor shall also contact the member to help resolve issues related to the billing. IHCP providers are prohibited from charging a member, or the family of the member, for any amount not paid as billed for a covered IHCP service. Provider acceptance of payment from the Contractor as payment in full is a condition of participation in the IHCP. An IHCP provider can xxxx a member only when the following conditions have been met:  The service rendered must be determined to be non-covered by the IHCP;  The member has exceeded the program limitations for a particular service;  The member must understand, before receiving the service, that the service is not covered under the IHCP, and that the member is responsible for the charges associated with the service; and  The provider must maintain documentation that the member voluntarily chose to receive the service, knowing that the IHCP did not cover the service. A generic consent form is not acceptable unless it identifies the specific procedure to be performed, and the member signs the consent before receiving the service. See the IHCP Provider Manual for more information. In cases where prior authorization is denied, a provider can xxxx a member for covered services if certain safeguards are in place and followed by the provider. The Contractor shall establish, communicate and monitor compliance with these procedures, which shall include at least the following:  The provider must establish that authorization has been requested and denied prior to rendering the service;  The provider has an opportunity to request review of the authorization decision by the Contractor. The Contractor must inform providers of the contact person, the means for contact, the information required to complete the review and the procedures for expedited review if necessary;  If the Contractor maintains the decision to deny authorization, the provider must inform the member that the service requires authorization, and that authorization has been denied—if the provider is an out-of-network provider, the provider must also explain that covered services may be available without cost in-network if authorization is provided;  The member must be informed of the right to contact the Contractor to file an appeal if the member disagrees with the decision to deny authorization;  The provider must inform the member of member responsibility for payment if the member chooses to or insists on receiving the services without authorization;  If the provider chooses to use a waiver to establish member responsibility for payment, use of such a waiver shall meet the following requirements:  The waiver is signed only after the member receives the appropriate notification.  The waiver does not contain any language or condition to the effect that if authorization is denied, the member is responsible for payment.  Providers must not use non-specific patient waivers. A waiver must be obtained for each encounter or patient visit that falls under the scenario of non-covered services.  The waiver must specify the date the services are provided and the services that fall under the waiver’s application.  The provider must have the right to appeal any denial of payment by the Contractor for denial of authorization.

Member Payment Liability. In accordance with 42 CFR 438.106, which relates to liability for payment, the Contractor and its subcontractors shall provide that members are not held liable for any of the following:  ▪ Any payments for covered services furnished under a contract, referral or other arrangement, to the extent that those payments are in excess of the amount that the member would owe if the Contractor provided the services directly;  ▪ Covered services provided to the member for which OMPP does not pay the Contractor;  ▪ Covered services provided to the member for which OMPP or the Contractor does not pay the provider that furnishes the services under a contractual, referral or other arrangement; and  ▪ The Contractor’s debts or subcontractor’s debts, in the event of the entity’s insolvency. The Contractor shall ensure that its providers do not balance xxxx its members, i.e., charge the member for covered services above the amount paid to the provider by the Contractor. If the Contractor is aware that an out-of-network, non-IHCP provider, such as an out-of- of-state emergency services provider, is balance billing a member, the Contractor shall instruct the provider to stop billing the member and to enroll in the IHCP in order to receive reimbursement from the Contractor. The Contractor shall also contact the member to help resolve issues related to the billing. IHCP providers are prohibited from charging a member, or the family of the member, for any amount not paid as billed for a covered IHCP service. Provider acceptance of payment from the Contractor as payment in full is a condition of participation in the IHCP. An IHCP provider can xxxx a member only when the following conditions have been met:  ▪ The service rendered must be determined to be non-covered by the IHCP;  ▪ The member has exceeded the program limitations for a particular service;  ▪ The member must understand, before receiving the service, that the service is not covered under the IHCP, and that the member is responsible for the charges associated with the service; and  ▪ The provider must maintain documentation that the member voluntarily chose to receive the service, knowing that the IHCP did not cover the service. A generic consent form is not acceptable unless it identifies the specific procedure to be performed, and the member signs the consent before receiving the service. See the IHCP Provider Manual for more information. In cases where prior authorization is denied, a provider can xxxx a member for covered services if certain safeguards are in place and followed by the provider. The Contractor shall establish, communicate and monitor compliance with these procedures, which shall include at least the following:  ▪ The provider must establish that authorization has been requested and denied prior to rendering the service;  ▪ The provider has an opportunity to request review of the authorization decision by the Contractor. The Contractor must inform providers of the contact person, the means for contact, the information required to complete the review and the procedures for expedited review if necessary;  ▪ If the Contractor maintains the decision to deny authorization, the provider must inform the member that the service requires authorization, and that authorization has been denied—if the provider is an out-of-network provider, the provider must also explain that covered services may be available without cost in-network if authorization is provided;  ▪ The member must be informed of the right to contact the Contractor to file an appeal if the member disagrees with the decision to deny authorization;  ▪ The provider must inform the member of member responsibility for payment if the member chooses to or insists on receiving the services without authorization;  ▪ If the provider chooses to use a waiver to establish member responsibility for payment, use of such a waiver shall meet the following requirements:  • The waiver is signed only after the member receives the appropriate notification.  • The waiver does not contain any language or condition to the effect that if authorization is denied, the member is responsible for payment.  • Providers must not use non-specific patient waivers. A waiver must be obtained for each encounter or patient visit that falls under the scenario of non-covered services.  • The waiver must specify the date the services are provided and the services that fall under the waiver’s application.  ▪ The provider must have the right to appeal any denial of payment by the Contractor for denial of authorization.

Member Payment Liability. In accordance with 42 CFR 438.106, which relates to liability for payment, the Contractor and its subcontractors shall provide that members are not held liable for any of the following:  ▪ Any payments for covered services furnished under a contract, referral or other arrangement, to the extent that those payments are in excess of the amount that the member would owe if the Contractor provided the services directly;  ▪ Covered services provided to the member for which OMPP does not pay the Contractor;  ▪ Covered services provided to the member for which OMPP or the Contractor does not pay the provider that furnishes the services under a contractual, referral or other arrangement; and  ▪ The Contractor’s debts or subcontractor’s debts, in the event of the entity’s insolvency. The Contractor shall ensure that its providers do not balance xxxx its members, i.e., charge the member for covered services above the amount paid to the provider by the Contractor. If the Contractor is aware that an out-of-network, non-IHCP provider, such as an out-of- of-state emergency services provider, is balance billing a member, the Contractor shall instruct the provider to stop billing the member and to enroll in the IHCP in order to receive reimbursement from the Contractor. The Contractor shall also contact the member to help resolve issues related to the billing. IHCP providers are prohibited from charging a member, or the family of the member, for any amount not paid as billed for a covered IHCP service. Provider acceptance of payment from the Contractor as payment in full is a condition of participation in the IHCP. An IHCP provider can xxxx a member only when the following conditions have been met:  ▪ The service rendered must be determined to be non-covered by the IHCP;  ▪ The member has exceeded the program limitations for a particular service;  ▪ The member must understand, before receiving the service, that the service is not covered under the IHCP, and that the member is responsible for the charges associated with the service; and  ▪ The provider must maintain documentation that the member voluntarily chose to receive the service, knowing that the IHCP did not cover the service. A generic consent form is not acceptable unless it identifies the specific procedure to be performed, and the member signs the consent before receiving the service. See the IHCP Provider Manual for more information. In cases where prior authorization is denied, a provider can xxxx a member for covered services if certain safeguards are in place and followed by the provider. The Contractor shall establish, communicate and monitor compliance with these procedures, which shall include at least the following:  The provider must establish that authorization has been requested and denied prior to rendering the service;  The provider has an opportunity to request review of the authorization decision by the Contractor. The Contractor must inform providers of the contact person, the means for contact, the information required to complete the review and the procedures for expedited review if necessary;  If the Contractor maintains the decision to deny authorization, the provider must inform the member that the service requires authorization, and that authorization has been denied—if the provider is an out-of-network provider, the provider must also explain that covered services may be available without cost in-network if authorization is provided;  The member must be informed of the right to contact the Contractor to file an appeal if the member disagrees with the decision to deny authorization;  The provider must inform the member of member responsibility for payment if the member chooses to or insists on receiving the services without authorization;  If the provider chooses to use a waiver to establish member responsibility for payment, use of such a waiver shall meet the following requirements:  The waiver is signed only after the member receives the appropriate notification.  The waiver does not contain any language or condition to the effect that if authorization is denied, the member is responsible for payment.  Providers must not use non-specific patient waivers. A waiver must be obtained for each encounter or patient visit that falls under the scenario of non-covered services.  The waiver must specify the date the services are provided and the services that fall under the waiver’s application.  The provider must have the right to appeal any denial of payment by the Contractor for denial of authorization.

Member Payment Liability. In accordance with 42 CFR 438.106, which relates to liability for payment, the Contractor and its subcontractors shall provide that members are not held liable for any of the following:  ▪ Any payments for covered services furnished under a contract, referral or other arrangement, to the extent that those payments are in excess of the amount that the member would owe if the Contractor provided the services directly;  ▪ Covered services provided to the member for which OMPP does not pay the Contractor;  ▪ Covered services provided to the member for which OMPP or the Contractor does not pay the provider that furnishes the services under a contractual, referral or other arrangement; and  ▪ The Contractor’s debts or subcontractor’s debts, in the event of the entity’s insolvency. The Contractor shall ensure that its providers do not balance xxxx its members, i.e., charge the member for covered services above the amount paid to the provider by the Contractor. If the Contractor is aware that an out-of-network, non-IHCP provider, such as an out-of- of-state emergency services provider, is balance billing a member, the Contractor shall instruct the provider to stop billing the member and to enroll in the IHCP in order to receive reimbursement from the Contractor. The Contractor shall also contact the member to help resolve issues related to the billingbil ling. IHCP providers are prohibited from charging a member, or the family of the member, for any amount not paid as billed for a covered IHCP service. Provider acceptance of payment from the Contractor as payment in full is a condition of participation in the IHCP. An IHCP provider can xxxx a member only when the following conditions have been met:  ▪ The service rendered must be determined to be non-covered by the IHCP;  ▪ The member has exceeded the program limitations for a particular service;  ▪ The member must understand, before receiving the service, that the service is not covered under the IHCP, and that the member is responsible for the charges associated with the service; and  ▪ The provider must maintain documentation that the member voluntarily chose to receive the service, knowing that the IHCP did not cover the service. A generic consent form is not acceptable unless it identifies the specific procedure to be performed, and the member signs the consent before receiving the service. See the IHCP Provider Manual for more information. In cases where prior authorization is denied, a provider can xxxx a member for covered services if certain safeguards are in place and followed by the provider. The Contractor shall establish, communicate and monitor compliance with these procedures, which shall include at least the following:  The provider must establish that authorization has been requested and denied prior to rendering the service;  The provider has an opportunity to request review of the authorization decision by the Contractor. The Contractor must inform providers of the contact person, the means for contact, the information required to complete the review and the procedures for expedited review if necessary;  If the Contractor maintains the decision to deny authorization, the provider must inform the member that the service requires authorization, and that authorization has been denied—if the provider is an out-of-network provider, the provider must also explain that covered services may be available without cost in-network if authorization is provided;  The member must be informed of the right to contact the Contractor to file an appeal if the member disagrees with the decision to deny authorization;  The provider must inform the member of member responsibility for payment if the member chooses to or insists on receiving the services without authorization;  If the provider chooses to use a waiver to establish member responsibility for payment, use of such a waiver shall meet the following requirements:  The waiver is signed only after the member receives the appropriate notification.  The waiver does not contain any language or condition to the effect that if authorization is denied, the member is responsible for payment.  Providers must not use non-specific patient waivers. A waiver must be obtained for each encounter or patient visit that falls under the scenario of non-covered services.  The waiver must specify the date the services are provided and the services that fall under the waiver’s application.  The provider must have the right to appeal any denial of payment by the Contractor for denial of authorization.

Member Payment Liability. In accordance with 42 CFR 438.106, which relates to liability for payment, the Contractor and its subcontractors shall provide that members are not held liable for any of the following:  • Any payments for covered services furnished under a contract, referral or other arrangement, to the extent that those payments are in excess of the amount that the member would owe if the Contractor provided the services directly;   Covered services provided to the member for which OMPP does not pay the Contractor;  • Covered services provided to the member for which OMPP or the Contractor does not pay the provider that furnishes the services under a contractual, referral or other arrangement; and   The Contractor’s debts or subcontractor’s debts, in the event of the entity’s insolvency. The Contractor shall ensure that its providers do not balance xxxx its members, i.e., charge the member for covered services above the amount paid to the provider by the Contractor. If the Contractor is aware that an out-of-network, non-IHCP provider, such as an out-of- of-state emergency services provider, is balance billing a member, the Contractor shall instruct the provider to stop billing the member and to enroll in the IHCP in order to receive reimbursement from the Contractor. The Contractor shall also contact the member to help resolve issues related to the billing. IHCP providers are prohibited from charging a member, or the family of the member, for any amount not paid as billed for a covered IHCP service. Provider acceptance of payment from the Contractor as payment in full is a condition of participation in the IHCP. An IHCP provider can xxxx a member only when the following conditions have been met:   The service rendered must be determined to be non-covered by the IHCP;   The member has exceeded the program limitations for a particular service;   The member must understand, before receiving the service, that the service is not covered under the IHCP, and that the member is responsible for the charges associated with the service; and   The provider must maintain documentation that the member voluntarily chose to receive the service, knowing that the IHCP did not cover the service. A generic consent form is not acceptable unless it identifies the specific procedure to be performed, and the member signs the consent before receiving the service. See the IHCP Provider Manual for more information. In cases where prior authorization is denied, a provider can xxxx a member for covered services if certain safeguards are in place and followed by the provider. The Contractor shall establish, communicate and monitor compliance with these procedures, which shall include at least the following:   The provider must establish that authorization has been requested and denied prior to rendering the service;   The provider has an opportunity to request review of the authorization decision by the Contractor. The Contractor must inform providers of the contact person, the means for contact, the information required to complete the review and the procedures for expedited review if necessary;   If the Contractor maintains the decision to deny authorization, the provider must inform the member that the service requires authorization, and that authorization has been denied—if the provider is an out-of-network provider, the provider must also explain that covered services may be available without cost in-network if authorization is provided;   The member must be informed of the right to contact the Contractor to file an appeal if the member disagrees with the decision to deny authorization;   The provider must inform the member of member responsibility for payment if the member chooses to or insists on receiving the services without authorization;   If the provider chooses to use a waiver to establish member responsibility for payment, use of such a waiver shall meet the following requirements:  o The waiver is signed only after the member receives the appropriate notification.  o The waiver does not contain any language or condition to the effect that if authorization is denied, the member is responsible for payment.  o Providers must not use non-specific patient waivers. A waiver must be obtained for each encounter or patient visit that falls under the scenario of non-covered services.  o The waiver must specify the date the services are provided and the services that fall under the waiver’s application.   The provider must have the right to appeal any denial of payment by the Contractor for denial of authorization.

Member Payment Liability. In accordance with 42 CFR 438.106, which relates to liability for payment, the Contractor and its subcontractors shall provide that members are not held liable for any of the following:  • Any payments for covered services furnished under a contract, referral or other arrangement, to the extent that those payments are in excess of the amount that the member would owe if the Contractor provided the services directly;   Covered services provided to the member for which OMPP does not pay the Contractor;  • Covered services provided to the member for which OMPP or the Contractor does not pay the provider that furnishes the services under a contractual, referral or other arrangement; and   The Contractor’s debts or subcontractor’s debts, in the event of the entity’s insolvency. The Contractor shall ensure that its providers do not balance xxxx its members, i.e., charge the member for covered services above the amount paid to the provider by the Contractor. If the Contractor is aware that an out-of-network, non-IHCP provider, such as an out-of- of-state emergency services provider, is balance billing a member, the Contractor shall instruct the provider to stop billing the member and to enroll in the IHCP in order to receive reimbursement from the Contractor. The Contractor shall also contact the member to help resolve issues related to the billing. IHCP providers are prohibited from charging a member, or the family of the member, for any amount not paid as billed for a covered IHCP service. Provider acceptance of payment from the Contractor as payment in full is a condition of participation in the IHCP. An IHCP provider can xxxx a member only when the following conditions have been met:   The service rendered must be determined to be non-covered by the IHCP;   The member has exceeded the program limitations for a particular service;   The member must understand, before receiving the service, that the service is not covered under the IHCP, and that the member is responsible for the charges associated with the service; and   The provider must maintain documentation that the member voluntarily chose to receive the service, knowing that the IHCP did not cover the service. A generic consent form is not acceptable unless it identifies the specific procedure to be performed, and the member signs the consent before receiving the service. See the IHCP Provider Manual for more information. In cases where prior authorization is denied, a provider can xxxx a member for covered services if certain safeguards are in place and followed by the provider. The Contractor shall establish, communicate and monitor compliance with these procedures, which shall include at least the following:   The provider must establish that authorization has been requested and denied prior to rendering the service;   The provider has an opportunity to request review of the authorization decision by the Contractor. The Contractor must inform providers of the contact person, the means for contact, the information required to complete the review and the procedures for expedited review if necessary;   If the Contractor maintains the decision to deny authorization, the provider must inform the member that the service requires authorization, and that authorization has been denied—if the provider is an out-of-network provider, the provider must also explain that covered services may be available without cost in-network if authorization is provided;   The member must be informed of the right to contact the Contractor to file an appeal if the member disagrees with the decision to deny authorization;   The provider must inform the member of member responsibility for payment if the member chooses to or insists on receiving the services without authorization;   If the provider chooses to use a waiver to establish member responsibility for payment, use of such a waiver shall meet the following requirements:  o The waiver is signed only after the member receives the appropriate notification.  o The waiver does not contain any language or condition to the effect that if authorization is denied, the member is responsible for payment.  o Providers must not use non-specific patient waivers. A waiver must be obtained for each encounter or patient visit that falls under the scenario of non-covered services.  o The waiver must specify the date the services are provided and the services that fall under the waiver’s application.   The provider must have the right to appeal any denial of payment by the Contractor for denial of authorization. This section should not be interpreted as interfering with a provider’s ability to hold HIP members liable for the emergency services co-payment or HIP Basic or HIP State Plan Basic member liability for allowable copayment amounts set forth in Section 4.1.2. Further, this section should not be interpreted as preventing payment of covered services with POWER Account funds before the member’s deductible has been met. However, if the Contractor permits providers to xxxx members for services that require authorization, but for which authorization is denied, as outlined above, POWER Account funds shall not be used to reimburse the provider for the non-covered service.

Member Payment Liability. In accordance with 42 CFR 438.106, which relates to liability for payment, the Contractor and its subcontractors shall provide that members are not held liable for any of the following:  ▪ Any payments for covered services furnished under a contract, referral or other arrangement, to the extent that those payments are in excess of the amount that the member would owe if the Contractor provided the services directly;  ▪ Covered services provided to the member for which OMPP does not pay the Contractor;  ▪ Covered services provided to the member for which OMPP or the Contractor does not pay the provider that furnishes the services under a contractual, referral or other arrangement; and  ▪ The Contractor’s debts or subcontractor’s debts, in the event of the entity’s insolvency. The Contractor shall ensure that its providers do not balance xxxx its members, i.e., charge the member for covered services above the amount paid to the provider by the Contractor. If the Contractor is aware that an out-of-network, non-IHCP provider, such as an out-of- of-state emergency services provider, is balance billing a member, the Contractor shall instruct the provider to stop billing the member and to enroll in the IHCP in order to receive reimbursement from the Contractor. The Contractor shall also contact the member to help resolve issues related to the billing. IHCP providers are prohibited from charging a member, or the family of the member, for any amount not paid as billed for a covered IHCP service. Provider acceptance of payment from the Contractor as payment in full is a condition of participation in the IHCP. An IHCP provider can xxxx a member only when the following conditions have been met:  ▪ The service rendered must be determined to be non-covered by the IHCP;  ▪ The member has exceeded the program limitations for a particular service;  ▪ The member must understand, before receiving the service, that the service is not covered under the IHCP, and that the member is responsible for the charges associated with the service; and  The provider must maintain documentation that the member voluntarily chose to receive the service, knowing that the IHCP did not cover the service. A generic consent form is not acceptable unless it identifies the specific procedure to be performed, and the member signs the consent before receiving the service. See the IHCP Provider Manual for more information. In cases where prior authorization is denied, a provider can xxxx a member for covered services if certain safeguards are in place and followed by the provider. The Contractor shall establish, communicate and monitor compliance with these procedures, which shall include at least the following:  The provider must establish that authorization has been requested and denied prior to rendering the service;  The provider has an opportunity to request review of the authorization decision by the Contractor. The Contractor must inform providers of the contact person, the means for contact, the information required to complete the review and the procedures for expedited review if necessary;  If the Contractor maintains the decision to deny authorization, the provider must inform the member that the service requires authorization, and that authorization has been denied—if the provider is an out-of-network provider, the provider must also explain that covered services may be available without cost in-network if authorization is provided;  The member must be informed of the right to contact the Contractor to file an appeal if the member disagrees with the decision to deny authorization;  The provider must inform the member of member responsibility for payment if the member chooses to or insists on receiving the services without authorization;  If the provider chooses to use a waiver to establish member responsibility for payment, use of such a waiver shall meet the following requirements:  The waiver is signed only after the member receives the appropriate notification.  The waiver does not contain any language or condition to the effect that if authorization is denied, the member is responsible for payment.  Providers must not use non-specific patient waivers. A waiver must be obtained for each encounter or patient visit that falls under the scenario of non-covered services.  The waiver must specify the date the services are provided and the services that fall under the waiver’s application.  The provider must have the right to appeal any denial of payment by the Contractor for denial of authorization.and

Member Payment Liability. In accordance with 42 CFR 438.106, which relates to liability for payment, the Contractor and its subcontractors shall provide that members are not held liable for any of the following:  ▪ Any payments for covered services furnished under a contract, referral or other arrangement, to the extent that those payments are in excess of the amount that the member would owe if the Contractor provided the services directly;  ▪ Covered services provided to the member for which OMPP does not pay the Contractor;  ▪ Covered services provided to the member for which OMPP or the Contractor does not pay the provider that furnishes the services under a contractual, referral or other arrangement; and  ▪ The Contractor’s debts or subcontractor’s debts, in the event of the entity’s insolvency. The Contractor shall ensure that its providers do not balance xxxx bill its members, i.e., charge the member for covered services above the amount paid to the provider by the Contractor. If the Contractor is aware that an out-of-network, non-IHCP provider, such as an out-of- of-state emergency services provider, is balance billing a member, the Contractor shall instruct the provider to stop billing the member and to enroll in the IHCP in order to receive reimbursement from the Contractor. The Contractor shall also contact the member to help resolve issues related to the billingbil ling. IHCP providers are prohibited from charging a member, or the family of the member, for any amount not paid as billed for a covered IHCP service. Provider acceptance of payment from the Contractor as payment in full is a condition of participation in the IHCP. An IHCP provider can xxxx bill a member only when the following conditions have been met:  ▪ The service rendered must be determined to be non-covered by the IHCP;  ▪ The member has exceeded the program limitations for a particular service;  ▪ The member must understand, before receiving the service, that the service is not covered under the IHCP, and that the member is responsible for the charges associated with the service; and  ▪ The provider must maintain documentation that the member voluntarily chose to receive the service, knowing that the IHCP did not cover the service. A generic consent form is not acceptable unless it identifies the specific procedure to be performed, and the member signs the consent before receiving the service. See the IHCP Provider Manual for more information. In cases where prior authorization is denied, a provider can xxxx a member for covered services if certain safeguards are in place and followed by the provider. The Contractor shall establish, communicate and monitor compliance with these procedures, which shall include at least the following:  The provider must establish that authorization has been requested and denied prior to rendering the service;  The provider has an opportunity to request review of the authorization decision by the Contractor. The Contractor must inform providers of the contact person, the means for contact, the information required to complete the review and the procedures for expedited review if necessary;  If the Contractor maintains the decision to deny authorization, the provider must inform the member that the service requires authorization, and that authorization has been denied—if the provider is an out-of-network provider, the provider must also explain that covered services may be available without cost in-network if authorization is provided;  The member must be informed of the right to contact the Contractor to file an appeal if the member disagrees with the decision to deny authorization;  The provider must inform the member of member responsibility for payment if the member chooses to or insists on receiving the services without authorization;  If the provider chooses to use a waiver to establish member responsibility for payment, use of such a waiver shall meet the following requirements:  The waiver is signed only after the member receives the appropriate notification.  The waiver does not contain any language or condition to the effect that if authorization is denied, the member is responsible for payment.  Providers must not use non-specific patient waivers. A waiver must be obtained for each encounter or patient visit that falls under the scenario of non-covered services.  The waiver must specify the date the services are provided and the services that fall under the waiver’s application.  The provider must have the right to appeal any denial of payment by the Contractor for denial of authorization.