Non-Participating Providers. Any treatment or service from a Non-Participating Provider, except in the case of an emergency or when specifically pre-authorized by AvMed, including Hospital care from a non-participating Physician or a non-participating Hospital, if elected by a Member. In such circumstances, coverage is excluded for the entire episode of care, except when the admission was due to an emergency or with the prior written authorization of AvMed.
Non-Participating Providers. 1. The Contractor shall pay for services furnished by non-participating providers to whom an enrollee was referred, even if erroneously referred, by his/her PCP or network specialist. Under no circumstances shall the enrollee bear the cost of such services when referral errors by the Contractor or its providers occur. It is the sole responsibility of the Contractor to provide regular updates on complete network information to all its providers as well as appropriate policies and procedures for provider referrals.
Non-Participating Providers. 1. The Contractor shall be responsible for developing and advising its enrollees and where applicable, authorized persons of procedures for obtaining emergency services, including emergency dental services, when it is not medically feasible for enrollees to receive emergency services from or through a participating provider, or when the time required to reach the participating provider would mean risk of permanent damage to the enrollee's health. The Contractor shall bear the cost of providing emergency service through non- participating providers.
Non-Participating Providers. A) Payment by the Contractor for general hospital emergency department services provided to an Enrollee by a Non-Participating Provider shall be at the Medicaid fee-for-service rate, inclusive of the capital component, in effect on the date that the service was rendered without regard to whether such services meet the definition of Emergency Medical Condition.
Non-Participating Providers. The Contractor shall cooperate with non-participating family planning providers accessed at the enrollee's option by establishing cooperative working relationships with such providers for accepting referrals from them for continued medical care and management of complex health care needs and exchange of enrollee information, where appropriate, to assure provision of needed care within the scope of this contract. The Contractor shall not deny coverage of family planning services for a covered diagnostic, preventive or treatment service solely on the basis that the diagnosis was made by a non-participating provider.
Non-Participating Providers. Participating Provider acknowledges and agrees that a Member may not receive the maximum benefits under his/her Health Benefits Plan if he/she is referred or admitted to a non-Participating Provider. When a Referral is required:
Non-Participating Providers. It is understood that in some instances Participants will require specialty care not available from a Participating Provider and that the FIDA Plan will arrange that such items and services be provided by a Non- Participating Provider. In such event, the FIDA Plan will promptly negotiate an agreement (“Single Case Agreement”) with a Non-Participating Provider at the applicable Medicaid or Medicare Fee-For-Service rate to treat the Participant until a qualified Participating Provider is available. The FIDA Plan shall make best efforts to have any Non-Participating Provider billing for services be enrolled in the Medicare program or New York State Medicaid program, as appropriate and in the same manner as Participating Providers under Section 2.8.1.2, prior to paying a claim.
Non-Participating Providers. It is understood that in some instances Participants will require specialty care not available from a Participating Provider and that the FIDA-IDD Plan will arrange that such items and services be provided by a Non-Participating Provider. In such event, the FIDA-IDD Plan will promptly negotiate an agreement (“Single Case Agreement”) with a Non-Participating Provider at the applicable Medicaid or Medicare Fee-For-Service rate to treat the Participant until a qualified Participating Provider is available. The FIDA-IDD Plan shall make best efforts to have any Non- Participating Provider billing for services be enrolled in the Medicare program or New York State Medicaid program, as appropriate and in the same manner as Participating Providers under Section 2.8.1.2, prior to paying a claim.
Non-Participating Providers. Premier Provider. Payment for covered services performed for You by a Premier Provider is calculated based on the Allowed Amount. Premier Providers may balance bill for the difference between the Delta Dental Premier Contracted Fee and the Delta Dental PPO Contracted Fee. Our payment is send directly to the Premier Provider who submitted the claim. We will advise You of any charges not payable by us for which You are responsible. These charges are generally Your share of the Allowed Amount, as well as any Deductibles, charges where the maximum has been exceeded, charges for non-covered services and/or balance billing amounts over the Delta Dental PPO Contracted Fee. Non-Delta Dental Provider. Payment for services performed by a Non-Delta Dental Provider is calculated based on the Allowed Amount. Non-Delta Dental Providers have no agreement with Us and may bill You for any difference between what We pay and the Submitted Fee. When dental services are received from a Non-Delta Dental Provider, Delta Dental’s payment is sent directly to the Member. You are responsible for payment of the Non- Delta Dental Provider’s Submitted Fee. Non-Delta Dental Providers will bill You for their normal charges, which may be higher than the Allowed Amount for the service. You may be required to pay the Provider Yourself and then submit a claim to Us for reimbursement. Since Our payment for services You receive may be less than the Non- Delta Dental Provider’s actual charges, Your out-of-pocket cost may be significantly higher. We advise You of any charges not payable by Us for which You are responsible. These charges are generally Your share of the Allowed Amount, as well as any Deductibles, charges where the maximum has been exceeded and/or charges for non- covered services.
Non-Participating Providers. 1. The contractor shall follow CMS regulations with regard to the use of non- participating providers.
