Common use of Out of Network Reimbursement Rules Clause in Contracts

Out of Network Reimbursement Rules. For reimbursement of out-of- network emergent or Urgent Care services, as defined by 42 C.F.R. §§ 424.101 and 405.400 respectively, the Health Care Professional is required to accept as payment in full by the Contractor the amounts the Health Care Professional could collect for that service if the Beneficiary were enrolled in original Medicare or Medicaid FFS. However, the Contractor is not required to reimburse the Health Care Professional more than the Health Care Professional’s charge for that service. A section 1861(u) provider of services may be paid an amount that is less than the amount it could receive if the beneficiary were enrolled in original Medicare or Medicaid FFS if the provider expressly notifies the Contractor in writing that it is billing an amount less than such amount. The original Medicare reimbursement amounts for section 1861(u) providers do not include payments under 42 C.F.R. §§ 412.105(g) and 413.76. For items and services that would traditionally be covered under Medicare FFS, the ICDS Plan is required to pay non-contracting Health Care Professionals and section 1861(u) providers of services the amount that the provider could collect for that service if the Beneficiary were enrolled in original Medicare (less any payments under 42 C.F.R. §§ 412.105(g) and 413.76 for section 1861(u) providers). This requirement applies regardless of the setting and type of care for authorized out-of-network services. Beneficiaries maintain balance billing protections. Nothing in the preceding provision shall restrict the right of the provider and the Contractor to negotiate a lower rate of payment.

Out of Network Reimbursement Rules. For reimbursement of outout- of-of- network emergent Emergency or Urgent Care services, as defined by 42 C.F.R. §§ 424.101 and 405.400 respectively, the Health Care Professional is required to accept as payment in full by the Contractor ICDS Plan the amounts the Health Care Professional could collect for that service if the Beneficiary were enrolled in original Medicare or Medicaid FFS. However, the Contractor ICDS Plan is not required to reimburse the Health Care Professional more than the Health Care Professional’s charge for that service. A section 1861(u) provider of services may be paid an amount that is less than the amount it could receive if the beneficiary Beneficiary were enrolled in original Medicare or Medicaid FFS if the provider expressly notifies the Contractor ICDS Plan in writing that it is billing an amount less than such amount. The original Medicare reimbursement amounts for section 1861(u) providers do not include payments under 42 C.F.R. §§ 412.105(g) and 413.76. For items and services that would traditionally be covered under Medicare FFS, the ICDS Plan is required to pay non-contracting Health Care Professionals and section 1861(u) providers of services the amount that the provider could collect for that service if the Beneficiary were enrolled in original Medicare (less any payments under 42 C.F.R. §§ 412.105(g) and 413.76 for section 1861(u) providers). This requirement applies regardless of the setting and type of care for authorized out-of-network services. Beneficiaries maintain balance billing protections. Nothing in the preceding provision shall restrict the right of the provider and the Contractor ICDS Plan to negotiate a lower rate of payment.

Out of Network Reimbursement Rules. For reimbursement of out-of- of-network emergent Emergency or Urgent Care services, as defined by 42 C.F.R. §§ 424.101 and 405.400 respectively, the Health Care Professional is required to accept as payment in full by the Contractor ICDS Plan the amounts the Health Care Professional could collect for that service if the Beneficiary were enrolled in original Medicare or Medicaid FFS. However, the Contractor ICDS Plan is not required to reimburse the Health Care Professional more than the Health Care Professional’s charge for that service. A section 1861(u) provider of services may be paid an amount that is less than the amount it could receive if the beneficiary Beneficiary were enrolled in original Medicare or Medicaid FFS if the provider expressly notifies the Contractor ICDS Plan in writing that it is billing an amount less than such amount. The original Medicare reimbursement amounts for section 1861(u) providers do not include payments under 42 C.F.R. §§ 412.105(g) and 413.76. For items and services that would traditionally be covered under Medicare FFS, the ICDS Plan is required to pay non-contracting Health Care Professionals and section 1861(u) providers of services the amount that the provider could collect for that service if the Beneficiary were enrolled in original Medicare (less any payments under 42 C.F.R. §§ 412.105(g) and 413.76 for section 1861(u) providers). This requirement applies regardless of the setting and type of care for authorized out-of-network services. Beneficiaries maintain balance billing protections. Nothing in the preceding provision shall restrict the right of the provider and the Contractor ICDS Plan to negotiate a lower rate of payment.