Non-Participating Health Care Provider definition

Non-Participating Health Care Provider means any health care provider who did not have a valid written contract with the Company to provide Covered Services or Supplies to Plan Members when the health care provider provided Covered Services or Supplies to a Plan Member. For each Provider Class Member and Provider Class Representative, the Released Claims only include claims that arose while each of those Provider Class Members and Provider Class Representatives was an “Out- Of-Network Health Care Provider” (or “Non-Participating Health Care Provider”) or an “Out- Of-Network Health Care Provider Group” (or “Non-Participating Health Care Provider Group”). Without limiting the foregoing, “provider” includes any and all of the following: physician, podiatrist, chiropractor, orthodontist, psychologist, psychiatrist, physical or occupational therapist, acupuncturist, laboratory technician, optometrist, social worker, physician assistant, nurse, midwife, nurse practitioner, nurse anesthetist, nutritionist, orthotist, prosthetist, audiologist, dentist, dental hygienist, oral surgeon, counselor, therapist, durable medical equipment provider, laboratory, pharmacist, pharmacy, respiratory therapist, surgical assistant, speech or hearing specialist, or speech pathologist.
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Non-Participating Health Care Provider. Group”) means a corporation, partnership, or other distinct legal entity that did not have a valid written contract with the Company to provide Covered Services or Supplies to Plan Members when it provided or billed for Covered Services or Supplies to a Plan Member. An Out-Of-Network Facility shall also be considered an Out-Of-Network Health Care Provider Group under this Agreement, but only to the extent that: (a) the bills were submitted by the Out-Of-Network Facility for Covered Services or Supplies provided by an Out-Of-Network Health Care Provider; or (b) (i) the Allowed Amount for the Out-of-Network Facility’s fees or charges for specific Covered Services or Supplies was based on the Ingenix Databases and (ii) those Covered Services or Supplies were provided to a Plan Member whose Plan was sitused or based in the State of New Jersey.
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Examples of Non-Participating Health Care Provider in a sentence

  • Except as otherwise authorized by CareFirst, if a Member chooses a Non-Participating Health Care Provider, Covered Services may be eligible for reduced benefits.

  • When Covered Services are provided by a Non-Participating Health Care Provider, out-of- network benefits apply.

  • All benefits for Covered Services will be payable to the Subscriber, or to the Non-Participating Health Care Provider, at the discretion of CareFirst.

  • In the case of a Dependent child enrolled pursuant to a court order, court approved requirement, or a QMSO, payment will be paid directly to the State of Maryland Department of Health or the non-insuring parent if proof is provided that such parent has paid the Non-Participating Health Care Provider.

  • The Member is responsible for ensuring a Non-Participating Health Care Provider obtains Hospital Pre- Certification and Review, both in and out of the Service Area.

  • If a Member chooses an In-Network Health Care Provider, the cost to the Member is lower than if the Member chooses an Out-of-Network Participating Health Care Provider or a Non-Participating Health Care Provider.

  • Non-Participating Health Care Provider means a Health Care Provider that does not contract with CareFirst.

  • Non-Participating Health Care Providers‌If a Member receives Covered Services from a Non-Participating Health Care Provider (health care providers who are not contracted with Sanford Health Plan), the Member will be responsible for notifying Sanford Health Plan of the receipt of services.

  • In the case of a Dependent child enrolled pursuant to a court order, court approved requirement, or a QMSO, payment will be paid directly to the State of Maryland Department of Health and Mental Hygiene or the non-insuring parent if proof is provided that such parent has paid the Non-Participating Health Care Provider.

  • If Sanford Health Plan needs copies of medical records to process the Member’s claim, the Member is responsible for obtaining such records from the Non-Participating Health Care Provider.

Related to Non-Participating Health Care Provider

  • Non-Participating Hospital means an Administrator Hospital that does not meet the definition of a Participating Hospital.

  • Non-Participating Hospice Care Program Provider means a Hospice Care Program Provider that either: (i) does not have a written agreement with the Claim Administrator or another Blue Cross and/or Blue Shield to provide services to participants in this benefits program, or; (ii) a Hospice Care Program Provider which has not been designated by a Blue Cross and/or Blue Shield Plan as a Participating Provider Option program.

  • Non-Participating Orthotic Provider means an Orthotic Provider who does not have a written agreement with the Claim Administrator or another Blue Cross and/or Blue Shield Plan to provide services to you at the time services are rendered.

  • Non-Participating Retail Health Clinic means a Retail Health Clinic which does not have a written agreement with the Claim Administrator or another Blue Cross and/or Blue Shield Plan to provide services to you at the time services are rendered.

  • Participating Hospital means an Administrator Hospital that has an agreement with the Claim Administrator or another Blue Cross and/or Blue Shield Plan to provide Hospital services to participants in the Participating Provider Option program.

  • Licensed health care provider means a physician, physician assistant, chiropractor, advanced registered nurse practitioner, nurse, physical therapist, or athletic trainer licensed by a board.

  • Non-Participating Home Infusion Therapy Provider means a Home Infusion Therapy Provider who does not have a written agreement with the Claim Administrator or another Blue Cross and/or Blue Shield Plan to provide services to you at the time services are rendered.

  • Health care provider or "provider" means:

  • Indian Health Care Provider means a health care program operated by the Indian Health Service (IHS) or by an Indian Tribe, Tribal Organization, or Urban Indian Organization (otherwise known as an I/T/U) as those terms are defined in § 4 of the Indian Health Care Improvement Act (25 USC § 1603). Indian Health Care Provider includes a 638 Facility and provision of Indian Health Service Contract Health Services (IHS CHS).

  • Participating Orthotic Provider means an Orthotic Provider who has a written agreement with the Claim Administrator or another Blue Cross and/or Blue Shield Plan to provide services to you at the time services are rendered.

  • Participating Hospice Care Program Provider means a Hospice Care Program Provider that either: (i) has a written agreement with the Claim Administrator or another Blue Cross and/or Blue Shield to provide services to participants in this benefits program, or; (ii) a Hospice Care Program Provider which has been designated by a Blue Cross and/or Blue Shield Plan as a Participating Provider Option program.

  • Participating Retail Health Clinic means a Retail Health Clinic which has a written agreement with the Claim Administrator or another Blue Cross and/or Blue Shield Plan to provide services to you at the time services are rendered.

  • Non-Participating Provider means an Administrator Hospital or Professional Provider which does not have a written agreement with the Claim Administrator or another Blue Cross and/or Blue Shield Plan to provide services to participants in the Participating Provider Option program or a facility which has not been designated by the Claim Administrator as a Participating Provider.

  • Non-Participating Clinical Professional Counselor means a Clinical Professional Counselor who does not have a written agreement with the Claim Administrator or another Blue Cross and/or Blue Shield Plan to provide services to you at the time services are rendered.

  • Licensed health care professional means a person who possesses a professional medical license that is valid in Oregon. Examples include, but are not limited to, a registered nurse (RN), nurse practitioner (NP), licensed practical nurse (LPN), medical doctor (MD), osteopathic physician (DO), respiratory therapist (RT), physical therapist (PT), physician assistant (PA), or occupational therapist (OT).

  • Non-Participating Prosthetic Provider means a Prosthetic Provider who does not have a written agreement with the Claim Administrator or another Blue Cross and/or Blue Shield Plan to provide services to you at the time services are rendered.

  • Participating provider means an Administrator Hospital or Professional Provider which has a written agreement with the Claim Administrator or another Blue Cross and/or Blue Shield Plan to provide services to participants in the Participating Provider Option program or an Administrator facility which has been designated by the Claim Administrator as a Participating Provider.

  • Participating Home Infusion Therapy Provider means a Home Infusion Therapy Provider who has a written agreement with the Claim Administrator or another Blue Cross and/or Blue Shield Plan to provide services to you at the time services are rendered.

  • Participating physician means a physician licensed in Virginia to practice medicine, who practices

  • Non-participating private hospital means a hospital that does not have a hospital purchaser provider agreement with Latrobe. (If you use a non-participating private hospital you may incur a large out-of- pocket expense.)

  • Non-Participating Optometrist means an Optometrist who does not have a written agreement with the Claim Administrator or another Blue Cross and/or Blue Shield Plan to provide services to you at the time services are rendered.

  • Qualified medical provider means the same as that term is defined in Section 26-61a-102.

  • Nonparticipating provider means a person, health care provider, practitioner, facility, or entity, acting within their scope of practice, that does not have a written contract to participate in a managed health care system's provider network, but provides health care services to enrollees of programs authorized under this chapter or other applicable law whose health care services are provided by the managed health care system.

  • Managed health care system means: (a) Any health care

  • Health care professional means a physician or other health care practitioner licensed, accredited or certified to perform specified health care services consistent with state law.

  • Participating Pharmacy means a pharmacy that has entered into a prescription drug plan agreement with the Pharmacy Benefit Manager listed on your identification card.