Nonparticipating provider definition

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 net- work, but provides health care services to enrollees of pro- grams authorized under this chapter or other applicable law whose health care services are provided by the managed health care system.

Nonparticipating provider means a provider who is not a participating provider.

Nonparticipating provider means a person, health care provider, practitioner, facility, or entity acting within their scope of prac- tice and licensure that:

Examples of Nonparticipating provider in a sentence

• Non-participating provider is a provider (doctor, hospital, pharmacy, etc.) that does not sign a contract to participate in the Contractor’s provider network.

• Non-participating provider benefits are not available for the services listed in items 2 and 3 above.

• Non-participating provider benefits are not available for the services listed in items 2, 4 and 7 below.

• The Member could be billed by a Participating Provider for services that Capital determines are not Medically Necessary but the Member chooses to have the service anyway.A Nonparticipating provider is not obligated to accept Capital’s Preauthorization denial or determination of Medical Necessity, and therefore, may bill a Member for services determined not to be Medically Necessary.

• A Member is solely responsible for payment of such services and can avoid this responsibility by choosing a Participating Provider.Even if a Participating Provider recommends that a Member receive services from a Nonparticipating provider, the Member is responsible for payment of all services determined by Capital to be not Medically Necessary.NOTE: A Provider’s belief that a service is appropriate for the Member does not mean the service is covered.

More Definitions of Nonparticipating provider

Nonparticipating provider means, with respect to the

Nonparticipating provider means a person who provides hospital or medical care pursuant to the Oklahoma Medicaid Program but does not have a managed care health services contract or subcontract within the Oklahoma Medicaid Healthcare Options System;

Nonparticipating provider means a health care entity or health care professional not in the contractor's participating provider network.

Nonparticipating provider means a healthcare provider who has not entered into a contract with a healthcare plan for the delivery of medical services;

Nonparticipating provider means a provider who is not contracted with the enrollee’s health care service plan to provide services under the enrollee’s plan contract.

Nonparticipating provider. ’ means a provider who is not contracted with a health care service plan.

Nonparticipating provider means a provider who is