For non-network providers Sample Clauses

For non-network providers. When a covered service is received from a non-network provider, the eligible service expense is the minimum amount required by applicable federal or state law to be paid to the non-network provider for the service. If and only if there is no minimum amount required by applicable federal or state law, then the eligible service expense for a non-network provider shall be as determined below.
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For non-network providers a. When a covered service is received from a non-network provider as a result of an emergency and there is not a network provider reasonably accessible to render the covered service, the eligible service expense is the lesser of (1) the negotiated fee, if any, that has been mutually agreed upon by us and the provider as payment in full (you will not be billed for the difference between the negotiated fee and the provider’s charge), or (2) the provider’s billed charge.;
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For non-network providers. For a Provider who does not have a written agreement with Claim Administrator or another Blue Cross and/or Blue Shield Plan to provide care to a Covered Person at the time Covered Services for medical benefits are rendered (“Non-Network Provider”), the Allowable Amount will be the lesser of: (a) the Non-Network Provider's Claim Charge, or; (b) Claim Administrator’s non-contracting Allowable Amount. Except as otherwise provided in this section ii, the non-contracting Allowable Amount is developed from base Medicare reimbursements adjusted by a predetermined factor established by Claim Administrator. Such factor shall be not less than 75% and will exclude any Medicare adjustment(s) which is/are based on information on the Claim. When a Medicare reimbursement rate is not available or is unable to be determined based on the information submitted on a Claim, the non-contracting Allowable Amount for Non-Network Providers will represent an average contract rate in aggregate for Network Providers adjusted by a predetermined factor established by Claim Administrator. Such factor shall be not less than 75% and shall be updated not less than every two years. Claim Administrator will utilize the same Claim processing rules and/or edits that it utilizes in processing Network Provider Claims for processing Claims submitted by Non-Network Providers which may also alter the Allowable Amount for a particular Covered Service. In the event Claim Administrator does not have any Claim edits or rules, Claim Administrator may utilize the Medicare claim rules or edits that are used by Medicare in processing the Claims. The Allowable Amount will not include any additional payments that may be permitted under the Medicare laws or regulations which are not directly attributable to a specific Claim, including, but not limited to, disproportionate share and graduate medical education payments. Any change to the Medicare reimbursement amount will be implemented by Claim Administrator within ninety (90) days after the effective date that such change is implemented by the Centers for Medicaid and Medicare Services, or its successor. The non-contracting Allowable Amount does not equate to the Provider's Claim Charge and Covered Persons receiving Covered Services from a Non-Network Provider will be responsible for the difference between the non-contracting Allowable Amount and the Non-Network Provider's Claim Charge, and this difference may be considerable. To find out Claim Administrator’...
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For non-network providers. For a Provider who does not have a written agreement with Claim Administrator or another Blue Cross and/or Blue Shield Plan to provide care to a Covered Person at the time Covered Services for medical benefits are rendered (“Non- Network Provider”), the Allowable Amount will be the lesser of:
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Related to For non-network providers

  • How Non-network Providers Are Paid If you receive care from a non-network provider, you are responsible for paying all charges for the services you received. You may submit a claim for reimbursement of the payments you made. For the limited circumstances listed below, your copayment and deductible will apply at the network level of benefits: • emergency care (emergency room, urgent care and ambulance services); • we specifically approve the use of a non-network provider for covered healthcare services, see Network Authorization in Section 5 for details; • covered healthcare services are rendered by a non-network provider at a network facility outside of your control; • otherwise, as required by law. For those circumstances where we cover services from a non-network provider, we reimburse you or the non-network provider, less any copayments and deductibles, up to the lesser of: • our allowance; • the non-network provider’s charge; or • the benefit limit. You are responsible for the deductible, if one applies, and the copayment, as well as any amount over the benefit limit that applies to the service you received. You are liable for the difference between the amount that the non-network provider bills and the payment we make for covered healthcare services. Generally, we send reimbursement to you, but we reserve the right to reimburse a non-network provider directly. We reimburse non-network provider services using the same guidelines we use to pay network providers. Generally, our payment for non-network provider services will not be more than the amount we pay for network provider services. If an allowance for a specific covered healthcare service cannot be determined by reference to a fee schedule, reimbursement will be based upon a calculation that reasonably represents the amount paid to network providers. For emergency services, we reimburse non- network providers, in accordance with R.I. Gen. Laws § 27-18-76, the greater of our allowance, our usual guidelines for paying non-network providers, or the amount that would be paid under Medicare, less any copayments or deductibles. Payments we make to you are personal. You cannot transfer or assign any of your right to receive payments under this agreement to another person or organization, unless the R.I. General Law §27-20-49 (Dental Insurance assignment of benefits) applies. For information about network authorization requests to seek covered healthcare services from a non-network provider when the covered healthcare service cannot be provided by a network provider, please see Network Authorization in Section 5.

  • NON-NETWORK PROVIDER is a provider that has not entered into a contract with us or any other Blue Cross and Blue Shield plan. For pediatric dental care services, non-network provider is a dentist that has not entered into a contract with us or does not participate in the Dental Coast to Coast Network. For pediatric vision hardware services, a non-network provider is a provider that has not entered into a contract with EyeMed, our vision care service manager.

  • The Web Services E-Verify Employer Agent agrees to, consistent with applicable laws, regulations, and policies, commit sufficient personnel and resources to meet the requirements of this MOU.

  • Service Management Effective support of in-scope services is a result of maintaining consistent service levels. The following sections provide relevant details on service availability, monitoring of in-scope services and related components.

  • Restricted Use By Outsourcers / Facilities Management, Service Bureaus or Other Third Parties Outsourcers, facilities management or service bureaus retained by Licensee shall have the right to use the Product to maintain Licensee’s business operations, including data processing, for the time period that they are engaged in such activities, provided that: 1) Licensee gives notice to Contractor of such party, site of intended use of the Product, and means of access; and 2) such party has executed, or agrees to execute, the Product manufacturer’s standard nondisclosure or restricted use agreement which executed agreement shall be accepted by the Contractor (“Non-Disclosure Agreement”); and 3) if such party is engaged in the business of facility management, outsourcing, service bureau or other services, such third party will maintain a logical or physical partition within its computer system so as to restrict use and access to the program to that portion solely dedicated to beneficial use for Licensee. In no event shall Licensee assume any liability for third party’s compliance with the terms of the Non-Disclosure Agreement, nor shall the Non-Disclosure Agreement create or impose any liabilities on the State or Licensee. Any third party with whom a Licensee has a relationship for a state function or business operation, shall have the temporary right to use Product (e.g., JAVA Applets), provided that such use shall be limited to the time period during which the third party is using the Product for the function or business activity.

  • Provider Network The Panel of health service Providers with which the Contractor contracts for the provision of covered services to Members and Out-of-network Providers administering services to Members.

  • SERVICE PROVIDER’S PERSONNEL 10.1 The Service Provider’s Personnel shall be regarded at all times as employees, agents or Subcontractors of the Service Provider and no relationship of employer and employee shall arise between Transnet and any Service Provider Personnel under any circumstances regardless of the degree of supervision that may be exercised over the Personnel by Transnet.

  • INDEPENDENT PERSONAL SERVICES 1. Income derived by a resident of a Contracting State in respect of professional services or other activities of an independent character shall be taxable only in that State except in the following circumstances, when such income may also be taxed in the other Contracting State:

  • DEPENDENT PERSONAL SERVICES 1. Subject to the provisions of Articles 16, 18 and 19, salaries, wages and other similar remuneration derived by a resident of a Contracting State in respect of an employment shall be taxable only in that State unless the employment is exercised in the other Contracting State. If the employment is so exercised, such remuneration as is derived therefrom may be taxed in that other State.

  • The Service Provider upon receipt of a notice contemplated under clause 19.1 shall discontinue the supply of all services or goods under this Agreement, to the extent specified, and on the date specified in the notice.

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