How Non-network Providers Are Paid Sample Clauses

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 pro...
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How Non-network Providers Are Paid. This plan does not cover services received from a non-network provider except for the special circumstances described below.
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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. 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. When covered healthcare services are received from a non-network provider, we reimburse you or the non-network provider, less any copayments and deductibles, based on: • the lesser of: • our allowance; • the non-network provider’s charge; or • the benefit limit; or • federal or state law, when applicable. 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 responsible for the difference between the amount that the non-network provider bills and the payment we make. Generally, we send reimbursement to you, but we reserve the right to reimburse a non-network provider directly. 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.
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How Non-network Providers Are Paid. This plan does not cover services received from a non-network provider except for the special circumstances described below. • Emergency room services (which may include post-stabilization services unless the non-network provider determines that you are able to travel using nonmedical transportation or nonemergency medical transportation and obtains your consent in writing before rendering the services); • Urgent care services; • Ground ambulance services; • Air ambulance services; • We specifically approve the use of a non-network provider for covered healthcare services, see Network Authorization in Section 5 for details; • Non-emergency covered healthcare services rendered by a non-network provider at certain network facilities* unless the non-network provider obtains your consent in writing before rendering the service;
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