Out-of-Network Providers. 4.8.19.1 If the Contractor’s network is unable to provide Medically Necessary Covered Services to a particular Member, the Contractor shall adequately and timely cover these services Out-of-Network for the Member. The Contractor must inform the Out-of Network Provider that the member cannot be balance billed.
Out-of-Network Providers. A. If Contractor’s network is unable to provide necessary services covered under the Contract to a particular Member, Contractor must adequately and timely cover these services out of network for the Member, for as long as the entity is unable to provide them. Out-of-network providers must coordinate with the entity with respect to payment. Contractor must ensure that cost to the Member is not greater than it would be if the services were furnished within the network.
Out-of-Network Providers. In the event that the Physician of a new Enrollee who is in an active, ongoing course of treatment or is in the third trimester of pregnancy is not an Affiliated Provider, Contractor will permit such Enrollee to continue an ongoing course of treatment with such Physician for up to ninety (90) days or through the postpartum period, or as otherwise required by Section 25 of the Managed Care Reform and Patients Rights Act only if the out-of-network Physician agrees to provide such ongoing course of treatment, and if such out-of-network Physician agrees to: (i) accept reimbursement at Contractor’s established rates based on a review of the level of services provided, (ii) adhere to Contractor’s QA requirements, (iii) provide necessary medical information related to health care, and (iv) adhere to Contractor’s policies and procedures, including, but not limited to, procedures regarding Referrals.
Out-of-Network Providers. If you elect to receive Covered Services and supplies from an Out-of-Network Provider, you will be balanced billed for and will be responsible to pay all amounts charged by the Out-of-Network Provider that are above the Allowed Amount. This means you may pay higher Out-of-Pocket Expenses for Covered Services and supplies you receive from Out-of-Network Providers. In addition to balance billing, when you receive care from an Out-of-Network Provider, you will also be responsible for any applicable Copay, Deductible, Coinsurance, amounts in excess of stated benefit maximums, and charges for non-covered services and supplies. Amounts in excess of the Allowed Amount do not accrue toward your Calendar Year Deductible or Out-of-Pocket Maximum.
Out-of-Network Providers. The Department will provide the Contractor with an expedited enrollment process to assign provider numbers for providers not already enrolled in Medicaid for emergency situations only.
Out-of-Network Providers. It is understood that in some instances Enrollees will require specialty care not available from a network provider and that the ICO will arrange that such services be provided by a non- network provider. In such event, ICO will negotiate a Single Case Agreement with a non-network provider at the applicable Medicaid or Medicare FFS rate to treat the Enrollee until a qualified network provider is available. The ICO shall make best efforts to have any non-network provider billing for services be enrolled in the Medicare Program or Michigan Medicaid Program, as appropriate and in the same manner as network providers under Section 2.7.1.2, prior to paying a Claim.
Out-of-Network Providers. In spending POWER Account funds, enrollees will be permitted to pay for the following covered services, even if obtained through out-of- network providers:
Out-of-Network Providers. 6.5.1 The DMO shall reimburse an out-of-network provider for an Enrolled Member who receives Medically Necessary services on or after the beginning date of the service period for the Agreement.
Out-of-Network Providers. (outside the state of Oklahoma) – the Provider’s usual charge, up to the amount that the on-site Blue Cross and Blue Shield Plan would reimburse a BlueCard PPO Provider for the same service. NOTE: For Covered Services Incurred outside the state of Oklahoma, the “Allowable Charge” will be determined by the Blue Cross and Blue Shield Plan (Host Plan) servicing that area. Payment will be based upon the Provider payment arrangements in effect between the Provider and the on-site Plan.
Out-of-Network Providers. For all populations eligible for services under this Contract, the Contractor shall:
