Circumstances in Which an Clause Samples

Circumstances in Which an. Enrollee May Be Billed (A) A Provider may bill an Enrollee for non-Covered Services only as outlined in this Contract. (B) A non-Covered Service is a service that is not covered under this Contract. (C) The Department shall specify to the Contractor the extent of Covered Service and items under the Contract. (D) An Enrollee may be billed for a non-Covered Service when all of the following conditions are met: (1) The Provider has an established policy for billing all patients for services not covered by a third party (i.e., the charge cannot be billed only to Enrollees); (2) The Provider has informed the Enrollee of its policy for billing patients for non- covered services; (3) The Provider has advised the Enrollee prior to rendering the non-covered service that the Enrollee shall be responsible for making payment; and (4) An agreement, in writing, is made between the Provider and the Enrollee that details the service and the amount to be paid by the Enrollee. (E) The Provider may bill the Enrollee for disputed services continued during the Appeal process if the requirements of Article 8.4.9(B) of this Contract and 42 CFR 431.230(b) are met.