How Non-Network Providers Are. Paid You are responsible for paying all charges from a non-network provider. You are liable for the difference between the amount that the non-network health care provider bills and the payment made for covered health care services. The copayments and deductibles you are responsible for are determined at the date of service and will not be retroactively adjusted for payments we make to providers under provider incentive, risk-sharing, care coordination, value-based or similar programs. Generally, we send reimbursement to you; but, we reserve the right to reimburse a non-network provider directly. We reimburse you or a non-network provider up to the maximum benefit or our allowance, less any copayments and deductibles which may apply to a covered health care service. We reimburse non-network provider services using the same guidelines used to pay network providers. If an allowance for a specific covered health care 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. Generally, our payment for non-network provider services will not be more than the amount that is paid for network provider services. Payments made to you are personal. You cannot transfer or assign any of your right to receive payments under this agreement to another person or organization.
How Non-Network Providers Are. Paid You are responsible for paying all charges from a non-network provider. You are liable for the difference between the amount that the non-network health care provider bills and the payment made for covered health care services. The copayments and deductibles you are responsible for are determined at the date of service and will not be retroactively adjusted for payments we make to providers under provider incentive, risk-sharing, care coordination, value-based or similar programs. Generally, this agreement sends reimbursement to you; but, this agreement reserves the right to reimburse a non-network provider directly. This agreement reimburses you or a non-network provider up to the maximum benefit or our allowance, less any copayments and deductibles which may apply to a covered health care service. This agreement reimburses non-network provider services using the same guidelines used to pay network providers. . If an allowance for a specific covered health care 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. Generally, our payment for non-network provider services will not be more than the amount that is paid for network provider services. Payments made 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 Rhode Island General Law §27-20-49 (Dental Insurance assignment of benefits) applies.
How Non-Network Providers Are. Paid Services received from a non-network provider are NOT COVERED except in the following limited circumstances: • Emergency care (Emergency Room Services and Ambulance Services); • We specifically approve the use of a non-network provider for covered health care services; • Covered health care services are rendered by a non-network provider at a network facility outside of your control as described in Section 4.1; • Hearing aids, in accordance with Rhode Island General Law § 27-20-46; • Hair prosthetics (wigs), in accordance with Rhode Island General Law §27-20-53; or • Enteral formula or food taken orally, in accordance with Rhode Island General Law §27-20- 56. If you receive care from a non-network provider, you are responsible for paying all charges from a non-network provider. You are liable for the difference between the amount that the non-network health care provider bills and the payment we make for covered health care services. The copayments and deductibles you are responsible for are determined at the date of service and will not be retroactively adjusted for payments we make to providers under provider incentive, risk-sharing, care coordination, value-based or similar programs. Generally, we send reimbursement to you; but, we do reserve the right to reimburse a non-network provider directly. We reimburse you or a non-network provider up to the maximum benefit or our allowance, less any copayments and deductibles (if any), which may apply to a covered health care service. We reimburse non-network provider services using the same guidelines we use to pay network providers. If an allowance for a specific covered health care 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. Generally, our payment for non-network provider services will not be more than the amount we pay for network provider services. 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 Rhode Island General Law §27-20-49 (Dental Insurance assignment of benefits) applies.
