In-Network Services Clause Samples
The In-Network Services clause defines the requirement that certain services must be provided by providers or facilities that are part of a designated network, typically established by an insurance plan or managed care organization. This clause specifies that covered individuals must seek care from approved, contracted providers to receive the highest level of benefits or to avoid additional costs. For example, a health insurance policy may only cover the full cost of a medical procedure if it is performed by a doctor or hospital within the insurer’s network. The core function of this clause is to control costs and ensure quality by directing patients to providers with whom the insurer has negotiated rates, thereby reducing out-of-pocket expenses and minimizing unexpected charges for the insured.
In-Network Services. Subject to Article III, Section 2.7, Timely Payment Requirement, the MCO must make timely payment within thirty (30) calendar days for clean claims to in-network providers for Medically Necessary, covered Contract services when:
1. Services were rendered to treat a medical emergency;
2. Services were rendered under the terms of the MCO’s Contract with the provider;
3. Services were prior authorized; or
4. Retro-authorization meeting medical necessity has been granted due to the nature of service.
In-Network Services. PPG Capitated Services and Shared Risk Services provided or arranged through PPG.
In-Network Services. The term "In-Network Services" means authorized treatment provided by a Network Provider.
In-Network Services. In-network services are services obtained from a Network Provider. The PCO must make timely payment for clean claims submitted by Network Providers in accordance with 40 P.S. §991.2166 and 31 Pa. Code §154.18. Except as required by law, the PCO is not financially liable for services rendered to treat a non-emergency condition in a hospital emergency room.
In-Network Services. Covered Services provided or arranged for through a Member’s selected or assigned PCP or PPG.
In-Network Services. The MCO must make timely payment within 30 calendar days for medically necessary, covered services rendered by in-network providers when:
In-Network Services. The Contractor shall be responsible for making timely payment for Medically Necessary, covered services rendered by Network Providers when:
a. Services were rendered to treat a medical emergency;
b. Services were rendered under the terms of the Contractor's agreement with the Provider;
c. Services were prior authorized; or
d. It is determined by the Department, after a hearing, that the services should have been authorized. The Contractor will not be financially liable for services rendered to treat a non-emergency condition in a hospital emergency room (except to the extent required elsewhere by law), unless the services were prior authorized or otherwise conformed to the terms of the Contractor's agreement with the Provider.