Network Provider Services. If you receive covered healthcare services from a network provider, the provider has agreed to accept our payment for covered healthcare services as payment in full, excluding your copayments, deductible (if any), and the difference between the benefit limit and our allowance, if any.
Network Provider Services. If you receive covered healthcare services from a network provider, the provider has agreed to accept our payment for covered healthcare services as payment in full, excluding your copayments, deductible (if any), and the difference between the benefit limit and our allowance, if any. This plan uses the Blue Choice New England provider network. Our service area for network providers includes Rhode Island, Connecticut, Maine, Massachusetts, and New Hampshire. When you receive healthcare services or supplies from a network provider in a state other than Rhode Island, your coverage and other requirements for healthcare services may be different from those described in this agreement. In this case, you may be entitled to receive additional coverage under this health plan as required by that state’s law. You should call our customer service office for more help if this applies to you.
Network Provider Services. If you receive covered healthcare services from a non-network provider, you will be responsible for the provider’s charge. The deductible and maximum out-of-pocket expenses are calculated based on the lower of our allowance or the provider’s charge, unless special circumstances apply or otherwise specifically stated. For additional information on how we pay non-network providers please see Section 6.
Network Provider Services. The TPA will hire and maintain sufficient provider relations and customer service staff to meet the needs of the Board and the participants. The TPA will report quarterly on the volume of calls received and the types of calls received. The TPA must staff a provider services department to be operated at least during regular business hours (e.g. 8:00 a.m. to 5:00 p.m. Central Time, Monday through Friday). The TPA must maintain a provider service office within the state of Mississippi throughout the term of the contract. Provider services staff must be proficient in:
1. Assisting providers with prior authorization and referral procedures, including the use of non- participating providers;
2. Assisting providers with claims payment procedures including electronic submission of claims in accordance with HIPAA and HITECH electronic data interchange (EDI) standards;
3. Handling provider complaints and grievances;
4. Educating providers as to their responsibilities under the Plan;
5. Educating providers as to covered medical services, excluded medical services and benefit limitations; and
6. Facilitation of medical record transfer among providers as necessary.
Network Provider Services
