Network Providers. If your claim from a Network Provider is approved, the Plan will pay Benefits directly to the Network Provider. Except for your Out-of-Pocket Costs, if applicable, you are not required to pay any balances to the Network Provider until the Plan determines what it will pay. If you receive services from a Network Provider that are not Covered Services, you will be responsible for the cost of those non-Covered Services. If a Network Provider, who is licensed to perform alternative or complementary treatment and therapy, who is operating within the scope of his or her license and provides services that are listed as Covered Services, your cost-sharing responsibility is outlined in the Schedule of Benefits.
Network Providers. In-network providers provide medical services for a negotiated fee. This fee is the allowed amount for in-network providers. When you receive covered services from an in-network provider, your medical bills will be reimbursed at a higher percentage (the in-network provider benefit level). In-network providers will not charge more than the allowed amount. This means that your portion of the charges for covered services will be lower. If a covered service is not available from an in-network provider, you can receive benefits for services provided by an out-of-network provider at the in-network benefit level. See Prior Authorization for details. Out-of-network providers are providers that are not part of your network. Your bills will be reimbursed at the lower percentage (the out-of-network benefit level) and the provider may bill you for charges above the allowed amount. You may also be required to submit the claim yourself. See Sending Us a Claim for details.
Network Providers. The term "Network Providers" means those Hospitals, Physicians and other providers of health care services selected and retained by the Contract Administrator as the exclusive provider of said services in a specific Network location.
Network Providers. Contractor shall establish, maintain, and monitor a Provider Network, including hospitals, PCPs, WHCPs, specialist Physicians, clinical laboratories, dentists, OB/GYNs, oral surgeons, pharmacies, behavioral‐health Providers, substance‐abuse Providers, CMHCs, and all other provider types.
5.7.1.1 This network shall be sufficient to provide adequate access to all Covered Services under the Contract, taking into consideration:
5.7.1.1.1 the anticipated number of Enrollees;
5.7.1.1.2 the expected utilization of services, in light of the characteristics and healthcare needs of Contractor’s Enrollees;
5.7.1.1.3 the number and types of Providers required to furnish the Covered Services;
5.7.1.1.4 the number of Network Providers who are not accepting new patients; and
5.7.1.1.5 the geographic location of Providers and Enrollees, taking into account distance, travel time, the means of transportation, and whether the location provides physical access for Enrollees with disabilities.
5.7.1.2 During the first year of this Contract for all Contracting Areas, Contractor shall enter into a contract with any willing and qualified Provider in the Contracting Area that renders Nursing Facility and waiver services, as set forth in Attachment I, so long as the Provider agrees to Contractor’s rate and adheres to Contractor’s QA requirements. To be considered a qualified Provider, the Provider must be in good standing with the Department’s FFS Medical Program. Contractor may establish quality standards in addition to those State and federal requirements and, after the first year of this Contract, contract only with Providers that meet such standards. Such standards must be approved by the Department, in writing, and Contractors may only terminate a contract of a Provider based on failure to meet such standards if two (2) criteria are met: 1) such standards have been in effect for at minimum one (1) year, and 2) Providers are informed at the time such standards come into effect.
5.7.1.3 For NFs and SLFs, Contractor must maintain the adequacy of its Provider Network sufficient to provide Enrollees with reasonable choice within each county of the Contracting Area, provided that each Network Provider meets all applicable State and federal requirements for participation in the HFS Medical Program. Contractor may require as a condition for participation in its network that a NF agree to provide access to Contractor’s or Subcontractor’s Care Management team by acting upon the team’s c...
Network Providers. To find out more about HMO contracting providers, refer to the website at xxx.xxxxxx.xxx for Provider Finder®, an Internet-based provider directory. It has important information about the locations and availability of providers, restrictions on accessibility and referrals to specialists, and information about limited provider networks. You may also request a hard copy or electronic copy of the provider directory, which is updated quarterly, by calling or writing Customer Service. The directories can also be found at xxx.xxxxxx.xxx. Upon admission to an inpatient facility, (e.g. hospital or skilled nursing facility), a participating physician other than your primary care physician may direct and oversee your care. Your (PCP) will be the one you call when you need medical advice, when you are sick and when you need preventive care such as immunizations. Your PCP may also be part of a "network" or association of medical professionals and facilities that work together to provide health care services in a timely, efficient and cost-effective manner. That means when you choose your PCP, you are also choosing a network and in most instances you are not allowed to receive services from any physician or health care professional, including your obstetrician-gynecologist (OB-GYN), that is not also part of your PCP's network. You will not be able to select any physician or health care professional outside of your PCP's network, even though that physician or health care provider is listed with your health plan. If you see any physician or provider outside of that network, even if the name of such physician or provider is listed in the provider directory, the cost of such services will not be covered under your health plan. Your PCP will play a key role in the delivery of your health care. The network to which your PCP belongs will provide or arrange for all of your care, so make sure that your PCP's network includes the specialists and hospitals that you prefer. If your PCP changes networks, you will be notified and will receive an updated ID card. You and your covered dependents may select the same or a different provider network, and the same or a different PCP within the network. You must go to an OB/GYN who is within the same provider network as your PCP. It is not required that you select an OB/GYN; you may choose to receive your OB/GYN services from your PCP. If you need help in locating a participating OB/GYN in your area, refer to the online provider directory ...
Network Providers. During the term of this Agreement, ACS will maintain a fully-credentialed network of ancillary health care service providers and will provide HealthSmart Participants access to those Network Providers. ACS will supply the names and provider demographics for each Network Provider to HealthSmart at least monthly in a mutually agreed-upon electronic format. HSPC shall not exclude ACS Network Providers for any purpose or reason other than the exceptions of (1) the necessity to have the provider remain with the HSPC network, (2) participation in ACS network would prohibit the provider from representation by HSPC for contracting via the administrative fee business model, and (3) inclusion of the ACS provider would cause potential harm or discord to HSPC provider rates or relationships. ACS will not notify its Network Providers that HealthSmart Participants will begin utilizing the Network Providers. ACS will notify their network providers of any new payor to the ACS network that HSPC participants will begin utilizing. The network contact letter must be approved by HSPC.
Network Providers. If you seek covered health care services from a BlueCHiP provider, you will only be responsible for your deductible, copayment, and/or the difference between the maximum benefit and our allowance if any, which may apply to a covered health care service. To see if a provider is a BlueCHiP provider, check your BlueCHiP Coordinated Health Plan Provider Directory, call our Customer Service Department at (401) 274-3500 or 0-000-000-0000 or TDD (000) 000-0000 or 0-000-000-0000, or visit our Web site xxXXXXXX.xxx If you are outside the local area you may seek covered health care services from a provider who participates with the BlueCard traditional indemnity network (a BlueCard provider). When you do so, you will only be responsible for your deductible, copayment, and/or the difference between the maximum benefit and the allowance (if any) based on the amount due under the BlueCard program policies. See Section 5.3 for more information on the BlueCard program. To see if a provider is a BlueCard provider, call BlueCard Access at the number shown on your BlueCHiP ID Card 0-000-000 BLUE (2583) or visit xxx.xxxx.xxx and use the “BlueCard Doctor and Hospital Finder – Traditional Indemnity Network”. If you receive covered health care services from a non-network provider, you will be responsible for the provider’s charge. You will then be reimbursed based on the lesser of the provider’s charge, our allowance, or the maximum benefit limit less your deductible and copayments (if any). The deductible and maximum out-of-pocket expenses are calculated based on our allowance and not on the provider’s charge. See Section 7.1 for more information on how to file a claim. Below is a summary of our coverage levels under this Flex Plan Rider. It includes information about copayments, deductibles, and some benefit limits. This summary is intended to give you a general understanding of the coverage available under this Rider. For more detailed information, please read Section 3.0 for the description of coverage for each particular covered health care service along with the related exclusions and Section 5.0 for a list of general exclusions. *Preauthorization is recommended for this service. BlueCHiP providers are responsible for obtaining preauthorization for all applicable covered health care services. See Section 8.0 - definition of preauthorization for details. Deductible The amount you must pay each plan year before we begin to pay for certain covered health care services. See G...
Network Providers. (a) The Health Services Manager must establish and maintain the HSM Network throughout the Term in accordance with this clause 15 and Schedule 2 (Statement of Work), comprising a network of health professionals and other providers sufficient and appropriate to deliver Health Care to Transferees and Recipients in accordance with this Contract.
(b) The Department may, by notice to the Health Services Manager, require that the Health Services Manager:
(i) consider employing, or including in its HSM Network, a provider nominated by the Department for the performance of certain services; or
(ii) remove a particular Network Provider from the HSM Network.
(c) A notice provided by the Department under clause 15(b)(i) may specify (among other things) the range or type of Health Care to be delivered or performed by the Department's nominated provider, and suggest any other terms for the Health Services Manager's employment or engagement of that provider. If the Department issues a notice under clause 15(b)(i), the Health Services Manager agrees to give due and proper consideration to the Department's proposal.
(d) If the Department issues a notice under clause 15(b)(ii), the Health Services Manager must comply with the notice, within twenty (20) Business Days of the date of the notice, or such further period as the Parties may agree.
(e) The Health Services Manager will not be liable for the acts or omissions of the Network Provider or its Network Provider Personnel, except and only to the extent provided in clause 56.
Network Providers. Members will have access to Network Providers that (i) have executed Network Provider Agreements required by AdvancePCS (as amended from time to time by AdvancePCS), and (ii) have agreed to perform pharmacy services for Members in accordance with the provider pricing schedule and the Plan. Network Providers may choose not to perform provider services for Members under this Agreement; however, no Network Provider may serve only some Members or provide only certain drugs (unless such Network Provider does not provide such drugs to any persons). AdvancePCS may provide Network Providers with Plan information in such format and media as AdvancePCS deems appropriate for the purpose of assisting such Network Providers in providing Benefits to Members.
Network Providers. Contractor shall establish, maintain, and monitor a Provider Network, including hospitals, PCPsprimary care Providers, WHCPs, specialist Physicians, clinical laboratories, dentists, OB/GYNs, oral surgeons, pharmacies, behavioral-health Providers, substance-abuse Providers, CMHCs, and all other provider types.
