Non-Network Providers. Non-Emergency Covered Services from a Non-Network Provider are not covered. It is your responsibility to ensure the Providers you receive services from are in the Health Options Network. In cases where a Network Provider is not available within certain time and distance standards from your residence within the Service Area, Health Options may approve your visit to a Non-Network Provider if you contact us and obtain approval beforehand. In this case, charges for the visit will be applied to your In-Network cost-sharing up to the Maximum Allowable Amount. Charges above the Maximum Allowable Amount will not apply to your Out-of-Network cost-sharing and will be your responsibility, if the Non-Network Provider chooses to bill you. This is sometimes referred to as Balance Billing. When there is an inadequate network, balance billing does not apply. When you receive services for a Medical Emergency, your Out-of-Pocket Costs (up to the Maximum Allowable Amount determined by Health Options) will be at the Network Provider level whether you see a Network Provider or a Non-Network Provider. Charges from Non-Network Providers above the Maximum Allowable Amount will not apply to your cost-sharing and will be your responsibility, if the Non-Network Provider chooses to bill you (known as balance billing). This means you may have financial responsibility greater than the cost- sharing described on your Schedule of Benefits. When there is an inadequate network, balance billing does not apply. Before you receive a service, you may call Community Health Options® (“Health Options”) toll-free at 1-855-624- 6463 (TTY/TDD: 711) to learn the network status of the provider. If we deny your claim, you have the right to appeal our decision by following the steps in section 8. For Medical Emergency services rendered by a Non- Network Provider, the Plan will provide Benefits at Network Provider Out-of-Pocket Costs based on the Maximum Allowable Amount, as determined by us, for the services received. In the event of a Surprise Bill Health Options will reimburse an Out-of-Network provider at the average network rate under an enrollee’s plan unless the carrier and provider agree otherwise.
Non-Network Providers. It is understood that in some instances, Enrollees will require specialty care not available from a Network Provider and that Contractor will arrange that such services be provided by a non‐Network Provider. In such event, Contractor will promptly negotiate an agreement (single case agreement) with a non‐Network Provider to treat the Enrollee until a qualified Network Provider is available. Contractor shall make best efforts to ensure that any non‐Network Provider billing for services rendered in Illinois is enrolled in the HFS Medical Program prior to paying a claim.
Non-Network Providers. 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; or Covered health care services are rendered by a non-network provider at a network facility outside of Subscriber Agreement
Non-Network Providers. 5.7.6.1 Contractor shall make reasonable efforts to negotiate single-case agreements with out-of-state Providers treating DCFS Youth in Care. In the event Contractor is not able to finalize single-case agreements with out-of-state Providers within four (4) weeks of the Comprehensive Implementation Date or within two (2) weeks of a DCFS Youth in Care being moved out-of-state, Contractor will notify DCFS. Contractor shall continue to identify alternate or other suitable care in an appropriate setting. Contractor shall assist DCFS in securing healthcare services and shall maintain responsibility for payment for all Medicaid covered services for DCFS Youth in Care who reside outside of Illinois.
Non-Network Providers. 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 the non-network provider. If the services are covered health care services and are rendered within the limited circumstances described above, you will be reimbursed up to the provider’s charge or the maximum benefit, less any copayments and deductibles, which may apply to the covered health care service. The deductible and maximum out-of-pocket expense are calculated based on our allowance and not on the provider’s charge, unless otherwise specifically stated in this agreement. Benefits may not be assigned, unless the Rhode Island General Laws § 27-19-54 (Dental Insurance assignment of benefits) applies. Deductible/Maximum out-of-pocket expense
Non-Network Providers. The MCO will pay for covered services provided by a non-network provider to any member pursuant to a court order, effective with the receipt of a written request for authorization from the non-MCO provider, and extending until the MCO issues a written denial of authorization. This requirement does not apply if the MCO issues a written denial of authorization within five (5) business days of receiving the request for referral.
Non-Network Providers. If you receive Covered Services from a Non-Network Provider, your cost-sharing will be higher, as described in the Out-of-Network portion of your Schedule of Benefits. It is your responsibility to ensure the Providers you receive services from are in the Health Options Network. If the Plan approves your claim for payment of services rendered by a Non-Network Provider, the Plan will pay Benefits up to the Maximum Allowable Amount. We will pay Benefits directly to you or to the Non-Network Provider. Charges above the Maximum Allowable Amount will not apply to your Out-of-Network cost-sharing and will be your responsibility, if the Non-Network Provider chooses to bill you. This means you may have financial responsibility greater than the cost-sharing described on your Schedule of Benefits. This is sometimes referred to as Balance Billing. When the Community Health Options network is inadequate, Balance Billing will not apply. Before you receive a service, you may call Community Health Options® (“Health Options”) toll-free at 1-855-624- 6463 (TTY/TDD: 711) to learn the network status of the provider. If we deny your claim, you have the right to appeal our decision by following the steps in section 8. For Medical Emergency services rendered by a Non- Network Provider, the Plan will provide Benefits at Network Provider Out-of-Pocket Costs based on the Maximum Allowable Amount, as determined by us, for the services received. In the event of a Surprise Bill Health Options will reimburse an Out-of-Network provider at the average network rate under an enrollee’s plan unless the carrier and provider agree otherwise.
Non-Network Providers. It is understood that in some instances, Enrollees will require specialty care not available from a Network Provider and that Contractor will arrange that such services be provided by a non-Network Provider. In such event, Contractor will promptly negotiate an agreement (single-case agreement) with a non-Network Provider to treat the Enrollee until a qualified Network Provider is available. Contractor shall make best efforts to ensure that any non-Network Provider billing for services rendered in Illinois is enrolled in the HFS Medical Program prior to paying a claim. Provider reimbursement. The Department may define an alternative payment methodology to which Contractor must adhere to when reimbursing Providers for provided services.
Non-Network Providers. If the Provider you see is not in our network (a Non‐Network Provider,), you will pay higher Out‐of‐Pocket Expenses for Covered Services and supplies because you are responsible for amounts above the Allowed Amount. When you are billed for the difference between the Allowed Amount and the Provider’s actual charge, this is known as balance billing. In addition to balance billing when you receive care from a Non‐Network Providers, you will be also responsible for applicable Copays, Deductibles, Coinsurance, amounts in excess of stated benefit maximums, and charges for non‐covered services and supplies. Amounts in excess of the Allowed Amount do not accrue toward your Calendar Year Deductible or Out‐of‐Pocket Maximum.
Non-Network Providers. You may elect to see a Non-Network Provider. However, please note some services require prior authorization, and your costs will be higher if you receive care from a Non-Network Provider. Please refer to Your Schedule of Benefits for more information. You may also be Balance Billed by the Non-Network Provider for the difference between the Non-Network Provider’s charge and the Allowed Amount. When You visit an Non-Network Provider for pre-authorized services not available from a Network Provider, We will: • pay the Claim at the Usual, Customary, and Reasonable rate for the service, less any patient Coinsurance, Copayment, or Deductible responsibility under the Plan; • pay the Claim at the preferred benefit cost-sharing level; and when issuing payment, provide You with an explanation of benefits. If You obtained Prior Authorization for Non-Network Services due to an access issue, We will cover the Covered Services at no greater cost to You than if the Covered Services were obtained from a Network Provider.
