Non-Participating Providers. Any treatment or service from a Non-Participating Provider, except in the case of an emergency or when specifically pre-authorized by AvMed, including Hospital care from a non-participating Physician or a non-participating Hospital, if elected by a Member. In such circumstances, coverage is excluded for the entire episode of care, except when the admission was due to an emergency or with the prior written authorization of AvMed.
Non-Participating Providers. 1. The Contractor shall be responsible for developing and advising its enrollees and where applicable, authorized persons of procedures for obtaining emergency services, including emergency dental services, when it is not medically feasible for enrollees to receive emergency services from or through a participating provider, or when the time required to reach the participating provider would mean risk of permanent damage to the enrollee's health. The Contractor shall bear the cost of providing emergency service through non- participating providers.
2. Non-contracted hospitals providing emergency services to Medicaid or NJ FamilyCare Members enrolled in the managed care program shall accept, as payment in full, 90% of the amounts that the non-contracted hospitals or non-participating provider of emergency services would receive from New Jersey Medicaid for the emergency services and/or any related hospitalization as if the beneficiary were enrolled in New Jersey fee-for-service Medicaid.
Non-Participating Providers. The Contractor shall cooperate with non-participating family planning providers accessed at the enrollee's option by establishing cooperative working relationships with such providers for accepting referrals from them for continued medical care and management of complex health care needs and exchange of enrollee information, where appropriate, to assure provision of needed care within the scope of this contract. The Contractor shall not deny coverage of family planning services for a covered diagnostic, preventive or treatment service solely on the basis that the diagnosis was made by a non-participating provider.
Non-Participating Providers. 1. The Contractor shall pay for services furnished by non-participating providers to whom an enrollee was referred, even if erroneously referred, by his/her PCP or network specialist. Under no circumstances shall the enrollee bear the cost of such services when referral errors by the Contractor or its providers occur. It is the sole responsibility of the Contractor to provide regular updates on complete network information to all its providers as well as appropriate policies and procedures for provider referrals.
2. The Contractor may pay an out-of-network hospital provider, located outside the State of New Jersey, the New Jersey Medicaid fee-for-service rate for the applicable services rendered.
3. Whenever the Contractor authorizes services by out-of-network providers, the Contractor shall require those out-of-network providers to coordinate with the Contractor with respect to payment. Further, the Contractor shall ensure that the cost to the enrollee is no greater than it would be if the services were furnished within the network.
4. Protecting managed care enrollees against liability for payment. As a general rule, if a participating or non-participating provider renders a covered service to a managed care enrollee, the provider’s sole recourse for payment, other than collection of any authorized cost-sharing, patient payment liability and /or third party liability, is the Contractor, not the enrollee. A provider may not seek payment from, and may not institute or cause the initiation of collection proceedings or litigation against, an enrollee, an enrollee’s family Member, any legal representative of the enrollee, or anyone else acting on the enrollee’s behalf unless subsections (a) through and including (f) or subsection (g) below apply:
a. The service is not a covered service; or (2) the service is determined to be medically unnecessary before it is rendered; or (3) the provider does not participate in the program either generally or for that service; and
b. The enrollee is informed in writing before the service is rendered that one or more of the conditions listed in subsection (a) above exist, and voluntarily agrees in writing before the service is rendered to pay for all or part of the provider’s charges; and
c. The service is not an emergency or related service covered by the provisions of 42 USC 1396u-2(b)(2)(A)(i), 42 CFR 438.114, N.J.S.A. 30:4D-6i or N.J.S.A. 30:4J-
4.1 (as both of these provisions may be amended by State Appropriations Act l...
Non-Participating Providers. The contractor shall pay for services furnished by non-participating providers to whom an enrollee was referred, even if erroneously referred, by his/her PCP or network specialist. Under no circumstances shall the enrollee bear the cost of such services when referral errors by the contractor or its providers occur. It is the sole responsibility of the contractor to provide regular updates on complete network information to all its providers as well as appropriate policies and procedures for provider referrals.
Non-Participating Providers. It is understood that in some instances Participants will require specialty care not available from a Participating Provider and that the FIDA Plan will arrange that such items and services be provided by a Non- Participating Provider. In such event, the FIDA Plan will promptly negotiate an agreement (“Single Case Agreement”) with a Non-Participating Provider at the applicable Medicaid or Medicare Fee-For-Service rate to treat the Participant until a qualified Participating Provider is available. The FIDA Plan shall make best efforts to have any Non-Participating Provider billing for services be enrolled in the Medicare program or New York State Medicaid program, as appropriate and in the same manner as Participating Providers under Section 2.8.1.2, prior to paying a claim.
Non-Participating Providers. A) Payment by the Contractor for general hospital emergency department services provided to an Enrollee by a Non- Participating Provider shall be at the Medicaid fee-for-service rate, inclusive of the capital component, in effect on the date that the service was rendered without regard to whether such services meet the definition of Emergency Medical Condition.
B) Payment by the Contractor for physician services provided to an Enrollee by a Non-Participating Provider while the Enrollee is receiving general hospital emergency department services shall be at the Medicaid fee-for-service rate in effect on the date the service was rendered without regard to whether such services meet the definition of Emergency Medical Condition.
Non-Participating Providers. Participating Provider acknowledges and agrees that a Member may not receive the maximum benefits under his/her Health Benefits Plan if he/she is referred or admitted to a non-Participating Provider. When a Referral is required:
5.13.1 Participating Provider shall refer Member to other Participating Providers unless such Participating Provider determines it would be medically inappropriate to do so or in the event the required medical services are not available through other Participating Providers. In the event Participating Provider engages in a pattern of referring Members to out-of-network or non-participating Providers, QualCare may terminate this Agreement in accordance with Article 10.
5.13.2 Participating Provider shall admit Member requiring Hospital Services to Participating Hospitals unless the necessary Hospital Services are not available at a Participating Hospital or in the case of an Emergency. Participating Provider shall obtain an appropriate Authorization prior to admitting any Member to a hospital, except in the case of an Emergency. In cases where an Emergency admission is required, Participating Provider shall notify QualCare or its designee of such Emergency admission within forty-eight (48) hours of such Emergency admission or the next business day, whichever is later.
Non-Participating Providers. A) Payment by the Contractor for general hospital emergency department services provided to an Enrollee by a Non-Participating Provider shall be at the Medicaid fee-for-service rate, inclusive of the capital component, in effect on the date that the service was rendered without regard to whether such services meet the definition of Emergency Medical Condition.
B) Payment by the Contractor for physician services provided to an Enrollee by a Non-Participating Provider while the Enrollee is receiving general hospital emergency department services shall be at the Medicaid fee-for-service rate in effect on the date the service was rendered without regard to whether such services meet the definition of Emergency Medical Condition.
C) Payment by the Contractor for CPEP services by Non-Participating Providers shall be at the same rate as for Participating Providers pursuant to this Section.
D) Payment by the Contractor for Crisis Intervention Services by Non- Participating Providers shall be at the same rate as for Participating Providers pursuant to this Section.
Non-Participating Providers. The contractor shall be responsible for developing and advising its enrollees and where applicable, authorized persons of procedures for obtaining emergency services, including emergency dental services, when it is not medically feasible for enrollees to receive emergency services from or through a participating provider, or when the time required to reach the participating provider would mean risk of permanent damage to the enrollee's health. The contractor shall bear the cost of providing emergency service through non-participating providers.
