Out-of-Network Providers. 4.8.19.1 If the Contractor’s network is unable to provide Medically Necessary Covered Services to a particular Member, the Contractor shall adequately and timely cover these services Out-of-Network for the Member. The Contractor must inform the Out-of Network Provider that the member cannot be balance billed.
4.8.19.2 The Contractor shall coordinate with Out-of-Network Providers regarding payment. For payment to Out-of-Network, or non-participating Providers, the following guidelines apply: · If the Contractor offers the service through an In-Network Provider(s), and the Member chooses to access the service (i.e., it is not an emergency) from an Out-of-Network Provider, the Contractor is not responsible for payment. · If the service is not available from an In-Network Provider, but the Contractor has three (3) Documented Attempts to contract with the Provider, the Contractor is not required to pay more than Medicaid FFS rates for the applicable service, less ten percent (10%). · If the service is available from an In-Network Provider, but the service meets the Emergency Medical Condition standard, and the Contractor has three (3) Documented Attempts to contract with the Provider, the Contractor is not required to pay more than Medicaid FFS rates for the applicable service, less ten percent (10%). · When paying out of state providers in an emergency situation: Be advised that the CMOs shall not allow a member to be held accountable for payment under these circumstances. · If the service is not available from an In-Network Provider and the Member requires the service and is referred for treatment to an Out-of-Network Provider, the payment amount is a matter between the CMO and the Out-of-Network Provider.
4.8.19.3 In the event that needed services are not available from an In-Network Provider and the Member must receive services from an Out-of-Network Provider, the Contractor must ensure that the Member is not charged more than it would have if the services were furnished within the network.
Out-of-Network Providers. If you elect to receive Covered Services and supplies from an Out-of-Network Provider, you will be balanced billed for and will be responsible to pay all amounts charged by the Out-of-Network Provider that are above the Allowed Amount. This means you may pay higher Out-of-Pocket Expenses for Covered Services and supplies you receive from Out-of-Network Providers. In addition to balance billing, when you receive care from an Out-of-Network Provider, you will also be responsible for any applicable Copay, Deductible, 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.
Out-of-Network Providers. In the event that the Physician of a new Enrollee who is in an active, ongoing course of treatment or is in the third trimester of pregnancy is not an Affiliated Provider, Contractor will permit such Enrollee to continue an ongoing course of treatment with such Physician for up to ninety (90) days or through the postpartum period, or as otherwise required by Section 25 of the Managed Care Reform and Patients Rights Act only if the out-of-network Physician agrees to provide such ongoing course of treatment, and if such out-of-network Physician agrees to: (i) accept reimbursement at Contractor’s established rates based on a review of the level of services provided, (ii) adhere to Contractor’s QA requirements, (iii) provide necessary medical information related to health care, and (iv) adhere to Contractor’s policies and procedures, including, but not limited to, procedures regarding Referrals.
Out-of-Network Providers. The Department will provide the Contractor with an expedited enrollment process to assign provider numbers for providers not already enrolled in Medicaid for emergency situations only.
Out-of-Network Providers. 9.7.1 If the Contractor’s network is unable to provide Medically Necessary Covered Services or FQHC Services to an Enrollee, the Contractor shall adequately and timely cover these services using Providers outside of its Network.
9.7.2 Except as provided with respect to Emergency Services (see Section 7.5.9.3.1.2 of this Contract) and FQHC Services, if the Contractor offers the service through a Provider in the Network but the Enrollee chooses to access the service from an Out-of-Network Provider, the Contractor is not responsible for payment of such Claims.
9.7.3 The Contractor must ensure that Out-of-Network Providers are duly licensed to provide the Covered Services for which they submit Claims.
9.7.4 ASES shall ensure, in setting Co-Payments, that in the event that a Co-Payment is imposed on Enrollees for an Out-of-Network service, the Co-Payment shall not exceed the Co-Payment that would apply if services were provided by a Provider in the General Network.
Out-of-Network Providers. A. If Contractor’s Network is unable to provide necessary services covered under the Contract to a particular Member, Contractor must adequately and timely cover these services out-of-Network for the Member, for as long as the entity is unable to provide them. Out-of-Network Providers must coordinate with the entity with respect to payment. Contractor must ensure that cost to the Member is not greater than it would be if the services were furnished within the Network.
B. Contractor shall provide for the completion of covered services by a terminated or Out-of-Network Provider at the request of a Member in accordance with the continuity of care requirements in Health and Safety Code Section 1373.
C. For newly enrolled SPD beneficiaries who request continued access, Contractor shall provide continued access for up to 12 months to an Out- of-Network Provider with whom they have an ongoing relationship if there are no quality of care issues with the Provider and the Provider will accept Contractor or Medi-Cal FFS rates, whichever is higher, in accordance with W & I Code 14182(b)(13) and (14). An ongoing relationship shall be determined by the Contractor identifying a link between a newly enrolled SPD beneficiary and an Out-of-Network Provider using FFS utilization data provided by DHCS.
D. In determining access to Out-of-Network Providers for mental health or substance use disorder benefits, Contractor must use processes, strategies, evidentiary standards, or other factors that are comparable to, and applied no more stringently than, the processes, strategies, evidentiary standards, or other factors for services identified within this Provision, in accordance with 42 CFR 438.910(d)(3).
Out-of-Network Providers. In spending POWER Account funds, enrollees will be permitted to pay for the following covered services, even if obtained through out-of- network providers:
i. Family planning services;
ii. Emergency medical services, subject to the prudent layperson standard of an “emergency medical condition,” as specified in 42 CFR 438.114;
iii. Medically necessary covered services, if the MCO’s network is unable to provide the service within a 30-mile radius for primary care and a 60-mile radius for specialty care of the enrollee’s residence; and
iv. Nurse practitioner services.
Out-of-Network Providers. It is understood that in some instances Enrollees will require specialty care not available from a network provider and that the ICO will arrange that such services be provided by a non- network provider. In such event, ICO will negotiate a Single Case Agreement with a non-network provider at the applicable Medicaid or Medicare FFS rate to treat the Enrollee until a qualified network provider is available. The ICO shall make best efforts to have any non-network provider billing for services be enrolled in the Medicare Program or Michigan Medicaid Program, as appropriate and in the same manner as network providers under Section 2.7.1.2, prior to paying a Claim.
2.7.4.4.1. If the ICO’s network is unable to provide necessary medical services covered under the Contract to a particular Enrollee, the ICO must adequately and timely cover these services out of network for the Enrollee, for as long as the ICO is unable to provide them. The ICO must ensure that there is no cost to the Enrollee as though the service was provided by an in-network provider for the following services:
2.7.4.4.1.1. Ventilator care in a nursing facility with a Medicaid contract for a Ventilator Dependent Care Unit; and
Out-of-Network Providers. (outside the state of Oklahoma) – the Provider’s usual charge, up to the amount that the on-site Blue Cross and Blue Shield Plan would reimburse a BlueCard PPO Provider for the same service.
Out-of-Network Providers. 6.5.1 The DMO shall reimburse an out-of-network provider for an Enrolled Member who receives Medically Necessary services on or after the beginning date of the service period for the Agreement.
6.5.2 The out-of-network provider must be enrolled with Arkansas Medicaid prior to receiving reimbursement.
