Out-of-Network Services. We Cover the services of Non-Participating Providers. See the Schedule of Benefits section of this Contract for the Non-Participating Provider services that are Covered. In any case where benefits are limited to a certain number of days or visits, such limits apply in the aggregate to in-network and out-of-network services.
Out-of-Network Services. (A) If the Contractor’s network of Participating Providers is unable to provide Medically Necessary Covered Services under this Contract to a particular Enrollee, the Contractor shall adequately and timely cover these services using a Non-Participating Provider for the Enrollee for as long as the Contractor is unable to provide them.
(B) The Contractor shall require Non-Participating Providers to coordinate with the Contractor with respect to payment and ensure that the cost to the Enrollee is no greater than it would be if the services were furnished within the network.
Out-of-Network Services. With the exception of certain self-referral services described in Section 6.2, and the requirements to allow continuity of care for pregnant women transferring to the Contractor in their third trimester described in Section 3.4, and members with presumptive eligibility seeking initial care, the Contractor may limit its coverage to services provided by in-network providers once the Contractor has met the network access standards set forth in Section 8. However, in accordance with 42 CFR 438.206(b)(4), which relates to coverage of out-of-network services, the Contractor shall authorize and pay for out-of- network care if the Contractor is unable to provide necessary covered medical services within sixty (60)-miles of the member’s residence by the Contractor’s provider network. In addition, upon at least thirty (30) calendar days’ advance notice, the State may also require the Contractor to begin providing out-of-network care in the event the Contractor is unable to provide necessary covered medical services within the Contractor’s provider network within specified timeliness standards defined by the State. The Contractor shall authorize these out-of-network services in the timeframes established in Section 9.3.2 and shall adequately cover the services for as long as the Contractor is unable to provide the covered services in-network. The Contractor shall require out-of-network providers to coordinate with the Contractor with respect to payment. Per 42 CFR 438.206(b)(5), the cost to the member for out-of-network services shall be no greater than it would be if the services were furnished in-network. The Contractor may require providers not contracted in the Contractor’s network to obtain prior authorization from the Contractor to render any non-self-referral or non-emergent services to Contractor members. If the out-of-network provider has not obtained such prior authorization, the Contractor may deny payment to that out-of-network provider. The Contractor shall cover and reimburse for all authorized, routine care provided to its members by out-of-network providers. The Contractor shall reimburse any out-of-network provider’s claim for authorized services at a negotiated rate or according to administrative code 405 IAC 10-9-4 (b) and State statute IC 12-15-44.5-5. Contractors shall make nurse practitioner services available to members. Members shall be allowed to use the services of nurse practitioners out-of-network if no nurse practitioner is available in t...
Out-of-Network Services. In accordance with Benefit Program requirements, Covered Services provided as a result of a Member’s self-referral to a PPO or HMO Provider or to a non-Participating Provider. Out-of-Network Services may be provided in area or out of area.
Out-of-Network Services. Subject to Article III, Section 2.7, Timely Payment Requirement, the MCO must make timely payment within thirty (30) calendar days for clean claims to out-of-network providers for Medically Necessary, covered services when:
1. Services were rendered to treat a Medical Emergency;
2. Services were for family planning and sexually transmitted diseases;
3. Services were prior authorized; or
4. Retro-authorization meeting medical necessity has been granted due to the nature of service. For non-emergency out-of-network services, the MCO may reimburse providers at eighty percent (80%) of the prevailing Medicaid FFS rate or higher, unless such services are deemed medically unnecessary, are not covered by the MCO, or do not receive authorization. Consistent with Article III, Section 1.2.2, reimbursement for emergency services provided out- of-network must be equal to the Medicaid prevailing FFS reimbursement level for emergency services, less any payments for direct costs of medical education and direct costs of graduate medical education included in the FFS reimbursement rate.
Out-of-Network Services. The MCO must cover services covered under the contract out-of-network for the enrollee if the network is unable to provide such services and must ensure that the cost to the enrollee is no greater than it would be if the services were furnished within the network. Services must be covered as adequately and timely as if such services were provided within the network, and for as long as the MCO is unable to provide them. To the extent possible, the MCO must encourage out-of-network providers to coordinate with the MCO with respect to payment.
Out-of-Network Services. Subject to Article III, 2.7, Timely Payment Requirement, the MCO must make timely payments to out-of-network providers for Medically Necessary, covered services when:
1. Services were rendered to treat a Medical Emergency, or
2. Services were for family planning and sexually transmitted diseases, or
3. Services were prior authorized. For authorized and non-authorized non-emergency out-of-network services, the MCO may reimburse providers at the eighty (80) percent of the prevailing Medicaid fee-for-service rate or higher, unless such services are deemed medically unnecessary or not covered by the MCO. Consistent with Article III, Section 1.2.2, reimbursement for emergency services provided out- of-network must be equal to the Medicaid prevailing fee-for-service (FFS) reimbursement level for emergency services, less any payments for direct costs of medical education and direct costs of graduate medical education included in the FFS reimbursement rate.
Out-of-Network Services. A. If the Contractor’s provider network is unable to provide necessary services, covered under this Contract, to a particular beneficiary, the Contractor shall adequately and timely cover the services out of network, for as long as the Contractor’s provider network is unable to provide them. (42 C.F.R. § 438.206(b)(4).)
B. The Contractor shall require that out-of-network providers coordinate authorization and payment with the Contractor. The Contractor must ensure that the cost to the beneficiary for services provided out of network pursuant to an authorization is no greater than it would be if the services were furnished within the Contractor’s network, consistent with Cal.ifornia Code of Regulations., tit.le 9, section 1810.365. (42 C.F.R. § 438.206(b)(5).)
C. Contractor shall comply with the requirements of California. Code of Regulations, tit.le 9, section 1830.220 regarding providing beneficiaries access to out-of-network providers when a provider is available in Contractor’s network.
D. Pursuant to Department guidance, Contractor shall submit to the Department for approval policies and procedures regarding authorization of out-of-network services to establish compliance with title 42 of the Code of Federal Regulations, section 438.910(d)(3).
Out-of-Network Services. A. If the Contractor’s provider network is unable to provide necessary services, covered under this Contract, to a particular beneficiary, the Contractor shall adequately and timely cover the services out-of-network, for as long as the Contractor’s provider network is unable to provide them. (42 C.F.R. § 438.206(b)(4).)
B. The Contractor shall require that out-of-network providers coordinate authorization and payment with the Contractor. The Contractor must ensure that the cost to the beneficiary for services provided out-of-network pursuant to an authorization is no greater than it would be if the services were furnished within the Contractor’s network, consistent with Cal. Code Regs., tit. 9, section 1810.365. (42 C.F.R. § 438.206(b)(5).)
C. The Contractor shall comply with the requirements of Cal. Code Regs., tit. 9, section 1830.220 regarding providing beneficiaries access to out-of- network providers when a provider is available in Contractor’s network.
D. Pursuant to Department guidance, the Contractor shall submit to the Department for approval policies and procedures regarding authorization of out-of-network services to establish compliance with title 42 of the Code of Federal Regulations, section 438.910(d)(3).
Out-of-Network Services. (A) If the Contractor’s network of Network Providers is unable to provide Medically Necessary Covered Services under this Contract to a particular Enrollee, the Contractor shall adequately and timely cover these services using a Non-Network Provider for the Enrollee for as long as the Contractor is unable to provide them.
(B) The Contractor shall require Non-Network Providers to coordinate with the Contractor with respect to payment and ensure that the cost to the Enrollee is no greater than it would be if the services were furnished within the network.
(C) The Contractor shall use processes, strategies, evidentiary standards, or other factors in determining access to Non-Network providers for mental health or substance use disorder benefits that are comparable to, and applied no more stringently than, the processes, and standards used in determining access to Non-Network providers for medical/surgical benefits in the same classification.
