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.
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 EXHIBIT 2.H HEALTHY INDIANA PLAN SCOPE OF WORK 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-net...
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:
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:
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).)
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. Report the number of services, by individual service, that are rendered by out-of- network providers ; and the percentage of services, by individual service, that are rendered by out-of-network providers.
Out-of-Network Services. If the Member’s PCP is part of a practice group or association of Health Professionals and Medically Necessary Covered Services are not available within the PCP’s limited provider network, the Member has the right to a Referral to a Participating Provider outside the PCP’s limited provider network. If Medically Necessary Covered Benefits are not available from Participating Providers, HMO will allow a Referral to a non-participating Provider. The following apply:
