Common use of Out-of-Network Services Clause in Contracts

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. Subject to Article III, Section 2.7, Timely Payment Requirement, the MCO must make timely payment within thirty (30) calendar days for clean claims 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; , 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%) percent of the prevailing Medicaid FFS fee-for-service 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 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. Subject to Article III, Section 2.73.7, Timely Payment Requirement, the MCO must make timely payment payments 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%) percent 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 1.2.22.2.2, 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. 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 or WVCHIP 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. Subject to Article III, Section 2.7, Timely Payment Requirement, the MCO must make timely payment within thirty (30) calendar days for clean claims 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; or. 4. Retro-authorization for specific services (e.g. lab testing) meeting medical necessity has been granted due to the nature of service. 5. For non-emergency out-of-network services, the MCO may reimburse providers at eighty percent (80%) percent of the prevailing Medicaid FFS fee-for-service rate or higher, unless such services are deemed medically unnecessary, are not covered by the MCO, or do not receive prior or retro authorization, for select services in which prior authorization cannot be obtained. Consistent with Article III, Section 1.2.2, reimbursement for emergency services provided out- out-of-network must be equal to the Medicaid prevailing FFS 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. Subject to Article III, Section 2.72.7.7, 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 diseasesSTDs; 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 or WVCHIP 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.