For non-network providers Sample Clauses

The 'For non-network providers' clause defines how services rendered by healthcare providers who are not part of an insurer's approved network are handled under an insurance policy. Typically, this clause outlines the reimbursement rates, coverage limitations, and any additional requirements or higher out-of-pocket costs that apply when a policyholder chooses or needs to use a provider outside the network. Its core function is to clarify the financial responsibilities and coverage differences for out-of-network care, helping policyholders understand the potential costs and limitations associated with using non-network providers.
For non-network providers a. When a covered service is received from a non-network provider as a result of an emergency and there is not a network provider reasonably accessible to render the covered service, the eligible service expense is the lesser of (1) the negotiated fee, if any, that has been mutually agreed upon by us and the provider as payment in full (you will not be billed for the difference between the negotiated fee and the provider’s charge), or (2) the provider’s billed charge.; b. When a covered service is received from a non-network provider as a result of an emergency and there is a network provider reasonably accessible to render the covered service, the eligible service expense is the negotiated fee, if any, that the provider has agreed to accept as payment in full (you will not be billed for the difference between the negotiated fee and the provider’s charge). However, if the provider has not agreed to accept a negotiated fee as payment in full, the eligible expense is the greatest of the following: i. the amount that would be paid under Medicare, ii. the amount for the covered service calculated using the same method we generally use to determine payments for out-of-network services, or iii. the contracted amount paid to network providers for the covered service. If there is more than one contracted amount with network providers for the covered service, the amount is the median of these amounts. c. When a covered service is received from a non-network provider as approved or authorized by us, the eligible service expense is the negotiated fee, if any, that the provider has agreed to accept as payment in full (you will not be billed for the difference between the negotiated fee and the provider’s charge). ). If there is no negotiated fee agreed to by the provider with us, the eligible service expense is the greater of (1) the amount that would be paid by Medicare, or (2) the contracted amount paid to network providers for the covered service. If there is more than one contracted amount with network providers for the covered service, the amount is the median of these amounts. You may be billed for the difference between the amount paid and the provider’s charge. d. When a covered service expense is received from a non-network provider because the service or supply is not of a type provided by any network provider, the eligible service expense is the negotiated fee, if any, that the provider has agreed to accept as payment in full (you will not be billed for the...
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For non-network providers. For a Provider who does not have a written agreement with Claim Administrator or another Blue Cross and/or Blue Shield Plan to provide care to a Covered Person at the time Covered Services for medical benefits are rendered (“Non- Network Provider”), the Allowable Amount will be the lesser of: 1. the Non-Network Provider's Claim Charge, or;
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For non-network providers. For a Provider who does not have a written agreement with Claim Administrator or another Blue Cross and/or Blue Shield Plan to provide care to a Covered Person at the time Covered Services for medical benefits are rendered (“Non- Network Provider”), the Allowable Amount for Non-Network Providers is developed from base Medicare reimbursements, excluding any Medicare adjustments using information on the Claim, and adjusted by a predetermined factor established by the Plan. Such factor will not be less than one-hundred percent (100%) of the base Medicare reimbursement rate unless a lower factor has been negotiated with the Non-Network Provider. For services for which a Medicare reimbursement rate is not available, the Allowable Amount for Non- Network Providers will represent an average contract rate for Network Providers adjusted by a predetermined factor established by the Plan and updated on a periodic basis. Such factor shall not be less than eighty percent (80%) of the average contract rates and will be updated not less than every two years. Claim Administrator will utilize the same Claim processing rules and/or edits that it utilizes in processing Network Provider Claims for processing Claims submitted by Non-Network Providers which may also alter the Allowable Amount for a particular service. In the event the Plan does not have any Claim edits or rules, the Plan may utilize the Medicare claim rules or edits that are used by Medicare in processing the Claims. The Allowable Amount will not include any additional payments that may be permitted under the Medicare laws or regulations which are not directly attributable to a specific Claim, including but not limited to, disproportionate share and graduate medical education payments. Any change to the Medicare reimbursement amount will be implemented by the Plan within ninety (90) days after the effective date that such change is implemented by the Centers for Medicaid and Medicare Services, or its successor.
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Related to For non-network providers

  • How Non-network Providers Are Paid This plan does not cover services received from a non-network provider except for the special circumstances described below.

  • NON-NETWORK PROVIDER is a provider that has not entered into a contract with us or any other Blue Cross and Blue Shield plan. For pediatric dental care services, non-network provider is a dentist that has not entered into a contract with us or does not participate in the Dental Coast to Coast Network. For pediatric vision hardware services, a non-network provider is a provider that has not entered into a contract with EyeMed, our vision care service manager.

  • The Web Services E-Verify Employer Agent agrees to, consistent with applicable laws, regulations, and policies, commit sufficient personnel and resources to meet the requirements of this MOU.

  • Service Management Effective support of in-scope services is a result of maintaining consistent service levels. The following sections provide relevant details on service availability, monitoring of in-scope services and related components.

  • SERVICE PROVIDER’S PERSONNEL 10.1 The Service Provider’s Personnel shall be regarded at all times as employees, agents or Subcontractors of the Service Provider and no relationship of employer and employee shall arise between Transnet and any Service Provider Personnel under any circumstances regardless of the degree of supervision that may be exercised over the Personnel by Transnet. 10.2 The Service Provider warrants that all its Personnel will be entitled to work in South Africa or any other country in which the Services are to be performed. 10.3 The Service Provider will ensure that its Personnel comply with all reasonable requirements made known to the Service Provider by Transnet concerning conduct at any Transnet premises or any other premises upon which the Services are to be performed [including but not limited to security regulations, policy standards and codes of practice and health and safety requirements]. The Service Provider will ensure that such Personnel at all times act in a lawful and proper manner in accordance with these requirements. 10.4 Transnet reserves the right to refuse to admit or to remove from any premises occupied by or on behalf of it, any Service Provider Personnel whose admission or presence would, in the reasonable opinion of Transnet, be undesirable or who represents a threat to confidentiality or security or whose presence would be in breach of any rules and regulations governing Transnet's Personnel, provided that Transnet notifies the Service Provider of any such refusal [with reasons why]. The reasonable exclusion of any such individual from such premises shall not relieve the Service Provider from the performance of its obligations under this Agreement. 10.5 The Service Provider agrees to use all reasonable endeavours to ensure the continuity of its Personnel assigned to perform the Services. If any re-assignment by the Service Provider of those Personnel is necessary, or if Transnet advises that any such Personnel assigned are in any respect unsatisfactory, including where any such Personnel are, or are expected to be or have been absent for any period, then the Service Provider will promptly supply a replacement of equivalent calibre and experience, and any such replacement shall be approved by Transnet prior to commencing provision of the Services, such approval not to be unreasonably withheld or delayed.