Common use of How Non-network Providers Are Paid Clause in Contracts

How Non-network Providers Are Paid. If you receive care from a non-network provider, you are responsible for paying all charges for the services you received. You may submit a claim for reimbursement of the payments you made. For the limited circumstances listed below, your copayment and deductible will apply at the network level of benefits: • emergency care (emergency room, urgent care and ambulance services); • we specifically approve the use of a non-network provider for covered healthcare services, see Network Authorization in Section 5 for details; • covered healthcare services are rendered by a non-network provider at a network For those circumstances where we cover services from a non-network provider, we reimburse you or the non-network provider, less any copayments and deductibles, up to the lesser of: • our allowance; • the non-network provider’s charge; or • the benefit limit. You are responsible for the deductible, if one applies, and the copayment, as well as any amount over the benefit limit that applies to the service you received. You are liable for the difference between the amount that the non-network provider bills and the payment we make for covered healthcare services. Generally, we send reimbursement to you, but we reserve the right to reimburse a non-network provider directly. We reimburse non-network provider services using the same guidelines we use to pay network providers. Generally, our payment for non-network provider services will not be more than the amount we pay for network provider services. If an allowance for a specific covered healthcare service cannot be determined by reference to a fee schedule, reimbursement will be based upon a calculation that reasonably represents the amount paid to network providers. For emergency services, we reimburse non- network providers, in accordance with R.I. Gen. Laws § 27-18-76, the greater of our allowance, our usual guidelines for paying non-network providers, or the amount that would be paid under Medicare, less any copayments or deductibles. Payments we make to you are personal. You cannot transfer or assign any of your right to receive payments under this agreement to another person or organization, unless the R.I. General Law §27-20-49 (Dental Insurance assignment of benefits) applies. For information about network authorization requests to seek covered healthcare services from a non-network provider when the covered healthcare service cannot be provided by a network provider, please see Network Authorization in Section 5.

How Non-network Providers Are Paid. If you receive care This plan does not cover services received from a non-network provider, you are responsible for paying all charges for provider except in the services you received. You may submit a claim for reimbursement of the payments you made. For the following limited circumstances listed below, your copayment and deductible will apply at the network level of benefitscircumstances: • emergency care (emergency room, urgent care and ambulance services); • we specifically approve the use of a non-network provider for covered healthcare services, see Network Authorization in Section 5 for details; • covered healthcare services are rendered by a non-network provider at a network If you receive care from a non-network provider, you are responsible for paying all charges for the services you received. For the limited circumstances listed above, you may submit a claim for reimbursement of the payments you made. Your copayment and deductible will apply at the network level of benefits as indicated in the Summary of Medical Benefits. For those circumstances where we cover services from a non-network provider, we reimburse you or the non-network provider, less any copayments and deductibles, up to the lesser of: • our allowance; • the non-network provider’s charge; or • the benefit limit. You are responsible for the deductible, if one applies, and the copayment, as well as any amount over the benefit limit that applies to the service you received. You are liable for the difference between the amount that the non-network provider bills and the payment we make for covered healthcare services. Generally, we send reimbursement to you, but we reserve the right to reimburse a non-network provider directly. We reimburse non-network provider services using the same guidelines we use to pay network providers. Generally, our payment for non-network provider services will not be more than the amount we pay for network provider services. If an allowance for a specific covered healthcare service cannot be determined by reference to a fee schedule, reimbursement will be based upon a calculation that reasonably represents the amount paid to network providers. For emergency services, we reimburse non- network providers, in accordance with R.I. Gen. Laws § 27-18-76, the greater of our allowance, our usual guidelines for paying non-network providers, or the amount that would be paid under Medicare, less any copayments or deductibles. Payments we make to you are personal. You cannot transfer or assign any of your right to receive payments under this agreement to another person or organization, unless the R.I. General Law §27-20-49 (Dental Insurance assignment of benefits) applies. For information about network authorization requests to seek covered healthcare services from a non-network provider when the covered healthcare service cannot be provided by a network provider, please see Network Authorization in Section 5.

How Non-network Providers Are Paid. If you receive care care, including emergency or urgent care, from a non-network provider, you are responsible for paying all charges for the services you received. You may submit a claim for reimbursement of the payments you made. For the limited circumstances listed below, your copayment and deductible will apply at the network level of benefits: • emergency care (emergency room, urgent care and ambulance services); • we specifically approve the use of a non-network provider for covered healthcare services, see Network Authorization in Section 5 for details; • covered healthcare services are rendered by a non-network provider at a network For those circumstances where we cover services from a non-network provider, we We reimburse you or the non-network provider, less any copayments and deductibles, provider up to the lesser of: • of our allowance; • , the non-network provider’s charge; , or • the benefit limit, less any copayments and deductibles. You are responsible for the deductible, if one applies, and the copayment, as well as any amount over the benefit limit that applies to the service you received. You are liable for the difference between For emergency or urgent care services, the amount that you pay is the non-same as a network provider bills and the payment we make for covered healthcare services. Generally, we send reimbursement to you, but we reserve the right to reimburse a non-network provider directlyprovider. We reimburse non-network provider services using the same guidelines we use to pay network providers. Generally, our payment for non-network provider services will not be more than the amount we pay for network provider services. If an allowance for a specific covered healthcare service cannot be determined by reference to a fee schedule, reimbursement will be based upon a calculation that reasonably represents the amount paid to network providers. For emergency services, we reimburse non- network providers, in accordance with R.I. Gen. Laws § 27-18-76, the greater of our allowance, our usual guidelines for paying non-network providers, or the amount that would be paid under Medicare, less any copayments or deductibles. You are liable for the difference between the amount that the non-network provider bills and the payment we make for covered healthcare services. Generally, we send reimbursement to you, but we reserve the right to reimburse a non-network provider directly. Payments we make to you are personal. You cannot transfer or assign any of your right to receive payments under this agreement to another person or organization, unless the R.I. General Law §27-20-49 (Dental Insurance assignment of benefits) applies. For information about network Network authorization requests to seek covered healthcare services from a non-network provider when the covered healthcare service cannot be provided by a network provider, please see provider is explained in Network Authorization in Section 5.

How Non-network Providers Are Paid. If you receive care This plan does not cover services received from a non-network provider, you are responsible for paying all charges for provider except in the services you received. You may submit a claim for reimbursement of the payments you made. For the following limited circumstances listed below, your copayment and deductible will apply at the network level of benefitscircumstances: • emergency care (emergency room, urgent care room services and ambulance services); • we specifically approve the use of a non-network provider for covered healthcare services, see Network Authorization in Section 5 for details; • covered healthcare services are rendered by a non-network provider at a network For those circumstances where we cover services facility outside of your control; If you receive care from a non-network provider, we you are responsible for paying all We reimburse you or the non-network provider, less any copayments and deductibles, provider up to the lesser of: • of our allowance; • , the non-network provider’s charge; , or • the benefit limit, less any copayments and deductibles. You are responsible for the deductible, if one applies, and the copayment, as well as any amount over the benefit limit that applies to the service you received. You are liable for the difference between For emergency or urgent care services, the amount that you pay is the non-same as a network provider bills and the payment we make for covered healthcare services. Generally, we send reimbursement to you, but we reserve the right to reimburse a non-network provider directlyprovider. We reimburse non-network provider services using the same guidelines we use to pay network providers. Generally, our payment for non-network provider services will not be more than the amount we pay for network provider services. If an allowance for a specific covered healthcare service cannot be determined by reference to a fee schedule, reimbursement will be based upon a calculation that reasonably represents the amount paid to network providers. For emergency services, we reimburse non- network providers, in accordance with R.I. Gen. Laws § 27-18-76, the greater of our allowance, our usual guidelines for paying non-network providers, or the amount that would be paid under Medicare, less any copayments or deductibles. You are liable for the difference between the amount that the non-network provider bills and the payment we make for covered healthcare services. Generally, we send reimbursement to you, but we reserve the right to reimburse a non-network provider directly. Payments we make to you are personal. You cannot transfer or assign any of your right to receive payments under this agreement to another person or organization, unless the R.I. General Law §27-20-49 (Dental Insurance assignment of benefits) applies. For information about network Network authorization requests to seek covered healthcare services from a non-network provider when the covered healthcare service cannot be provided by a network provider, please see provider is explained in Network Authorization in Section 5.

How Non-network Providers Are Paid. If you receive care This plan does not cover services received from a non-network provider, you are responsible for paying all charges for provider except in the services you received. You may submit a claim for reimbursement of the payments you made. For the following limited circumstances listed below, your copayment and deductible will apply at the network level of benefitscircumstances: •  emergency care (emergency room, urgent care room services and ambulance services); •  we specifically approve the use of a non-network provider for covered healthcare services, see Network Authorization in Section 5 for details; •  covered healthcare services are rendered by a non-network provider at a network For those circumstances where we cover services facility outside of your control; If you receive care from a non-network provider, we you are responsible for paying all We reimburse you or the non-network provider, less any copayments and deductibles, provider up to the lesser of: • of our allowance; • , the non-network provider’s charge; , or • the benefit limit, less any copayments and deductibles. You are responsible for the deductible, if one applies, and the copayment, as well as any amount over the benefit limit that applies to the service you received. You are liable for the difference between For emergency or urgent care services, the amount that you pay is the non-same as a network provider bills and the payment we make for covered healthcare services. Generally, we send reimbursement to you, but we reserve the right to reimburse a non-network provider directlyprovider. We reimburse non-network provider services using the same guidelines we use to pay network providers. Generally, our payment for non-network provider services will not be more than the amount we pay for network provider services. If an allowance for a specific covered healthcare service cannot be determined by reference to a fee schedule, reimbursement will be based upon a calculation that reasonably represents the amount paid to network providers. For emergency services, we reimburse non- network providers, in accordance with R.I. Gen. Laws § 27-18-76, the greater of our allowance, our usual guidelines for paying non-network providers, or the amount that would be paid under Medicare, less any copayments or deductibles. You are liable for the difference between the amount that the non-network provider bills and the payment we make for covered healthcare services. Generally, we send reimbursement to you, but we reserve the right to reimburse a non-network provider directly. Payments we make to you are personal. You cannot transfer or assign any of your right to receive payments under this agreement to another person or organization, unless the R.I. General Law §27-20-49 (Dental Insurance assignment of benefits) applies. For information about network Network authorization requests to seek covered healthcare services from a non-network provider when the covered healthcare service cannot be provided by a network provider, please see provider is explained in Network Authorization in Section 5.

How Non-network Providers Are Paid. If you receive care from a non-network provider, you are responsible for paying all charges for the services you received. You may submit a claim for reimbursement of the payments you made. For the limited circumstances listed below, your copayment and deductible will apply at the network level of benefits: •  emergency care (emergency room, urgent care and ambulance services); •  we specifically approve the use of a non-network provider for covered healthcare services, see Network Authorization in Section 5 for details; •  covered healthcare services are rendered by a non-network provider at a network For those circumstances where we cover services from a non-network provider, we reimburse you or the non-network provider, less any copayments and deductibles, up to the lesser of: •  our allowance; •  the non-network provider’s charge; or •  the benefit limit. You are responsible for the deductible, if one applies, and the copayment, as well as any amount over the benefit limit that applies to the service you received. You are liable for the difference between the amount that the non-network provider bills and the payment we make for covered healthcare services. Generally, we send reimbursement to you, but we reserve the right to reimburse a non-network provider directly. We reimburse non-network provider services using the same guidelines we use to pay network providers. Generally, our payment for non-network provider services will not be more than the amount we pay for network provider services. If an allowance for a specific covered healthcare service cannot be determined by reference to a fee schedule, reimbursement will be based upon a calculation that reasonably represents the amount paid to network providers. For emergency services, we reimburse non- network providers, in accordance with R.I. Gen. Laws § 27-18-76, the greater of our allowance, our usual guidelines for paying non-network providers, or the amount that would be paid under Medicare, less any copayments or deductibles. Payments we make to you are personal. You cannot transfer or assign any of your right to receive payments under this agreement to another person or organization, unless the R.I. General Law §27-20-49 (Dental Insurance assignment of benefits) applies. For information about network authorization requests to seek covered healthcare services from a non-network provider when the covered healthcare service cannot be provided by a network provider, please see Network Authorization in Section 5.

How Non-network Providers Are Paid. If you receive care from a non-network provider, you are responsible for paying all charges for the services you received. You may submit a claim for reimbursement of the payments you made. For the limited circumstances listed below, your copayment and deductible will apply at the network level of benefits: • emergency care (emergency room, urgent care and ambulance services); • we specifically approve the use of a non-network provider for covered healthcare services, see Network Authorization in Section 5 for details; • covered healthcare services are rendered by a non-network provider at a network • otherwise, as required by law. For those circumstances where we cover services from a non-network provider, we reimburse you or the non-network provider, less any copayments and deductibles, up to the lesser of: • our allowance; • the non-network provider’s charge; or • the benefit limit. You are responsible for the deductible, if one applies, and the copayment, as well as any amount over the benefit limit that applies to the service you received. You are liable for the difference between the amount that the non-network provider bills and the payment we make for covered healthcare services. Generally, we send reimbursement to you, but we reserve the right to reimburse a non-network provider directly. We reimburse non-network provider services using the same guidelines we use to pay network providers. Generally, our payment for non-network provider services will not be more than the amount we pay for network provider services. If an allowance for a specific covered healthcare service cannot be determined by reference to a fee schedule, reimbursement will be based upon a calculation that reasonably represents the amount paid to network providers. For emergency services, we reimburse non- network providers, in accordance with R.I. Gen. Laws § 27-18-76, the greater of our allowance, our usual guidelines for paying non-network providers, or the amount that would be paid under Medicare, less any copayments or deductibles. Payments we make to you are personal. You cannot transfer or assign any of your right to receive payments under this agreement to another person or organization, unless the R.I. General Law §27-20-49 (Dental Insurance assignment of benefits) applies. For information about network authorization requests to seek covered healthcare services from a non-network provider when the covered healthcare service cannot be provided by a network provider, please see Network Authorization in Section 5.

How Non-network Providers Are Paid. If you receive care This plan does not cover services received from a non-network provider, you are responsible for paying all charges for provider except in the services you received. You may submit a claim for reimbursement of the payments you made. For the following limited circumstances listed below, your copayment and deductible will apply at the network level of benefitscircumstances: •  emergency care (emergency room, urgent care and ambulance services); •  we specifically approve the use of a non-network provider for covered healthcare services, see Network Authorization in Section 5 for details; •  covered healthcare services are rendered by a non-network provider at a network If you receive care from a non-network provider, you are responsible for paying all charges for the services you received. For the limited circumstances listed above, you may submit a claim for reimbursement of the payments you made. Your copayment and deductible will apply at the network level of benefits as indicated in the Summary of Medical Benefits. For those circumstances where we cover services from a non-network provider, we reimburse you or the non-network provider, less any copayments and deductibles, up to the lesser of: •  our allowance; •  the non-network provider’s charge; or •  the benefit limit. You are responsible for the deductible, if one applies, and the copayment, as well as any amount over the benefit limit that applies to the service you received. You are liable for the difference between the amount that the non-network provider bills and the payment we make for covered healthcare services. Generally, we send reimbursement to you, but we reserve the right to reimburse a non-network provider directly. We reimburse non-network provider services using the same guidelines we use to pay network providers. Generally, our payment for non-network provider services will not be more than the amount we pay for network provider services. If an allowance for a specific covered healthcare service cannot be determined by reference to a fee schedule, reimbursement will be based upon a calculation that reasonably represents the amount paid to network providers. For emergency services, we reimburse non- network providers, in accordance with R.I. Gen. Laws § 27-18-76, the greater of our allowance, our usual guidelines for paying non-network providers, or the amount that would be paid under Medicare, less any copayments or deductibles. Payments we make to you are personal. You cannot transfer or assign any of your right to receive payments under this agreement to another person or organization, unless the R.I. General Law §27-20-49 (Dental Insurance assignment of benefits) applies. For information about network authorization requests to seek covered healthcare services from a non-network provider when the covered healthcare service cannot be provided by a network provider, please see Network Authorization in Section 5.

How Non-network Providers Are Paid. If you receive care care, including emergency or urgent care, from a non-network provider, you are responsible for paying all charges for the services you received. You may submit a claim for reimbursement of the payments you made. For the limited circumstances listed below, your copayment and deductible will apply at the network level of benefits: • emergency care (emergency room, urgent care and ambulance services); • we specifically approve the use of a non-network provider for covered healthcare services, see Network Authorization in Section 5 for details; • covered healthcare services are rendered by a non-network provider at a network For those circumstances where we cover services from a non-network provider, we We reimburse you or the non-network providerprovider up to the lesser of our allowance, the non-n e t w o r k pchr aorgev, ior dthee bren’ esfit limit, less any copayments and deductibles, up to the lesser of: • our allowance; • the non-network provider’s charge; or • the benefit limit. You are responsible for the deductible, if one applies, and the copayment, as well as any amount over the benefit limit that applies to the service you received. You are liable for the difference between For emergency or urgent care services, the amount that you pay is the non-same as a network provider bills and the payment we make for covered healthcare services. Generally, we send reimbursement to you, but we reserve the right to reimburse a non-network provider directlyprovider. We reimburse non-network provider services using the same guidelines we use to pay network providers. Generally, our payment for non-network provider services will not be more than the amount we pay for network provider services. If an allowance for a specific covered healthcare service cannot be determined by reference to a fee schedule, reimbursement will be based upon a calculation that reasonably represents the amount paid to network providers. For emergency services, we reimburse non- network providers, in accordance with R.I. Gen. Laws § 27-18-76, the greater of our allowance, our usual guidelines for paying non-network providers, or the amount that would be paid under Medicare, less any copayments or deductibles. You are liable for the difference between the amount that the non-network provider bills and the payment we make for covered healthcare services. Generally, we send reimbursement to you, but we reserve the right to reimburse a non-network provider directly. Payments we make to you are personal. You cannot transfer or assign any of your right to receive payments under this agreement to another person or organization, unless the R.I. General Law §27-20-49 (Dental Insurance assignment of benefits) applies. For information about network Network authorization requests to seek covered healthcare services from a non-network provider when the covered healthcare service cannot be provided by a network provider, please see provider is explained in Network Authorization in Section 5.

How Non-network Providers Are Paid. If you receive care from a non-network provider, you are responsible for paying all charges for the services you received. You may submit a claim for reimbursement of the payments you made. For the limited circumstances listed below, your copayment and deductible will apply at the network level of benefits: • emergency care (emergency room, urgent care and ambulance services); • we specifically approve the use of a non-network provider for covered healthcare services, see Network Authorization in Section 5 for details; • covered healthcare services are rendered by a non-network provider at a network facility outside of your control; • otherwise, as required by law. For those circumstances where we cover services from a non-network provider, we reimburse you or the non-network provider, less any copayments and deductibles, up to the lesser of: • our allowance; • the non-network provider’s charge; or • the benefit limit. You are responsible for the deductible, if one applies, and the copayment, as well as any amount over the benefit limit that applies to the service you received. You are liable for the difference between the amount that the non-network provider bills and the payment we make for covered healthcare services. Generally, we send reimbursement to you, but we reserve the right to reimburse a non-network provider directly. We reimburse non-network provider services using the same guidelines we use to pay network providers. Generally, our payment for non-network provider services will not be more than the amount we pay for network provider services. If an allowance for a specific covered healthcare service cannot be determined by reference to a fee schedule, reimbursement will be based upon a calculation that reasonably represents the amount paid to network providers. For emergency services, we reimburse non- network providers, in accordance with R.I. Gen. Laws § 27-18-76, the greater of our allowance, our usual guidelines for paying non-network providers, or the amount that would be paid under Medicare, less any copayments or deductibles. Payments we make to you are personal. You cannot transfer or assign any of your right to receive payments under this agreement to another person or organization, unless the R.I. General Law §27-20-49 (Dental Insurance assignment of benefits) applies. For information about network authorization requests to seek covered healthcare services from a non-network provider when the covered healthcare service cannot be provided by a network provider, please see Network Authorization in Section 5.

How Non-network Providers Are Paid. If you receive care from a non-network provider, you are responsible for paying all charges for the services you received. You may submit a claim for reimbursement of the payments you made. For the limited circumstances listed below, your copayment and deductible will apply at the network level of benefits: •  emergency care (emergency room, urgent care and ambulance services); •  we specifically approve the use of a non-network provider for covered healthcare services, see Network Authorization in Section 5 for details; •  covered healthcare services are rendered by a non-network provider at a network facility outside of your control;  otherwise, as required by law. For those circumstances where we cover services from a non-network provider, we reimburse you or the non-network provider, less any copayments and deductibles, up to the lesser of: •  our allowance; •  the non-network provider’s charge; or •  the benefit limit. You are responsible for the deductible, if one applies, and the copayment, as well as any amount over the benefit limit that applies to the service you received. You are liable for the difference between the amount that the non-network provider bills and the payment we make for covered healthcare services. Generally, we send reimbursement to you, but we reserve the right to reimburse a non-network provider directly. We reimburse non-network provider services using the same guidelines we use to pay network providers. Generally, our payment for non-network provider services will not be more than the amount we pay for network provider services. If an allowance for a specific covered healthcare service cannot be determined by reference to a fee schedule, reimbursement will be based upon a calculation that reasonably represents the amount paid to network providers. For emergency services, we reimburse non- network providers, in accordance with R.I. Gen. Laws § 27-18-76, the greater of our allowance, our usual guidelines for paying non-network providers, or the amount that would be paid under Medicare, less any copayments or deductibles. Payments we make to you are personal. You cannot transfer or assign any of your right to receive payments under this agreement to another person or organization, unless the R.I. General Law §27-20-49 (Dental Insurance assignment of benefits) applies. For information about network authorization requests to seek covered healthcare services from a non-network provider when the covered healthcare service cannot be provided by a network provider, please see Network Authorization in Section 5.