Common use of Out-of-Network Provider Reimbursement Clause in Contracts

Out-of-Network Provider Reimbursement. The Contractor shall reimburse any out-of-network provider’s claim for authorized services provided to HIP members at 98% of the Medicare rate or, if the service does not have a Medicare rate, 128% of the Medicaid rate for that service. Notwithstanding the foregoing, out- of-network services provided to HIP members eligible pursuant to Section 3.3.1 and billed by a hospital provider, shall be reimbursable at standard Medicaid rates, rather than the higher HIP Medicare rates. Contractor must reimburse claims for members who chose the MCE during the HPE application process on the admission date.

Out-of-Network Provider Reimbursement. The Contractor shall reimburse any out-of-network provider’s claim for authorized services provided to HIP members at 98% of the Medicare rate or, if the service does not have a Medicare rate, 128% of the Medicaid rate for that service. Notwithstanding the foregoing, out- out-of-network services provided to HIP members eligible pursuant to Section 3.3.1 and billed by a hospital provider, shall be reimbursable at standard Medicaid rates, rather than the higher HIP Medicare rates. Contractor must reimburse claims for members who chose the MCE during the HPE application process on the admission date.