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

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: 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. For authorized and non-authorized non-emergency out-of-network services, the MCO may reimburse providers at the eighty (80) percent of the prevailing Medicaid fee-for-service rate or higher, unless such services are deemed medically unnecessary or not covered by the MCO. Consistent with Article III, Section 1.2.2, reimbursement for emergency services provided out- of-network must be equal to the Medicaid prevailing 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.