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

Out-of-Network Services. (A) If the Contractor’s network of Network Providers is unable to provide Medically Necessary Covered Services under this Contract to a particular Enrollee, the Contractor shall adequately and timely cover these services using a Non-Network Provider for the Enrollee for as long as the Contractor is unable to provide them. (B) The Contractor shall require Non-Network Providers to coordinate with the Contractor with respect to payment and ensure that the cost to the Enrollee is no greater than it would be if the services were furnished within the network. (C) The Contractor shall use processes, strategies, evidentiary standards, or other factors in determining access to Non-Network providers for mental health or substance use disorder benefits that are comparable to, and applied no more stringently than, the processes, and standards used in determining access to Non-Network providers for medical/surgical benefits in the same classification.

Out-of-Network Services. (A) If the Contractor’s network of Network Providers is unable to provide Medically Necessary Covered Services under this Contract to a particular Enrollee, the Contractor shall adequately and timely cover these services using a Non-Network Provider for the Enrollee Enrollee, for as long as the Contractor is unable to provide them. (B) The Contractor shall require Non-Network Providers to coordinate with the Contractor with respect to payment and ensure that the cost to the Enrollee is no greater than it would be if the services were furnished within the network. (C) The Contractor shall use processes, strategies, evidentiary standards, or other factors in determining access to Non-Network providers Providers for mental health or substance use disorder benefits that are comparable to, and applied no more stringently than, the processes, and standards used in determining access to Non-Network providers Providers for medical/surgical benefits in the same classification.