PROVIDER NETWORK STATUS Clause Samples

The PROVIDER NETWORK STATUS clause defines the requirements and expectations regarding a healthcare provider's participation in a specific insurance or managed care network. It typically outlines whether the provider is considered in-network or out-of-network for the purposes of patient coverage and reimbursement, and may specify obligations for maintaining network status or notifying parties of any changes. This clause ensures that patients and payers understand the provider's network affiliation, which directly affects coverage levels, out-of-pocket costs, and administrative processes, thereby reducing confusion and disputes over billing and insurance claims.
PROVIDER NETWORK STATUS. For Covered Services performed by an In-Network Provider, the allowed amount for this plan is the rate the Provider has agreedwith Alliant to accept as reimbursement for the Covered Services. Because In-Network Providers have agreed to accept the allowed amount as payment in full for that service, they should not send You a bill or collect for amounts above the allowed amount. However, You may receive a bill or be asked to pay all or a portion of the allowed amount to the extent You have not met Your Deductible or have a copayment or Coinsurance. Please call Customer Service at (▇▇▇) ▇▇▇-▇▇▇▇ for help in finding an In-Network Provider or visit ▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇. Providers who have not signed a contract with Us and are not in any of Our networks are Out-of-Network Providers. For certain Covered Services and depending on Your plan design, You may be required to pay a part of the MAC as Your cost share amount (e.g., Deductible, copayment, and/or Coinsurance). Please see the Summary of Benefits and Coverage for Your cost share responsibilities and limitations or call Customer Service at (▇▇▇) ▇▇▇-▇▇▇▇ to learn how Your plan’s benefits or cost share amounts may vary by the type of Provider You use. Alliant will not provide any reimbursement for non-Covered Services. You will be responsible for the total amount billed by Your Provider for Non-Covered Services. Both services specifically excluded by the terms of Your policy/plan and those received after benefits have been exhausted are Non-Covered Services. Benefits may be exhausted by exceeding, for example, calendar year day/visit limits. In some circumstances, such as where there is no In-Network Provider available for the Covered Service, We may authorize the in-network cost share amounts (Deductible, Copayment, and/or Coinsurance) to apply to a claim for a Covered Service You receive from an Out-of-Network Provider. In such circumstance, You must contact Us in advance of obtaining the Covered Service. We also may authorize the in-network cost share amounts to apply to a claim for Covered Services if You receive Emergency Services from an Out-of-Network Provider and are not able to contact Us until after the Covered Service is rendered. If We authorize a Covered Service so that You are responsible for the in-network cost share amounts, You may still beliable for the difference between the MAC and the Out-of-Network Provider’s charge. Please contact Customer Service at (▇▇▇)▇▇▇-▇▇▇▇ for Authorized Services info...
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PROVIDER NETWORK STATUS. The Maximum Allowed Amount may vary depending upon whether the Provider is a Participating Provider or a Non-Participating Provider. A Participating Provider is a Provider who is in the managed network for this specific Contract or in a special center of excellence/or other closely managed specialty network. For Covered Services performed by a Participating Provider, the Maximum Allowed Amount for this Plan is the rate the Provider has agreed with Anthem to accept as reimbursement for the Covered Services. Because Participating Providers have agreed to accept the Maximum Allowed Amount as payment in full for those Covered Services, they should not send you a bill or collect for amounts above the Maximum Allowed Amount. However, you may receive a bill or be asked to pay all or a portion of the Maximum Allowed Amount to the extent you have not met your Deductible or have a Copayment or Coinsurance. Please call Customer Service for help in finding a Participating Provider or visit Our website at ▇▇▇.▇▇▇▇▇▇.▇▇▇. Providers who have not signed any contract with Us and are not in any of Our networks are Non- Participating Providers, subject to Blue Cross Blue Shield Association rules governing claims filed by certain ancillary providers. For Covered Services you receive from a Non-Participating Provider that have been Prior Authorized by Us, the Maximum Allowed Amount for this Plan will be one of the following as determined by Anthem:
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PROVIDER NETWORK STATUS. The Maximum Allowed Amount may vary depending upon whether the provider is a Prudent Buyer Plan Provider, a Non-Prudent Buyer Plan Provider or a Related Health Provider. Prudent Buyer Plan Providers and CME. For covered services performed by a Prudent Buyer Plan Provider or CME the Maximum Allowed Amount for this Plan will be the rate the Prudent Buyer Plan Provider or CME has agreed with us to accept as reimbursement for the covered services. Because Prudent Buyer Plan Providers have agreed to accept the Maximum Allowed Amount as payment in full for those covered services, they should not send you a bill or collect for amounts above the Maximum Allowed Amount. However, you may receive a bill or be asked to pay all or a portion of the Maximum Allowed Amount to the extent you have not met your Deductible or have a Co-Payment. Please call the customer service telephone number on your ID card for help in finding a Prudent Buyer Plan Provider or visit ▇▇▇.▇▇▇▇▇▇.▇▇▇/▇▇. If you go to a Hospital which is a Prudent Buyer Plan Provider, you should not assume all providers in that Hospital are also Prudent Buyer Plan Providers. To receive the greater benefits afforded when covered services are provided by a Prudent Buyer Plan Provider, you should request that all your provider services (such as services by an anesthesiologist) be performed by Prudent Buyer Plan Providers whenever you enter a Hospital. If you are planning to have outpatient surgery, you should first find out if the facility where the surgery is to be performed is an Ambulatory Surgical Center. An Ambulatory Surgical Center is licensed as a separate facility even though it may be located on the same grounds as a Hospital (although this is not always the case). If the center is licensed separately, you should find out if the facility is a Prudent Buyer Plan Provider before undergoing the surgery.
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Related to PROVIDER NETWORK STATUS

  • Provider Directory a. The Contractor shall make available in electronic form and, upon request, in paper form, the following information about its network providers: i. The provider’s name as well as any group affiliation; ii. Street address(es); iii. Telephone number(s); iv. Website URL, as appropriate; v. Specialty, as appropriate; vi. Whether the provider will accept new beneficiaries; vii. The provider’s cultural and linguistic capabilities, including languages (including American Sign Language) offered by the provider or a skilled medical interpreter at the provider’s office, and whether the provider has completed cultural competence training; and viii. Whether the provider’s office/facility has accommodations for people with physical disabilities, including offices, exam room(s) and equipment. b. The Contractor shall include the following provider types covered under this Agreement in the provider directory: i. Physicians, including specialists ii. Hospitals

  • Supplier Diversity Seller shall comply with ▇▇▇▇▇’s Supplier Diversity Program in accordance with Appendix V.

  • Provider Services Charges for the following Services when ordered by a Physician for the treatment of an Injury or Illness.

  • Volunteer Peer Assistants 1. Up to eight (8)

  • 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.