§ 27-13-36-5 — Referrals to out of network providers

(a) The provisions of the section do not apply
until July 1, 1999.
(b) When an enrollee's primary care provider determines that the
enrollee needs a particular health care service and the health
maintenance organization determines that the type of health care
service needed by the enrollee to treat a specific condition:
(1) is a covered service; and
(2) is not available from the health maintenance organization's
network of participating providers;
the primary care provider and the health maintenance organization
shall refer the enrollee to an appropriate provider who is not a
participating provider within a reasonable amount of time and within
a reasonable proximity of the enrollee.
(c) When an enrollee receives health care services from a provider
to whom the enrollee was referred as described in subsection (b), the
health maintenance organization shall pay the out of network provider
the lesser of the following:
(1) The usual, customary, and reasonable charge in the health
maintenance organization's service area for the health care
services provided by the out of network provider.
(2) An amount agreed to between the health maintenance
organization and the out of network provider.
The enrollee's treating provider may collect from the enrollee only the
deductible or copayment, if any, that the enrollee would be responsible
to pay if the health care services had been provided by a participating
provider. The enrollee may not be billed by the health maintenance
organization or by the out of network provider for any difference
between the out of network provider's charge and the amount paid by
the health maintenance organization to the out of network provider as
provided in this subsection.
(d) A contract between a health maintenance organization and a
primary care provider may not provide for a financial or other penalty
to the primary care provider for making a determination allowed under
subsection (b).

Legislative History

As added by P.L.69-1998, SEC.14.