What is the expected reimbursement from a payor for non-contracted providers who provide emergency and referral services?
The HMO Act requires that carriers reimburse non-contracted providers who furnish emergency services and authorized referral services at a usual and customary or agreed rate. Texas Insurance Code ยง1301.155(b) pertaining to preferred provider benefit plans requires that carriers pay non contracted providers at the preferred provider rate or percentage if services are not available from preferred providers in the service area or if an insured cannot reasonably reach a preferred provider to receive emergency care.
