(iv) A covered service provided to an insured by an
out-of-network provider at an in-network facility when
the insured did not have the ability to make an informed
choice of the provider of the health care service.
(2) The term does not include any of the following:
(i) A balance bill for a health care service
rendered by an out-of-network provider when an in-network
provider is available and the insured has elected to
receive the service from an out-of-network provider
rather than an in-network provider.
(ii) A health care service for which an entity,
other than an insurer under a health insurance policy, is
responsible.
(3) Nothing in this definition shall be construed to
prohibit an insurer from appropriately utilizing reasonable
medical management techniques.
Amend Bill, page 10, by inserting between lines 1 and 2
"Usual, customary and reasonable rate." The seventy-fifth
percentile of all charged amounts for a particular health care
service performed by a provider which is in the same or similar
specialty and provided in the same geographic area as reported
in a benchmarking database maintained by a nonprofit
organization designated by the commissioner and not affiliated
with an insurer or provider.
Amend Bill, page 10, lines 9 and 10, by striking out ", but
not earlier than 10 business days prior to admission or date of
service" and inserting
and there are 10 business days between the date when the
health care service is scheduled and the date when the health
care service is scheduled to be provided
Amend Bill, page 10, lines 12 through 14, by striking out
"Nothing in this act shall prohibit an insurer from" in line 12
and all of lines 13 and 14 and inserting
Notice provided less than 10 business days before the date
when the health care service will be provided shall not be
considered fair notice to allow the insured to make an informed
choice to receive a health care service from an out-of-network
provider.
Amend Bill, page 10, line 20, by striking out "providers" and
inserting
provider
Amend Bill, page 11, line 10, by inserting after "service"
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