Provider Responsibilities and Considerations

This policy outlines the responsibilities of all providers (both professional and facility) that are accepted into our PPO network.

Following the terms below ensures the least amount of out-of-pocket expense to the patient. In-network health care providers must:

• Bill using in-network/contracted credentials (NPI, EIN, etc.) associated with where the services are performed. Providers may not bill using sister/parent company credentials.
• Refer/admit covered persons only to hospitals that are in network with the member’s benefit plan.*  
• Refer covered persons only to medical specialists and other health care providers that are in network with the member’s benefit plan.*  
• Arrange vacation and call coverage to be provided by a provider that is in network with the member’s benefit plan.

*Except under circumstances identified in the agreement.