Network dentists and x-ray laboratories (“Participating Providers”) who treat members agree to accept contracted rates as payment for the services they provide.
For services provided by dentists and x-ray laboratories who have not contracted to treat members (“Non-Participating Providers”), the amounts that will be allowed for such services and processed for payment (“Non-Participating Provider Reimbursement Amounts”) are based on the member contracts. These amounts may be determined based on fee schedules or a database produced by FAIR Health, Inc., as supported by member certificates, and also may be subject to deductibles, co-pays, and other limitations.
Because there is no Provider contract or participating agreement, a Non-Participating Provider has not agreed to a reimbursement rate for services provided to members. Therefore, absent a regulation or law, the Non-Participating Provider can bill the member for the difference between the amounts they charge and the Non-Participating Provider Reimbursement Amount. Members are responsible for paying Non-Participating Providers this difference. Depending on the service, this difference can be substantial.
At this time, Non-Participating Provider Reimbursement Amounts will continue to be determined as described above. This page will be updated if there are any changes to the methods used to determine Non-Participating Provider Reimbursement Amounts.