Care providers in our network are contracted with Oxford to provide specific services to members. Care providers participating with Oxford must follow Oxford referral, precertification and privileging policies and procedures. You may not bill members for unpaid charges related to covered services except for applicable copays, co- insurance or permitted deductibles. This includes balance billing a member for a covered service denied by Oxford because there was no referral or authorization on file with Oxford when one was required.
Exceptions: The instances in which you are authorized to balance bill a member are as follows. You are still required to follow Oxford’s privileging, referral and/or precertification requirements. In these instances, you may balance bill the member billed charges. To the extent that the terms and conditions of your contract conflict with these guidelines, the terms and conditions of your contract prevail. You may balance bill a member when any of the following apply:
If you are uncertain whether a service is covered, you must make reasonable efforts to contact us and obtain coverage determination before seeking payment from a member. You are prohibited from balance billing the member for covered services when claims are denied for administrative reasons (lack of referral or authorization when one was required, etc.). If a member has been inappropriately balance billed by a care provider, the member has the right to file a complaint or grievance, verbally or in writing, regarding the balance billing. Participating care providers who repeatedly violate these restrictions will be subject to discipline up to and including termination of their provider Agreement. If you inappropriately balance-bill a member, Oxford will hold the member harmless and pursue the matter directly with you.
Out-of-pocket amounts for outpatient and inpatient care vary by group, type of care provider and type of benefit plan. Check the member’s health care ID for the out-of-pocket cost specific to their benefit plan.