All claims for services provided to Managed Care Organization (MCO)-enrolled members must be submitted directly to the appropriate MCO, adhering to the MCO's claims submission and timeliness guidelines. If a provider sees an MCO-enrolled member which the provider is not enrolled with, the out-of-network provider will be reimbursed at 80 percent for all services.
Reimbursement for covered services is additionally dependent on requirements of the
member's MCO, such as prior authorization.
The provider may accept the 80 percent out-of-network rate from the member's MCO or the provider may choose to contract with the member's MCO.