Non-Contracting Providers

40.3 – Non-Contracting Providers (Rev. 99, Issued: 05-27-11, Effective: 05-27-11, Implementation: 05-27-11) A provider is a non-contracting provider if the provider is not a direct-contracting provider or a deemed provider. Generally, these providers furnish emergency services to PFFS plan members. The following examples illustrate when a provider is considered non-contracting: Example 1: A provider who provides care in an emergency to an unconscious individual is a non-contracting provider, if the provider did not know prior to furnishing services that the individual is a member of a PFFS plan. Example 2: A provider who, prior to furnishing services, did not have reasonable access to the PFFS plan’s terms and conditions of payment, is also considered non-contracting. The payment rules for non-contracting providers under the three types of PFFS plans are discussed in sections 70 and 80.1 of this chapter. The rules for services furnished by non- contracting providers are also described in section 20.7 of Chapter 4 of this manual.