Lesser of Provider Reimbursement Policy
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This policy governs how Network Health determines allowed reimbursement when a provider's billed charge is less than any contractual or fixed reimbursement rate; it applies to all lines of business and all Network Health products and affects participating providers and claims processing.
No material clinical or coverage changes in this revision.
Payment Determination Rules
Lesser-of payment criteria
Payment determination rules when a provider's billed charge is less than any contractual or fixed reimbursement rate:
ALL of the following
- Network Health will not reimburse providers in excess of their billed charges, regardless of any contractual and/or fixed rate methodology.
- Allowed reimbursement amount for each billed line = the lesser of: (a) the provider's billed charge for that line, or (b) the contractual and/or fixed rate.
Billing Lines and Allowed Amount Rules
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