(a) A provider may only seek reimbursement from a CHIP
managed care organization for a covered service provided to a CHIP
member. A provider may not seek reimbursement or attempt to obtain
payment from a CHIP member, the CHIP member's family, or the CHIP
member's guardian for a covered service.
(b) The provisions of subsection (a) of this section
apply to all covered services provided to a CHIP member, including
emergency services provided by an out-of-network provider, in compliance
with federal regulations (42 C.F.R. §457.515(f)).
(c) The provisions of subsection (a) of this section
do not apply to:
(1) co-payment authorized under Subchapter C, Division
2 of this title (relating to Cost-Sharing Requirements);
(2) a covered service of CHIP with a capped benefit
level, once the CHIP member exceeds the benefit cap; or
(3) services that are not covered services under CHIP.
(d) Providers may not bill or take other recourse against
the CHIP member, the CHIP member's family, or the CHIP member's guardian
for claims denied as a result of error attributed to the provider
or Claims Processing Entity.
(e) This rule applies to providers that participate
in a CHIP managed care organization's network and out-of-network providers.
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