265.913 Managed Care and Medicare “Carve-Out” Services:
In those instances where an insurance company has “carved out” specific services, and has contracted with an outside party to arrange and pay for these services, and then denies reimbursement on the basis that such payment is no longer their responsibility, MSSNY to (1) advocate for a physician’s ability to seek payment directly from the patient without being considered a violation of the physician’s participation agreement; and (2) seek legislation, regulation or other appropriate means to assure that participating physicians and patients are given advance written notification by payors that the plan has carved out the provision of and payment for specific services such as radiology or diagnostic studies to a specific third party. (HOD 2007-66; Reaffirmed HOD 2017)
