IQVIA Benefits Handbook
OUT-OF-NETWORK BENEFITS
In the Aetna plans, you can choose to visit an out-of-network physician, hospital or other provider at any time. If you receive covered services on an out-of-network basis:
- Services performed by providers not participating in the network will be reimbursed at the out-of-network level of benefits, based on Maximum Reimbursable Charge (MRC) limits for covered services. You are responsible for any amounts above the MRC limits.
- For out-of-network care, you are responsible for filing any required claim forms, obtaining authorizations for hospital admissions and obtaining any required pre-certification for services.
For most services, Maximum Reimbursable Charge (MRC) limits are based on a fee schedule (developed using a Medicare-based methodology). For some services, MRC limits are based on what providers with similar professional backgrounds, education and experience charge for a specific service within a given area. The plans cover costs up to MRC limits and you are responsible for paying any portion of the bill over the limits. Charges above MRC amounts will not apply toward your deductible, coinsurance or annual out-of-pocket maximum.