Nonparticipating Referral Provider Law and Legal Definition

Nonparticipating referral provider means a provider other than a participating provider with whom a health maintenance organization has arranged to provide health care services to enrollees. A nonparticipating referral provider is generally arranged by referral through its participating providers.

Payment or reimbursement for health care services provided by nonparticipating referral providers, that is made by a health maintenance organization shall exceed five percent of total costs of health care services. Such excess payment or reimbursement above five percent shall be combined with the costs for services. [Va. Code Ann. § 38.2-4300].