Res 1988-077 - Laserfiche WebLink

Home Browse Search

A. B. SB-A2 SECTION XI SCHEDULE OF BENEFITS H.a1th S.rvio.. R.nd.r.d By Participating Provid.r. A Covered Person shall be entitled to the Medically Necessary Health Services described in this section if provided by or authorized by a Participating Primary Care Physician or Psychiatric Primary Provider. These Health Services are subJect to (1) the limitations, exclusions and other provisions of this Contract, and (2) payment by the Covered Person of the Copayment Charge specified for any service, and (3) payment of the Health Services Fee required for coverage under this Contract. A Covered Person shall also be entitled to those same Medically Necessary Health Services when provided by or through other Participating Specialist Physicians with prior written authorization by the Health Plan following a referral by a Participating Primary Care Physician or Psychiatric Primary Provider. Authorization by a Participating Primary Care Physician or Psychiatric Primary Provider and prior written approval by the Health Plan will not be required in the event of a true emergency. HOWEVER, SUCH EMERGENCIES WILL BE SUBJECT TO A RETROSPECTIVE REVIEW, AND SHOULD THE LEVEL OF CARE RECEIVED INDICATE THAT A TRUE EMERGENCY DID NOT EXIST, PAYMENT WILL BE DENIED AND WILL BECOME THE FINANCIAL RESPONSIBILITY OF THE MEMBER. SHOULD COVERED PERSON RECEIVE CARE WITHOUT THE PRIOR AUTHORIZATION AND WRITTEN APPROVAL, COVERED PERSON WILL BE RESPONSIBLE FOR ALL COSTS INCURRED IN SUCH CARE. R.f.rra1 H..1th S.rvic.. R.nd.r.d by Non-Participating Provid.r. 1. In the event that specific Healtn Services cannot be provided by or through Participating Providers, a Covered Person shall be entitled to coverage for Eligible Expenses for Medically Necessary Health Services of non-participating providers, subJect to the terms and conditions of this section. 2. Such Health Services must be requested and recommended to Health Plan by a Participating Primary Care Physician and authorized in writing in advance by Health Plan, and are subJect to all the terms, conditions, limitations, and exclusions of the Contract. 3. IT IS THE COVERED PERSON'S RESPONSIBILITY TO OBTAIN THE REQUIRED WRITTEN APPROVAL PRIOR TO RECEIVING SERVICES FROM NON- PARTICIPATING PROVIDERS. SHOULD THE COVERED PERSON RECEIVE CARE FROK A NON-PARTICIPATING PROVIDER, INCLUDING HOSPITALIZATION, WITHOUT THE REQUIRED WRITTEN APPROVAL BY HEALTH PLAN, THE COVERED PERSON WILL BE RESPONSIBLE FOR ALL ASSOCIATED COSTS. FAILURE OF THE PARTICIPATING PROVIDER TO OBTAIN NECESSARY PRIOR WRITTEN PLAN APPROVAL WILL IN NO WAY EXCUSE THE COVERED PERSON'S RESPONSIBILITY TO OBTAIN THE HEALTH PLAN'S WRITTEN APPROVAL EXCEPT WHEN IT IS IMPOSSIBLE FOR HIM OR HER TO DO SO BEFORE SEEKING SERVICES FROM OR THROUGH NON-PARTICIPATING PROVIDERS. -1-