Common use of Accessing Care Clause in Contracts

Accessing Care. Members are entitled to Covered Services from either: • GHO’s Managed Health Care Network, referred to as “MHCN,” or • Community Providers or Preferred Community Providers on a Self-Referred basis. Members may choose either health care delivery option at any time during or for differing episodes of illness or injury, except during a scheduled inpatient admission. Benefits paid under one option will not be duplicated under the other option. Under the Agreement, the level of benefits available for services received at or upon Referral by the MHCN is generally greater than the level of benefits available for services received from Community Providers. In order for services to be covered at the higher benefit level, services must be obtained by MHCN Providers at MHCN Facilities, except as follows: • Emergency care, • Self-Referral to women’s MHCN health care providers, as set forth below, • Visits with MHCN-Designated Self-Referral Specialists, as set forth below, • Care provided pursuant to a Referral. Referrals must be requested by the Member’s MHCN Personal Physician and approved by GHO, and • Other services as specifically set forth in the Allowances Schedule and Section IV. Some services are covered only when obtained from or upon Referral by the MHCN. All inpatient admissions prescribed by a Community Provider must be authorized in advance by GHO. Members may refer to Sections IV.A. and IV.C. for more information about inpatient admissions.