Common use of Managed Care Program Requirements Clause in Contracts

Managed Care Program Requirements. SHL's Managed Care Program requires the Insured, Plan Providers and SHL to work together. All Plan Providers have agreed to participate in SHL’s Managed Care Program. Plan Providers have agreed to accept SHL’s Reimbursement Schedule amount as payment in full for Covered Services, less the Insured’s payment of any applicable Calendar Year Deductible, Copayment or Coinsurance amount, whereas Non-Plan Providers have not. Insureds enrolled under SHL’s Exclusive Provider Organization (EPO) Plans who use the services of Non-Plan Providers will receive no benefit payments or reimbursement for amounts for any Covered Service, except  in the case of Emergency Services or Urgently Needed Services or  other Covered Services provided by a Non-Plan Provider that are Prior Authorized by SHL’s Managed Care Program. This includes any Prior Authorized Covered Services obtained from a Non-Plan outpatient facility, such as a laboratory, radiological facility (x-ray), or any complex diagnostic or therapeutic services. In no event will SHL pay more than the maximum payment allowance established in the SHL Reimbursement Schedule.