Managed Care Program Requirements. HPN's Managed Care Program requires the Member, Plan Providers and HPN to work together. All Plan Providers have agreed to participate in HPN’s Managed Care Program. Plan Providers have agreed to accept HPN’s Reimbursement Schedule amount as payment in full for Covered Services, less the Member’s payment of any applicable Calendar Year Deductible, Copayment or Coinsurance amount, whereas Non-Plan Providers have not. Members enrolled under HPN’s HMO 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 for other Covered Services, as defined in this AOC, provided by a Non-Plan Provider that are Prior Authorized by HPN’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 HPN pay more than the maximum payment allowance established in the HPN Reimbursement Schedule. It is the Member's responsibility to verify that the Provider selected is a Plan Provider before receiving any non-Emergency Services and to comply with all other rules of HPN’s Managed Care Program.
Appears in 1 contract
Sources: Agreement of Coverage
Managed Care Program Requirements. HPN's Managed Care Program requires the Member, Plan Providers and HPN to work together. All Plan Providers have agreed to participate in HPN’s Managed Care Program. Plan Providers have agreed to accept HPN’s Reimbursement Schedule amount as payment in full for Covered Services, less the Member’s payment of any applicable Calendar Year Deductible, Copayment or Coinsurance amount, whereas Non-Plan Providers have not. Members enrolled under HPN’s HMO 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 for other Covered Services, as defined in this AOC, provided by a Non-Plan Provider that are Prior Authorized by HPN’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 HPN pay more than the maximum payment allowance established in the HPN Reimbursement Schedule. It is the Member's responsibility to verify that the Provider selected is a Plan Provider before receiving any non-Emergency Services and to comply with all other rules of HPN’s Managed Care Program.
Appears in 1 contract
Sources: Agreement of Coverage