Out-of-Plan Use of Non-Emergency Services Clause Samples

The Out-of-Plan Use of Non-Emergency Services clause defines the rules and limitations for obtaining non-emergency medical care from providers or facilities that are not part of the health plan’s approved network. Typically, this clause outlines when and how a member may seek such services, what prior authorizations may be required, and how costs like copayments or coinsurance may differ compared to in-network care. Its core function is to manage costs and ensure members understand the financial and procedural implications of seeking non-emergency care outside the plan’s network, thereby encouraging use of in-network providers and controlling overall plan expenses.
Out-of-Plan Use of Non-Emergency Services. Unless otherwise specified in this Contract, where an Enrollee utilizes services available under the Health Plan other than emergency services from a non-contract provider, the Health Plan shall not be liable for the cost of such utilization unless the Health Plan referred the Enrollee to the non-contract provider or authorized such out-of-plan utilization. The Health Plan shall provide timely approval or denial of authorization of out-of-plan use through the assignment of a prior authorization number, which refers to and documents the approval. A Health Plan may not require paper authorization as a condition of receiving treatment if the plan has an automated authorization system. Written follow up documentation of the approval must be provided to the out-of-plan provider within one (1) Business Day from the request for approval. The Enrollee shall be liable for the cost of such unauthorized use of contract-covered services from non-contract providers. In accordance with section 409.912, F.S., the Health Plan shall reimburse any hospital or physician that is outside the Health Plan’s authorized geographic service area for Health Plan authorized services provided by the hospital or physician to plan members at a rate negotiated with the hospital or physician for the provision of services or according to the lesser of the following: a. The usual and customary charge made to the general public by the hospital or physician; or b. The Florida Medicaid reimbursement rate established for the hospital or physician. The plan shall reimburse all out-of-plan providers pursuant to section 641.3155, F.S.
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Out-of-Plan Use of Non-Emergency Services. The Health Plan shall provide timely approval or denial of authorization of out-of-network use through the assignment of a prior authorization number, which refers to and documents the approval. The Health Plan may not require paper authorization as a condition of receiving treatment if the Health Plan has an automated authorization WellCare of Florida, Inc. d/b/a Staywell Health Plan of Florida Medicaid HMO Non-Reform Contract system. Written follow-up documentation of the approval must be provided to the out-of-network provider within one (1) business day from the request for approval. For capitated Health Plan enrollees, the enrollee shall be liable for the cost of such unauthorized use of covered services from non-participating providers.
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Related to Out-of-Plan Use of Non-Emergency Services

  • Emergency Services The parties recognize that in the event of a strike or lockout, situations may arise of an emergency nature. To this end, the Employer and the Union will agree to provide services of an emergency nature.

  • Emergency Service Leave ‌ Where employees' services are required for emergency operations by request from the Provincial Emergency Program or appropriate police authority, leave from work as required may be granted without loss of basic pay. If any remuneration, other than for expenses, is received, it shall be remitted to the Employer.

  • Developer Compensation for Emergency Services If, during an Emergency State, the Developer provides services at the request or direction of the NYISO or Connecting Transmission Owner, the Developer will be compensated for such services in accordance with the NYISO Services Tariff.

  • Emergency Services Leave (a) An Employee who engages in a voluntary emergency management activity is entitled to be absent without loss of pay from his or her employment for a total of 5 days per annum commencing at the start of each calendar year. For the avoidance of doubt, any days not utilised by the Employee by the end of the calendar year, do not carry over into the subsequent year. (b) Voluntary emergency management activity has the meaning provided by the FWA.

  • Emergency Room Services This plan covers services received in a hospital emergency room when needed to stabilize or initiate treatment in an emergency. If your condition needs immediate or urgent, but non-emergency care, contact your PCP or use an urgent care center. This plan covers bandages, crutches, canes, collars, and other supplies incidental to your treatment in the emergency room as part of our allowance for the emergency room services. Additional services provided in the emergency room such as radiology or physician consultations are covered separately from emergency room services and may require additional copayments. The amount you pay is based on the type of service being rendered. Follow-up care services, such as suture removal, fracture care or wound care, received at the emergency room will require an additional emergency room copayment. Follow- up care services can be obtained from your primary care provider or a specialist. See Dental Services in Section 3 for information regarding emergency dental care services.