Common use of Refer to Clause in Contracts

Refer to. Generally you will not have claims to file or papers to fill out in order for a claim to be paid. The Practitioner/Provider will ▇▇▇▇ us directly for the cost of services. Most services require Cost Sharing (Deductible, Coinsurance and/or Copayments) at the time of service. The amount of Cost Sharing for each service can be found in your Summary of Benefits and Coverage. In-network Practitioners and Providers cannot ▇▇▇▇ you for any additional costs over and above your Cost Sharing amounts. We do not require our In-network Practitioners/Providers to comply with any specified numbers, targeted averages, or maximum duration of patient visits. Out-of-network Practitioners/Providers are health care Practitioners/Providers, including non-medical facilities, who have not entered into an agreement with us to provide Health Care Services to PHP Members. Covered Health Care Services obtained from an Out-of-network Practitioner/Provider or outside the Service Area will not be Covered unless such services are not reasonably available from an In-network Practitioner/Provider or in cases of an emergency. You will not pay higher or additional Cost Sharing amounts under such circumstances. Services provided by an Out-of-network Practitioner/Provider, except Emergency services, require that your Primary Care Physician request and obtain written approval (Authorization) from our Medical Director BEFORE services are rendered. Otherwise, you will be responsible for payment. Please refer to the Prior Authorization Section for more information on Prior Authorization requirements. If the services of an Out-of-network Practitioner/Provider are required, your In-network Practitioner/Provider must request and obtain Prior Authorization from our Medical Director BEFORE services are performed, otherwise, we will not Cover the services and you will be responsible for payment. Before the Medical Director may deny a request for specialist services that are unavailable from an In-Network Practitioner/Provider, the request must be reviewed by a specialist similar to the type of specialist to whom the Prior Authorization is requested. In determining whether a Prior Authorization to an Out-of-network Practitioner/Provider is reasonable, we will consider the following circumstances:  Availability – The In-network Practitioner/Provider is not reasonably available to see you in a timely fashion as dictated by the clinical situation.  Competency – The In-network Practitioner/Provider does not have the necessary training or expertise required to render the service or treatment.  Geography – The In-network Practitioner/Provider is not located within a reasonable distance from your residence. A “reasonable distance” is defined as travel that would not place you at any medical risk.  Continuity – If the requested Out-of-network Practitioner/Provider has a well-established professional relationship with you and is providing ongoing treatment of a specific medical problem, you will be allowed to continue seeing that specialist for a minimum of 30 days as needed to ensure continuity of care. 

Refer to. Generally Before you are admitted as an Inpatient to a Hospital, Skilled Nursing Facility or other facility or before you receive certain Covered Health Care Services and supplies, you must request and obtain approval, known as Authorization. All diabetes related services are provided in accordance with State law. For diabetes related services, please refer to the Diabetes Services Section. Prior Authorization is a clinical evaluation process to determine if the requested Health Care Service is Medically Necessary, a Covered Benefit, and if it is being delivered in the most appropriate health care setting. Our Medical Director or other clinical professional will not have claims to file or papers to fill out in order review the requested Health Care Service and, if it meets our requirements for a claim to be paidCoverage and Medical Necessity, it is Authorized (approved) before those services are provided. The Prior Authorization process and requirements are regularly reviewed and updated based on various factors including evidence-based practice guidelines, medical trends, Practitioner/Provider participation, state procedures. and federal regulations, and our policies and A Prior Authorization will ▇▇▇▇ us directly specify the length of time for which the Authorization is valid, in no eve t shall be for more than twenty-four (24) months. You may revoke an Authorization at any time. A consumer or customer who is the subject of nonpublic personal information may revoke an authorization pro ided pursuant to this rule at any time, subject to the rights of an individual who acted in reliance on the authorization prior to notice of the revocation. Certain services and supplies are Covered Benefits only if we Authorize them prior to the actual service or delivery of supplies. This does not apply to Benefits mandated by law. Authorization means our decision that a Health Care Service requested by your Practitioner/Provider or by you has been reviewed and, based upon information available, meets our requirements for Coverage and Medical Necessity, and the requested Health Care Service is therefore approved. required Prior Authorization is not obtained for services by Out-of-Network Practitioners/Providers, except for Emergency Care, the Member may be responsible for the cost resulting charges. Services provided beyond the scope of servicesthe Prior Authorization may not be Covered. Most services require Cost Sharing (Deductible, Coinsurance and/or Copayments) at the time of service. The amount of Cost Sharing for each service can be found in your Summary of Benefits and Coverage. In-network Practitioners and Providers cannot ▇▇▇▇ When you for any additional costs over and above your Cost Sharing amounts. We do not require our seek specific Covered Services from In-network Practitioners/Providers Providers, our In- network Practitioner/Provider is responsible for obtaining Prior Authorization from us before providing the Covered Services, except for Emergency Care. You will not be liable for charges resulting from the In-network Practitioner’s/Provider’s failure to comply with any specified numbersobtain the required Prior Authorization.  If required medical services are not available from In-network Practitioners/Providers, targeted averages, or maximum duration of patient visits. the Primary Care Physician must request Prior Authorization and obtain written Authorization from our Medical Director before you may receive Out-of-network Practitioners/Providers are health care Practitioners/Providers, including non-medical facilities, who have not entered into an agreement with us to provide Health Care Services to PHP Members. Covered Health Care Services obtained from an Out-of-network Practitioner/Provider or outside the Service Area will not be Covered unless such services are not reasonably available from an In-network Practitioner/Provider or in cases of an emergency. You will not pay higher or additional Cost Sharing amounts under such circumstancesservices. Services provided by an Out-of-network Practitioner/Provider, except Emergency services, require that your Primary Care Physician request and obtain written approval (Authorization) from our Medical Director BEFORE services are rendered. Otherwise, you will be responsible for payment. Please refer to the Prior Authorization Section for more information on Prior Authorization requirements. If the services of an Out-of-network Practitioner/Provider are required, your Inmay not be Covered unless this Authorization is obtained prior to receiving the services. You may be responsible for charges resulting from failure to obtain Prior Authorization for services provided by the Out-of- network Practitioner/Provider must request and obtain Prior Authorization from our Medical Director BEFORE services are performed, otherwise, we will not Cover the services and you will be responsible for payment. Before the Medical Director may deny a request for specialist services that are unavailable from an In-Network Practitioner/Provider, the request must be reviewed by a specialist similar to the type of specialist to whom the Prior Authorization is requested. In determining whether a Prior Authorization referral to an Out-of-network Practitioner/Provider is reasonablenecessary, we we, in consultation with your referring In-network Physician and/or PCP will consider the following circumstances:  Availability – The In-network Practitioner/Provider is not reasonably available to see you in a timely fashion as dictated by the clinical situation.  Competency – The In-network Practitioner/Provider does not have the necessary training or expertise required to render the service or treatment.  Geography – The In-network Practitioner/Provider is not located within a reasonable distance from your the patient’s residence. A “reasonable distance” is defined as travel that would not place you at any medical risk.  Continuity – If the requested Out-of-network Practitioner/Provider has a well-well- established professional relationship with you and is providing ongoing treatment of a specific medical problem, you will be allowed to continue seeing that specialist for a minimum of 30 thirty (30) days as needed to ensure continuity of care.  Any Prior Authorization requested s i m p l y for your convenience will not be considered to be reasonable. Prior Authorization is required for Inpatient admissions, and all services related to the inpatient admission before you receive these services In-network or Out-of-network from any Practitioner/Provider, Health Care Facility or other Health Care Professional. Our network of Practitioners/Providers will obtain Prior Authorization for you when you receive care In- network. You are responsible for obtaining Prior Authorization before you receive care Out- of-network, except for Emergency Care. f you want to know more about Prior Authorization, please call our Presbyterian Customer ervice Center, as soon as possible before services are provided, Monday through Friday from :00 a.m. to 6:00 p.m. at (▇▇▇) ▇▇▇-▇▇▇▇ or toll-free at ▇-▇▇▇-▇▇▇-▇▇▇▇. Hearing impaired users may call the TTY line at 711 or toll-free ▇-▇▇▇-▇▇▇-▇▇▇▇. You may also visit our website at ▇▇▇.▇▇▇.▇▇▇.

Refer to. Generally Before you are admitted as an Inpatient to a Hospital, Skilled Nursing Facility or other facility or before you receive certain Covered Health Care Services and supplies, you must request and obtain approval, known as Authorization. All diabetes related services are provided in accordance with State law. For diabetes related services, please refer to the Diabetes Services Section. Prior Authorization is a clinical evaluation process to determine if the requested Health Care Service is Medically Necessary, a Covered Benefit, and if it is being delivered in the most appropriate health care setting. Our Medical Director or other clinical professional will not have claims to file or papers to fill out in order review the requested Health Care Service and, if it meets our requirements for a claim to be paidCoverage and Medical Necessity, it is Authorized (approved) before those services are provided. The Prior Authorization process and requirements are regularly reviewed and updated based on various factors including evidence-based practice guidelines, medical trends, Practitioner/Provider participation, state and federal regulations, and our policies and procedures. A Prior Authorization will ▇▇▇▇ us directly specify the length of time for which the Authorization is valid, which in no event shall be for more than twenty-four (24) months. You may revoke an Authorization at any time. A consumer or customer who is the subject of nonpublic personal information may revoke an authorization provided pursuant to this rule at any time, subject to the rights of an individual who acted in reliance on the authorization prior to notice of the revocation. Certain services and supplies are Covered Benefits only if we Authorize them prior to the actual service or delivery of supplies. This does not apply to Benefits mandated by law. Authorization means our decision that a Health Care Service requested by your Practitioner/Provider or by you has been reviewed and, based upon information available, meets our requirements for Coverage and Medical Necessity, and the requested Health Care Service is therefore approved. If a required Prior Authorization is not obtained for services by Out-of-Network Practitioners/Providers, except for Emergency Care, the Member may be responsible for the cost resulting charges. Services provided beyond the scope of servicesthe Prior Authorization may not be Covered. Most services require Cost Sharing (Deductible, Coinsurance and/or Copayments) at the time of service. The amount of Cost Sharing for each service can be found in your Summary of Benefits and Coverage. In-network Practitioners and Providers cannot ▇▇▇▇ When you for any additional costs over and above your Cost Sharing amounts. We do not require our seek specific Covered Services from In-network Practitioners/Providers Providers, our In- network Practitioner/Provider is responsible for obtaining Prior Authorization from us before providing the Covered Services, except for Emergency Care. You will not be liable for charges resulting from the In-network Practitioner’s/Provider’s failure to comply with any specified numbersobtain the required Prior Authorization. If required medical services are not available from In-network Practitioners/Providers, targeted averages, or maximum duration of patient visits. the Primary Care Physician must request Prior Authorization and obtain written Authorization from our Medical Director before you may receive Out-of-network Practitioners/Providers are health care Practitioners/Providers, including non-medical facilities, who have not entered into an agreement with us to provide Health Care Services to PHP Members. Covered Health Care Services obtained from an Out-of-network Practitioner/Provider or outside the Service Area will not be Covered unless such services are not reasonably available from an In-network Practitioner/Provider or in cases of an emergency. You will not pay higher or additional Cost Sharing amounts under such circumstancesservices. Services provided by an Out-of-network Practitioner/Provider, except Emergency services, require that your Primary Care Physician request and obtain written approval (Authorization) from our Medical Director BEFORE services are rendered. Otherwise, you will be responsible for payment. Please refer to the Prior Authorization Section for more information on Prior Authorization requirements. If the services of an Out-of-network Practitioner/Provider are required, your Inmay not be Covered unless this Authorization is obtained prior to receiving the services. You may be responsible for charges resulting from failure to obtain Prior Authorization for services provided by the Out-of- network Practitioner/Provider must request and obtain Prior Authorization from our Medical Director BEFORE services are performed, otherwise, we will not Cover the services and you will be responsible for payment. Before the Medical Director may deny a request for specialist services that are unavailable from an In-Network Practitioner/Provider, the request must be reviewed by a specialist similar to the type of specialist to whom the Prior Authorization is requested. In determining whether a Prior Authorization referral to an Out-of-network Practitioner/Provider is reasonablenecessary, we we, in consultation with your referring In-network Physician and/or PCP will consider the following circumstances:  ➢ Availability – The In-network Practitioner/Provider is not reasonably available to see you in a timely fashion as dictated by the clinical situation.  ➢ Competency – The In-network Practitioner/Provider does not have the necessary training or expertise required to render the service or treatment.  ➢ Geography – The In-network Practitioner/Provider is not located within a reasonable distance from your the patient’s residence. A “reasonable distance” is defined as travel that would not place you at any medical risk.  ➢ Continuity – If the requested Out-of-network Practitioner/Provider has a well-well- established professional relationship with you and is providing ongoing treatment of a specific medical problem, you will be allowed to continue seeing that specialist for a minimum of 30 thirty (30) days as needed to ensure continuity of care. ➢ Any Prior Authorization requested s i m p l y for your convenience will not be considered to be reasonable.