Authorization Denial Clause Samples

Authorization Denial. We will inform you in writing if we deny a prior or retroactive authorization request. Our notice to you will explain why we denied the request and will provide you with instructions for disputing our decision if you disagree. A summary of the dispute resolution process is included in this document. Please refer to the Table of Contents. You have a right to request information about the guidance we followed to deny your request, even if you do not dispute our decision. THIS ENDORSEMENT MAY CHANGE YOUR AGREEMENT WITH US. IF THE TERMS OF THIS ENDORSEMENT CONFLICT WITH ANY INFORMATION IN YOUR EOC, THE TERMS OF THIS ENDORSEMENT CONTROL. OUT-OF-NETWORK CARE AND BILLS If you receive care under any of the circumstances below from a provider who is not in your network, these are your rights: • You are only responsible for paying what you would owe for the same care from an in-network provider or facility. • You do NOT need to get prior authorization for emergency services. • Your care can continue until your condition has stabilized. If you require additional care after stabilization, call us at (▇▇▇) ▇▇▇-▇▇▇▇ and we will help you receive that care from an in-network provider. • You cannot be balance billed. • you did not consent to services from an out-of-network provider, • you were not offered the service from an in-network provider, or • the service was not available from an in-network provider - as determined by your healthcare provider and your health insurance company. If you get a ▇▇▇▇ from an out-of-network provider under any of the above circumstances that you do not believe is owed: • Call us first at (▇▇▇) ▇▇▇-▇▇▇▇. We will try to the resolve the issue with the provider on your behalf. • Contact the New Mexico Office of Superintendent of Insurance if the problem has not been resolved by us - ▇▇▇.▇▇▇.▇▇▇▇▇.▇▇.▇▇ or 1-855-4ASK-OSI (▇-▇▇▇-▇▇▇-▇▇▇▇). To help stop improper out-of-network bills, we will: • Notify you if your provider leaves our network and allow you transitional care with that provider at the in-network benefit level for up to 90 days depending on your condition and course of treatment. • Verify the accuracy of our provider directory information at least every 90 days. • Confirm whether a provider is in-network if you contact us at (▇▇▇) ▇▇▇-▇▇▇▇. If our representative provides inaccurate information that you rely on in choosing a provider, you will only be responsible for paying your in-network Cost Sharing amount for care received from tha...