Common use of Authorized Referrals Clause in Contracts

Authorized Referrals. In some circumstances, We may authorize In-Network Provider Cost Share amounts (Deductible, Copayment, and/or Coinsurance) to apply to a claim for a Covered Service You receive from an Out-of-Network Provider. In such circumstance, You or Your Physician or Provider must request Precertification and contact Us in advance of obtaining the Covered Service and obtain Our written approval to have the services provided by Out-of-Network Provider. It is Your responsibility to ensure that We have been contacted. If We certify an In-Network Provider Cost Share amount to apply to a Covered Service received from an Out-of-Network Provider, You will only be responsible for any Copayments, Coinsurance, and/or Deductibles stated in this Agreement. Please contact Us at 1-855-Oscar-55 for Authorized Referral information or to request authorization. Approvals of authorizations to Out-of- Network Providers will not be made for the convenience of You or another treating Provider and may not necessarily be to the specific Out-of-Network Provider You requested. The written authorization (the certification letter) will indicate the specific service that is approved and the specific provider that is approved to provide it. If We approve the authorization, all services performed by the Out-of-Network Provider are subject to a treatment plan approved by Us in consultation with Your In-Network Provider, the Out-of-Network Provider and You. Xxxxx can help You find an In-Network Provider specific to Your Plan by calling customer service at 1-855-Oscar-55 or visit Us at xxx.xxxxxxx.xxx. Your Oscar ID card identifies You and contains important health care coverage information. Carrying Your ID card at all times will ensure You always have access to this coverage information when You need it. Make sure You show Your ID card to Your doctor, Hospital, pharmacist, or other health care Provider so they know You are covered by Xxxxx. Out-of-Area Services and Out-of-Network Providers Outside Oscar’s Service Area Outside of Our Service area, Oscar covers only Emergency or Urgent Care services. If You need to go to an Out-of-Network out-of-area Provider for an Emergency or Urgent Care, the charges for that care are covered. Additionally, subject to Our prior approval, We may cover transplant services, or other highly specialized services through an Oscar designated Provider which is Out-of-Area. To the extent that the services of Out-of-Network or out-of-area Providers are covered, You are liable for the applicable Copayments, Coinsurance and/or Deductibles stated in this Agreement. When You are traveling abroad and need medical care You can call the Oscar Service Center at 1-855-Oscar-55. They are available 8am-8pm PST, Monday through Friday and 8am-6pm PST on Saturday. If You need inpatient Hospital care, Your Provider should contact Us for Precertification. If You need Emergency medical care, go to the nearest Hospital. There is no need to call before You receive Emergency care. Refer to the section titled GETTING APPROVAL FOR BENEFITS to learn how to get Authorization when You need to be admitted to the Hospital for non-Emergency care. For care obtained when You are traveling outside of the United States, You may need to pay for the following services up front: • Doctor services; • Inpatient Hospital care; and • Outpatient services. You will need to file a claim form for any payments made up front. You can obtain filing forms as well as further information by calling customer service at 1-855-Oscar-55 or by visiting xxx.xxxxxxx.xxx. Additional information on claims for services received while traveling abroad: • You are responsible, at Your expense, for obtaining an English language translation of foreign country Provider claims and medicalrecords. • The exchange rate utilized for: o Inpatient Hospital care is based on the date of admission. o Outpatient and professional services are based on the date of service. o You will find the address for mailing the claim on the form. A claim is incurred on the date the service is provided to You. This is important because You must be enrolled and eligible to receive benefits on the date the service is provided. A claim must be submitted in order for Us to record the services and consider them for benefits. We will record claims in Our records in the order in which Your claims are processed, not necessarily in the order in which You receive the service or supply. We only provide benefits for Covered Services that are Medically Necessary. Benefits and benefit limits are described in WHAT IS COVERED – MEDICAL and in the SUMMARY OF BENEFITS. Either the Subscriber or Provider of service must claim benefits by sending Xxxxx properly completed claims forms itemizing the services or supplies received and the charges. These claim forms must be received by Xxxxx within one hundred eighty (180) from the date of services or supplies are received. If the claim is for an Out-of-Network Emergency Center or Urgent Care Center, these claim forms must be received by Oscar within one hundred eighty (180) days from the date of services. Xxxxx will not be liable for benefits if a completed claim form is not furnished to Oscar within this time period, except in the absence of legal capacity. Claims forms must be used, canceled checks or receipts are not acceptable.

Authorized Referrals. In some circumstances, We may authorize In-Network Provider Cost Share amounts (Deductible, Copayment, and/or Coinsurance) to apply to a claim for a Covered Service You receive from an Out-of-Network Provider. In such circumstance, You or Your Physician or Provider must request Precertification and contact Us in advance of obtaining the Covered Service and obtain Our written approval to have the services provided by Out-of-Network Provider. It is Your responsibility to ensure that We have been contacted. If We certify an In-Network Provider Cost Share amount to apply to a Covered Service received from an Out-of-Network Provider, You will only be responsible for any Copayments, Coinsurance, and/or Deductibles stated in this Agreement. Please contact Us at 1-855-Oscar-55 for Authorized Referral information or to request authorization. Approvals of authorizations to Out-of- of-Network Providers will not be made for the convenience of You or another treating Provider and may not necessarily be to the specific Out-of-Network Provider You requested. The written authorization (the certification letter) will indicate the specific service that is approved and the specific provider that is approved to provide it. If We approve the authorization, all services performed by the Out-of-Network Provider are subject to a treatment plan approved by Us in consultation with Your In-Network Provider, the Out-of-Network Provider and You. Xxxxx can help You find an In-Network Provider specific to Your Plan by calling customer service at 1-855-Oscar-55 or visit Us at xxx.xxxxxxx.xxx. Your Oscar ID card identifies You and contains important health care coverage information. Carrying Your ID card at all times will ensure You always have access to this coverage information when You need it. Make sure You show Your ID card to Your doctor, Hospital, pharmacist, or other health care Provider so they know You are covered by Xxxxx. Out-of-Area Services and Out-of-Network Providers Outside Oscar’s Service Area Outside of Our Service area, Oscar covers only Emergency or Urgent Care services. If You need to go to an Out-of-Network out-of-area Provider for an Emergency or Urgent Care, the charges for that care are covered. Additionally, subject to Our prior approval, We may cover transplant services, or other highly specialized services through an Oscar designated Provider which is Out-of-Area. To the extent that the services of Out-of-of- Network or out-of-area Providers are covered, You are liable for the applicable Copayments, Coinsurance and/or Deductibles stated in this Agreement. When You are traveling abroad and need medical care medicalcare You can call the Oscar Service Center at 1-855-Oscar-55. They are available 8am-8pm PST, Monday through Friday and 8am-6pm PST on Saturday. If You need inpatient Hospital care, Your Provider should contact Us for Precertification. If You need Emergency medical care, go to the nearest Hospital. There is no need to call before You receive Emergency care. Refer to the section titled GETTING APPROVAL FOR BENEFITS to learn how to get Authorization when You need to be admitted to the Hospital for non-Emergency care. For care obtained when You are traveling outside of the United States, You may need to pay for the following services up front: • Doctor services; • Inpatient Hospital care; and • Outpatient services. You will need to file a claim form for any payments made up front. You can obtain filing forms as well as further information by calling customer service at 1-855-Oscar-55 or by visiting xxx.xxxxxxx.xxx. Additional information on claims for services received while traveling abroad: • You are responsible, at Your expense, for obtaining an English language translation of foreign country Provider claims and medicalrecords. • The exchange rate utilized for: o Inpatient Hospital care is based on the date of admission. o Outpatient and professional services are based on the date of service. o You will find the address for mailing the claim on the form. A claim is incurred on the date the service is provided to You. This is important because You must be enrolled and eligible to receive benefits on the date the service is provided. A claim must be submitted in order for Us to record the services and consider them for benefits. We will record claims in Our records in the order in which Your claims are processed, not necessarily in the order in which You receive the service or supply. We only provide benefits for Covered Services that are Medically Necessary. Benefits and benefit limits are described in WHAT IS COVERED – MEDICAL and in the SUMMARY OF BENEFITS. Either the Subscriber or Provider of service must claim benefits by sending Xxxxx properly completed claims forms itemizing the services or supplies received and the charges. These claim forms must be received by Xxxxx within one hundred eighty (180) from the date of services or supplies are received. If the claim is for an Out-of-Network Emergency Center or Urgent Care Center, these claim forms must be received by Oscar within one hundred eighty (180) days from the date of services. Xxxxx will not be liable for benefits if a completed claim form is not furnished to Oscar within this time period, except in the absence of legal capacity. Claims forms must be used, canceled checks or receipts are not acceptable.

Authorized Referrals. In some circumstances, We may authorize In-Network Provider Cost Share amounts (Deductible, Copayment, and/or Coinsurance) to apply to a claim for a Covered Service You receive from an Out-of-Network Provider. In such circumstance, You or Your Physician or Provider must request Precertification and contact Us in advance of obtaining the Covered Service and obtain Our written approval to have the services provided by Out-of-Network Provider. It is Your responsibility to ensure that We have been contacted. If We certify an In-Network Provider Cost Share amount to apply to a Covered Service received from an Out-of-Network Provider, You will only be responsible for any Copayments, Coinsurance, and/or Deductibles stated in this Agreement. Please contact Us at 1-855-Oscar-55 for Authorized Referral information or to request authorization. Approvals of authorizations to Out-of- Network Providers will not be made for the convenience of You or another treating Provider and may not necessarily be to the specific Out-of-Network Provider You requested. The written authorization (the certification letter) will indicate the specific service that is approved and the specific provider that is approved to provide it. If We approve the authorization, all services performed by the Out-of-Network Provider are subject to a treatment plan approved by Us in consultation with Your In-Network Provider, the Out-of-Network Provider and You. Xxxxx can help You find an In-Network Provider specific to Your Plan by calling customer service at 1-855-Oscar-55 or visit Us at xxx.xxxxxxx.xxx. Your Oscar ID card identifies You and contains important health care coverage information. Carrying Your ID card at all times will ensure You always have access to this coverage information when You need it. Make sure You show Your ID card to Your doctor, Hospital, pharmacist, or other health care Provider so they know You are covered by Xxxxx. Out-of-Area Services and Out-of-Network Providers Outside Oscar’s Service Area Outside of Our Service area, Oscar covers only Emergency or Urgent Care services. If You need to go to an Out-of-Network out-of-area Provider for an Emergency or Urgent Care, the charges for that care are covered. Additionally, subject to Our prior approval, We may cover transplant services, or other highly specialized services through an Oscar designated Provider which is Out-of-Area. To the extent that the services of Out-of-of- Network or out-of-area Providers are covered, You are liable for the applicable Copayments, Coinsurance and/or Deductibles stated in this Agreement. When You are traveling abroad and need medical care You can call the Oscar Service Center at 1-855-Oscar-55. They are available 8am-8pm PST, Monday through Friday and 8am-6pm PST on Saturday. If You need inpatient Hospital care, Your Provider should contact Us for Precertification. If You need Emergency medical care, go to the nearest Hospital. There is no need to call before You receive Emergency care. Refer to the section titled GETTING APPROVAL FOR BENEFITS to learn how to get Authorization when You need to be admitted to the Hospital for non-Emergency care. For care obtained when You are traveling outside of the United States, You may need to pay for the following services up front: • Doctor services; • Inpatient Hospital care; and • Outpatient services. You will need to file a claim form for any payments made up front. You can obtain filing forms as well as further information by calling customer service at 1-855-Oscar-55 or by visiting xxx.xxxxxxx.xxx. Additional information on claims for services received while traveling abroad: • You are responsible, at Your expense, for obtaining an English language translation of foreign country Provider claims and medicalrecordsmedical records. • The exchange rate utilized for: o Inpatient Hospital care is based on the date of admission. o Outpatient and professional services are based on the date of service. o You will find the address for mailing the claim on the form. A claim is incurred on the date the service is provided to You. This is important because You must be enrolled and eligible to receive benefits on the date the service is provided. A claim must be submitted in order for Us to record the services and consider them for benefits. We will record claims in Our records in the order in which Your claims are processed, not necessarily in the order in which You receive the service or supply. We only provide benefits for Covered Services that are Medically Necessary. Benefits and benefit limits are described in WHAT IS COVERED – MEDICAL and in the SUMMARY OF BENEFITS. Either the Subscriber or Provider of service must claim benefits by sending Xxxxx properly completed claims forms itemizing the services or supplies received and the charges. These claim forms must be received by Xxxxx within one hundred eighty (180) from the date of services or supplies are received. If the claim is for an Out-of-Network Emergency Center or Urgent Care Center, these claim forms must be received by Oscar within one hundred eighty (180) days from the date of services. Xxxxx will not be liable for benefits if a completed claim form is not furnished to Oscar within this time period, except in the absence of legal capacity. Claims forms must be used, canceled checks or receipts are not acceptable.

Authorized Referrals. In some circumstances, We may authorize In-Network Provider Cost Share amounts (Deductible, Copayment, and/or Coinsurance) to apply to a claim for a Covered Service You receive from an Out-of-Network Provider. In such circumstance, You or Your Physician or Provider must request Precertification and contact Us in advance of obtaining the Covered Service and obtain Our written approval to have the services provided by Out-of-Network Provider. It is Your responsibility to ensure that We have been contacted. If We certify an In-Network Provider Cost Share amount to apply to a Covered Service received from an Out-of-Network Provider, You will only be responsible for any Copayments, Coinsurance, and/or Deductibles stated in this Agreement. Please contact Us at 1-855-Oscar-55 for Authorized Referral information or to request authorization. Approvals of authorizations to Out-of- Network Providers will not be made for the convenience of You or another treating Provider and may not necessarily be to the specific Out-of-Network Provider You requested. The written authorization (the certification letter) will indicate the specific service that is approved and the specific provider that is approved to provide it. If We approve the authorization, all services performed by the Out-of-Network Provider are subject to a treatment plan approved by Us in consultation with Your In-Network Provider, the Out-of-Network Provider and You. Xxxxx can help You find an In-Network Provider specific to Your Plan by calling customer service at 1-855-Oscar-55 or visit Us at xxx.xxxxxxx.xxx. Your Oscar ID card identifies You and contains important health care coverage information. Carrying Your ID card at all times will ensure You always have access to this coverage information when You need it. Make sure You show Your ID card to Your doctor, Hospital, pharmacist, or other health care Provider so they know You are covered by Xxxxx. Out-of-Area Services and Out-of-Network Providers Outside Oscar’s Service Area Outside of Our Service area, Oscar covers only Emergency or Urgent Care services. If You need to go to an Out-of-Network out-of-area Provider for an Emergency or Urgent Care, the charges for that care are covered. Additionally, subject to Our prior approval, We may cover transplant services, or other highly specialized services through an Oscar designated Provider which is Out-of-Area. To the extent that the services of Out-of-Network or out-of-area Providers are covered, You are liable for the applicable Copayments, Coinsurance and/or Deductibles stated in this Agreement. When You are traveling abroad and need medical care medicalcare You can call the Oscar Service Center at 1-855-Oscar-55. They are available 8am-8pm PST, Monday through Friday and 8am-6pm PST on Saturday. If You need inpatient Hospital care, Your Provider should contact Us for Precertification. If You need Emergency medical care, go to the nearest Hospital. There is no need to call before You receive Emergency care. Refer to the section titled GETTING APPROVAL FOR BENEFITS to learn how to get Authorization when You need to be admitted to the Hospital for non-Emergency care. For care obtained when You are traveling outside of the United States, You may need to pay for the following services up front: • Doctor services; • Inpatient Hospital care; and • Outpatient services. You will need to file a claim form for any payments made up front. You can obtain filing forms as well as further information by calling customer service at 1-855-Oscar-55 or by visiting xxx.xxxxxxx.xxx. Additional information on claims for services received while traveling abroad: • You are responsible, at Your expense, for obtaining an English language translation of foreign country Provider claims and medicalrecordsmedical records. • The exchange rate utilized for: o Inpatient Hospital care is based on the date of admission. o Outpatient and professional services are based on the date of service. o You will find the address for mailing the claim on the form. A claim is incurred on the date the service is provided to You. This is important because You must be enrolled and eligible to receive benefits on the date the service is provided. A claim must be submitted in order for Us to record the services and consider them for benefits. We will record claims in Our records in the order in which Your claims are processed, not necessarily in the order in which You receive the service or supply. We only provide benefits for Covered Services that are Medically Necessary. Benefits and benefit limits are described in WHAT IS COVERED – MEDICAL and in the SUMMARY OF BENEFITS. Either the Subscriber or Provider of service must claim benefits by sending Xxxxx properly completed claims forms itemizing the services or supplies received and the charges. These claim forms must be received by Xxxxx within one hundred eighty (180) from the date of services or supplies are received. If the claim is for an Out-of-Network Emergency Center or Urgent Care Center, these claim forms must be received by Oscar within one hundred eighty (180) days from the date of services. Xxxxx will not be liable for benefits if a completed claim form is not furnished to Oscar within this time period, except in the absence of legal capacity. Claims forms must be used, canceled checks or receipts are not acceptable.

Authorized Referrals. In some circumstances, We may authorize In-Network Provider Cost Share amounts (Deductible, Copayment, and/or Coinsurance) to apply to a claim for a Covered Service You receive from an Out-of-Network Provider. In such circumstance, You or Your Physician or Provider must request Precertification and contact Us in advance of obtaining the Covered Service and obtain Our our written approval to have the services provided by Out-of-Network Provider. It is Your responsibility to ensure that We have been contacted. If We certify an In-Network Provider Cost Share amount to apply to a Covered Service received from an Out-of-Network Provider, You will only be responsible for any Copayments, Coinsurance, and/or Deductibles stated in this Agreementagreement. Please contact Us at 1-1- 855-Oscar-55 for Authorized Referral information or to request authorization. Approvals of authorizations to Out-of- of-Network Providers will not be made for the convenience of You or another treating Provider and may not necessarily be to the specific Out-of-Network Provider You requested. The written authorization (the certification letter) will indicate the specific service that is approved and the specific provider that is approved to provide it. If We approve the authorization, all services performed by the Out-of-Network Provider are subject to a treatment plan approved by Us in consultation with Your In-Network Provider, the Out-of-Network Provider and You. Xxxxx can help You find an In-Network Provider specific to Your Plan by calling customer service at 1-855-Oscar-55 or visit Us at xxx.xxxxxxx.xxx. Your Oscar ID card identifies You and contains important health care coverage information. Carrying Your ID card at all times will ensure You always have access to this coverage information when You need it. Make sure You show Your ID card to Your doctor, Hospital, pharmacist, or other health care Provider so they know You are covered by Xxxxx. Out-of-Area Services and Out-of-Network Providers Outside Oscar’s Service Area Outside of Our Service area, Oscar covers only Emergency or Urgent Care services. If You need to go to an Out-of-Network out-of-area Provider for an Emergency or Urgent Care, the charges for that care are covered. Additionally, subject to Our our prior approval, We may cover transplant services, or other highly specialized services through an Oscar designated Provider which is Out-of-Area. To the extent that the services of Out-of-Network or of- Network, out-of-area Providers are covered, You are liable for the applicable Copayments, Coinsurance and/or Deductibles stated in this Agreement. When You are traveling abroad and need medical care You can call the Oscar Service Center at 1-855-Oscar-55. They are available 8am-8pm PST, Monday through Friday and 8am-6pm PST on Saturday. If You need inpatient Hospital care, Your Provider should contact Us for Precertification. If You need Emergency medical care, go to the nearest Hospital. There is no need to call before You receive Emergency care. Refer to the section titled part GETTING APPROVAL FOR BENEFITS to learn how to get Authorization when You need to be admitted to the Hospital for non-Emergency care. For care obtained when You you are traveling outside of the United States, You may need to pay for the following services up front: • Doctor services; • Inpatient Hospital care; and • Outpatient services. You will need to file a claim form for any payments made up front. You can obtain filing forms as well as further information by calling customer service at 1-855-Oscar-55 or by visiting xxx.xxxxxxx.xxx. Additional information on claims for services received while traveling abroad: • You are responsible, at Your your expense, for obtaining an English language translation of foreign country Provider claims and medicalrecordsmedical records. • The exchange rate utilized for: o Inpatient Hospital care is based on the date of admission. o Outpatient and professional services are based on the date of service. o You will find the address for mailing the claim on the form. A claim is incurred on the date the service is provided to You. This is important because You must be enrolled and eligible to receive benefits on the date the service is provided. A claim must be submitted in order for Us to record the services and consider them for benefits. We will record claims in Our our records in the order in which Your claims are processed, not necessarily in the order in which You receive the service or supply. We only provide benefits for Covered Services that are Medically Necessary. Benefits and benefit limits are described in WHAT IS COVERED – MEDICAL and in the SUMMARY OF BENEFITS. Either Copayments and Coinsurance are outlined in the Subscriber SUMMARY OF BENEFITS. Your Copayment and Coinsurance may be a fixed dollar amount per day, per visit, and/or it may be a percentage of the Negotiated Fee Rate. Xxxxx can help You find an In-Network Provider specific to Your Plan by calling customer service at 1-855-Oscar-55 or Provider of service must claim benefits by sending Xxxxx properly completed claims forms itemizing the services or supplies received and the chargesvisit Us at xxx.xxxxxxx.xxx. These claim forms must be received amounts are Your financial responsibility. After Your Deductible is satisfied, Copayments are normally paid by Xxxxx within one hundred eighty (180) from You at the date of time services or supplies are receivedperformed. If Your Plan contains a Deductible, You must satisfy the In-Network medical Deductible before We will make payment for services You receive, except for certain services as stated in the sections below. Additionally, the medical Deductible is explained in the SUMMARY OF BENEFITS. While Your Coinsurance financial responsibility may also be collected by the Provider at the time services are performed, the Provider may choose to bill You for these services after they have submitted the claim to us. Cost sharing for services with Copayments is for an Out-of-Network Emergency Center the lesser of the Copayment amount or Urgent Care Center, these claim forms must be received by Oscar within one hundred eighty (180) days from the date Negotiated Fee Rate. Described below are Your Coinsurance and Out of services. Xxxxx will not be liable for benefits if a completed claim form is not furnished to Oscar within this time period, except in the absence of legal capacity. Claims forms must be used, canceled checks or receipts are not acceptablePocket Maximums.

Authorized Referrals. If there is not a participating provider within a 50-mile radius of the member's residence, a member can request an authorized referral to a non-participating provider. If the referral request is approved, the physician will be reimbursed at 100%, after deductible and copay of the network rate usual & customary charges. In some circumstances, We Anthem may authorize In-Network Provider Cost Share cost share amounts (Deductible, Copayment, Copayment and/or Coinsurance) to apply to a claim for a Covered Service You receive the member receives from an Out-of-Network Provider. In such circumstance, You the member or Your their Physician or Provider must request Precertification and contact Us Anthem in advance of obtaining the Covered Service and obtain Our written approval to have the services provided by Out-of-Network ProviderService. It is Your the member’s responsibility to ensure that We have Anthem has been contacted. If We certify Anthem authorizes an In-Network Provider Cost Share cost share amount to apply to a Covered Service received from an Out-of-Network Provider, You will only the member also may still be responsible for any Copayments, Coinsurance, and/or Deductibles stated in this Agreement. Please contact Us at 1-855-Oscar-55 for Authorized Referral information or to request authorization. Approvals of authorizations to Out-of- Network Providers will not be made liable for the convenience of You or another treating Provider difference between the Maximum Allowed Amount and may not necessarily be to the specific Out-of-Network Provider You requested. The written authorization (the certification letter) will indicate the specific service that is approved and the specific provider that is approved to provide it. If We approve the authorization, all services performed by the Out-of-Network Provider are subject to a treatment plan approved by Us in consultation with Your In-Network Provider, the Out-of-Network Provider and You. Xxxxx can help You find an In-Network Provider specific to Your Plan by calling customer service at 1-855-Oscar-55 or visit Us at xxx.xxxxxxx.xxx. Your Oscar ID card identifies You and contains important health care coverage information. Carrying Your ID card at all times will ensure You always have access to this coverage information when You need it. Make sure You show Your ID card to Your doctor, Hospital, pharmacist, or other health care Provider so they know You are covered by Xxxxx. Out-of-Area Services and Out-of-Network Providers Outside Oscar’s Service Area Outside of Our Service area, Oscar covers only Emergency or Urgent Care services. If You need to go to an Out-of-Network out-of-area Provider for an Emergency or Urgent Care, the charges for that care are covered. Additionally, subject to Our prior approval, We may cover transplant services, or other highly specialized services through an Oscar designated Provider which is Out-of-Area. To the extent that the services of Out-of-Network or out-of-area Providers are covered, You are liable for the applicable Copayments, Coinsurance and/or Deductibles stated in this Agreement. When You are traveling abroad and need medical care You can call the Oscar Service Center at 1-855-Oscar-55. They are available 8am-8pm PST, Monday through Friday and 8am-6pm PST on Saturday. If You need inpatient Hospital care, Your Provider should contact Us for Precertification. If You need Emergency medical care, go to the nearest Hospital. There is no need to call before You receive Emergency care. Refer to the section titled GETTING APPROVAL FOR BENEFITS to learn how to get Authorization when You need to be admitted to the Hospital for non-Emergency care. For care obtained when You are traveling outside of the United States, You may need to pay for the following services up front: • Doctor services; • Inpatient Hospital care; and • Outpatient services. You will need to file a claim form for any payments made up front. You can obtain filing forms as well as further information by calling customer service at 1-855-Oscar-55 or by visiting xxx.xxxxxxx.xxx. Additional information on claims for services received while traveling abroad: • You are responsible, at Your expense, for obtaining an English language translation of foreign country Provider claims and medicalrecords. • The exchange rate utilized for: o Inpatient Hospital care is based on the date of admission. o Outpatient and professional services are based on the date of service. o You will find the address for mailing the claim on the form. A claim is incurred on the date the service is provided to You. This is important because You must be enrolled and eligible to receive benefits on the date the service is provided. A claim must be submitted in order for Us to record the services and consider them for benefits. We will record claims in Our records in the order in which Your claims are processed, not necessarily in the order in which You receive the service or supply. We only provide benefits for Covered Services that are Medically Necessary. Benefits and benefit limits are described in WHAT IS COVERED – MEDICAL and in the SUMMARY OF BENEFITS. Either the Subscriber or Provider of service must claim benefits by sending Xxxxx properly completed claims forms itemizing the services or supplies received and the charges. These claim forms must be received by Xxxxx within one hundred eighty (180) from the date of services or supplies are receivedcharge. If the claim is member receives prior authorization for an Out-of-Network Emergency Center or Urgent Care CenterProvider due to network adequacy issues, these claim forms must be received by Oscar within one hundred eighty (180) days from the date of services. Xxxxx will not member also may still be liable for benefits if the difference between the Maximum Allowed Amount and the Out-of-Network Provider’s charge, unless the claim involves a completed claim form Surprise Billing Claim. Contact Member Services at the telephone number on the back of the member’s Identification Card for Authorized Referrals information or to request authorization. It is important to understand that the member may be referred by In-Network Providers to other Providers who may be contracted with the Claims Administrator but are not part of the Plan’s network of In-Network Providers. In such case, any claims incurred would be paid as Out-of-Network Provider services, even though the Provider may be a participating Provider with the Claims Administrator. It is the member’s responsibility to confirm that the Provider they are seeing or have been referred to see is an In- Network Provider with the Plan. While the Plan has provided a network of In-Network Providers, it is important to understand that the Claims Administrator has many contracting Providers who are not participating in the network of Providers for the Plan. Any claims incurred with a participating Provider, who is not furnished to Oscar within this time period, except participating in the absence network panel of legal capacityProviders, will be paid as Out-of-Network Provider services, even if the member has been referred by another participating Provider. Claims forms must Covered expenses for claims incurred due to an emergency as determined by the diagnostic code that the provider applies will be usedpaid as defined in the applicable plan documents. The definition of emergency is also as defined in the applicable plan documents. The District agrees to pay 100% of uncovered emergency costs after the co-pay including the actual cost of an ambulance if needed. In the event that the provider determines the event was not an emergency and was related to placing the patient’s health in serious jeopardy, canceled checks serious impairment to bodily functions, or receipts are not acceptableserious dysfunction of any bodily organ or part, then the insured has the right to appeal.

Authorized Referrals. In some circumstances, We may authorize In-Network Provider Cost Share amounts (Deductible, Copayment, and/or Coinsurance) to apply to a claim for a Covered Service You receive from an Out-of-Network Provider. In such circumstance, You or Your Physician or Provider must request Precertification and contact Us in advance of obtaining the Covered Service and obtain Our our written approval to have the services provided by Out-of-Network Provider. It is Your responsibility to ensure that We have been contacted. If We certify an In-Network Provider Cost Share amount to apply to a Covered Service received from an Out-of-Network Provider, You will only be responsible for any Copayments, Coinsurance, and/or Deductibles stated in this Agreementagreement. Please contact Us at 1-1- 855-Oscar-55 for Authorized Referral information or to request authorization. Approvals of authorizations to Out-of- of-Network Providers will not be made for the convenience of You or another treating Provider and may not necessarily be to the specific Out-of-Network Provider You requested. The written authorization (the certification letter) will indicate the specific service that is approved and the specific provider that is approved to provide it. If We approve the authorization, all services performed by the Out-of-Network Provider are subject to a treatment plan approved by Us in consultation with Your In-Network Provider, the Out-of-Network Provider and You. Xxxxx can help You find an In-Network Provider specific to Your Plan by calling customer service at 1-855-Oscar-55 or visit Us at xxx.xxxxxxx.xxx. Your Oscar ID card identifies You and contains important health care coverage information. Carrying Your ID card at all times will ensure You always have access to this coverage information when You need it. Make sure You show Your ID card to Your doctor, Hospital, pharmacist, or other health care Provider so they know You are covered by Xxxxx. Out-of-Area Services and Out-of-Network Providers Outside Oscar’s Service Area Outside of Our our Service area, Oscar covers only Emergency or Urgent Care services. If You need to go to an Out-of-Network out-of-area Provider for an Emergency or Urgent Care, the charges for that care are covered. Additionally, subject to Our our prior approval, We may cover transplant services, or other highly specialized services through an Oscar designated Provider which is Out-of-Area. To the extent that the services of Out-of-Network or of- Network, out-of-area Providers are covered, You are liable for the applicable Copayments, Coinsurance and/or Deductibles stated in this Agreement. When You are traveling abroad and need medical care You can call the Oscar Service Center at 1-855-Oscar-55. They are available 8am-8pm PST, Monday through Friday and 8am-6pm PST on Saturday. If You need inpatient Hospital care, Your Provider should contact Us for Precertification. If You need Emergency medical care, go to the nearest Hospital. There is no need to call before You receive Emergency care. Refer to the section titled part GETTING APPROVAL FOR BENEFITS to learn how to get Authorization when You need to be admitted to the Hospital for non-Emergency care. For care obtained when You you are traveling outside of the United States, You may need to pay for the following services up front: • Doctor services; • Inpatient Hospital care; and • Outpatient services. You will need to file a claim form for any payments made up front. You can obtain filing forms as well as further information by calling customer service at 1-855-Oscar-55 or by visiting xxx.xxxxxxx.xxx. Additional information on claims for services received while traveling abroad: • You are responsible, at Your your expense, for obtaining an English language translation of foreign country Provider claims and medicalrecordsmedical records. • The exchange rate utilized for: o Inpatient Hospital care is based on the date of admission. o Outpatient and professional services are based on the date of service. o You will find the address for mailing the claim on the form. A claim is incurred on the date the service is provided to You. This is important because You must be enrolled and eligible to receive benefits on the date the service is provided. A claim must be submitted in order for Us to record the services and consider them for benefits. We will record claims in Our our records in the order in which Your claims are processed, not necessarily in the order in which You receive the service or supply. We only provide benefits for Covered Services that are Medically Necessary. Benefits and benefit limits are described in WHAT IS COVERED – MEDICAL and in the SUMMARY OF BENEFITS. Either Copayments and Coinsurance are outlined in the Subscriber SUMMARY OF BENEFITS. Your Copayment and Coinsurance may be a fixed dollar amount per day, per visit, and/or it may be a percentage of the Negotiated Fee Rate. Xxxxx can help You find an In-Network Provider specific to Your Plan by calling customer service at 1-855-Oscar-55 or Provider of service must claim benefits by sending Xxxxx properly completed claims forms itemizing the services or supplies received and the chargesvisit Us at xxx.xxxxxxx.xxx. These claim forms must be received amounts are Your financial responsibility. After Your Deductible is satisfied, Copayments are normally paid by Xxxxx within one hundred eighty (180) from You at the date of time services or supplies are receivedperformed. If Your Plan contains a Deductible, You must satisfy the In-Network medical Deductible before We will make payment for services You receive, except for certain services as stated in the sections below. Additionally, the medical Deductible is explained in the SUMMARY OF BENEFITS. While Your Coinsurance financial responsibility may also be collected by the Provider at the time services are performed, the Provider may choose to bill You for these services after they have submitted the claim to us. Cost sharing for services with Copayments is for an Out-of-Network Emergency Center the lesser of the Copayment amount or Urgent Care Center, these claim forms must be received by Oscar within one hundred eighty (180) days from the date Negotiated Fee Rate. Described below are Your Coinsurance and Out of services. Xxxxx will not be liable for benefits if a completed claim form is not furnished to Oscar within this time period, except in the absence of legal capacity. Claims forms must be used, canceled checks or receipts are not acceptablePocket Maximums.

Authorized Referrals. In some circumstances, We may authorize In-In Network Provider Cost Share amounts (Deductible, Copayment, and/or Coinsurance) to apply to a claim for a Covered Service You receive from an Out-of-Out of Network Provider. In such circumstance, You or Your Physician or Provider must request Precertification and contact Us in advance of obtaining the Covered Service and obtain Our our written approval to have the services provided by Out-of-Out of Network Provider. It is Your responsibility to ensure that We have been contacted. If We certify an In-In Network Provider Cost Share amount to apply to a Covered Service received from an Out-of-Out of Network Provider, You will only be responsible for any Copayments, Coinsurance, and/or Deductibles stated in this Agreementagreement. Please contact Us at 1-855-Oscar-55 for Authorized Referral information or to request authorization. Approvals of authorizations to Out-of- of-Network Providers will not be made for the convenience of You or another treating Provider and may not necessarily be to the specific Out-of-Network Provider You requested. The written authorization (the certification letter) will indicate the specific service that is approved and the specific provider that is approved to provide it. If We approve the authorization, all services performed by the Out-of-Network Provider are subject to a treatment plan approved by Us in consultation with Your In-In Network Provider, the Out-of-Network Provider and You. Xxxxx can help You find an In-In Network Provider specific to Your Plan by calling customer service at 1-855-Oscar-55 or visit Us at xxx.xxxxxxx.xxx. Your Oscar ID card identifies You and contains important health care coverage information. Carrying Your ID card at all times will ensure You always have access to this coverage information when You need it. Make sure You show Your ID card to Your doctor, Hospital, pharmacist, or other health care Provider so they know You are covered by Xxxxx. Out-of-Area Services and Out-of-Network Providers Outside Oscar’s Service Area Outside of Our Service area, Oscar covers only Emergency or Urgent Care services. If You need to go to an Out-of-Network out-of-area Provider for an Emergency or Urgent Care, the charges for that care are covered. Additionally, subject to Our prior approval, We may cover transplant services, or other highly specialized services through an Oscar designated Provider which is Out-of-Area. To the extent that the services of Out-of-Network or out-of-area Providers are covered, You are liable for the applicable Copayments, Coinsurance and/or Deductibles stated in this Agreement. When You are traveling abroad and need medical care You can call the Oscar Service Center at 1-855-Oscar-55. They are available 8am-8pm PST, Monday through Friday and 8am-6pm PST on Saturday. If You need inpatient Hospital care, Your Provider should contact Us for Precertification. If You need Emergency medical care, go to the nearest Hospital. There is no need to call before You receive Emergency care. Refer to the section titled GETTING APPROVAL FOR BENEFITS to learn how to get Authorization when You need to be admitted to the Hospital for non-Emergency care. For care obtained when You are traveling outside of the United States, You may need to pay for the following services up front: • Doctor services; • Inpatient Hospital care; and • Outpatient services. You will need to file a claim form for any payments made up front. You can obtain filing forms as well as further information by calling customer service at 1-855-Oscar-55 or by visiting xxx.xxxxxxx.xxx. Additional information on claims for services received while traveling abroad: • You are responsible, at Your expense, for obtaining an English language translation of foreign country Provider claims and medicalrecords. • The exchange rate utilized for: o Inpatient Hospital care is based on the date of admission. o Outpatient and professional services are based on the date of service. o You will find the address for mailing the claim on the form. A claim is incurred on the date the service is provided to You. This is important because You must be enrolled and eligible to receive benefits on the date the service is provided. A claim must be submitted in order for Us to record the services and consider them for benefits. We will record claims in Our records in the order in which Your claims are processed, not necessarily in the order in which You receive the service or supply. We only provide benefits for Covered Services that are Medically Necessary. Benefits and benefit limits are described in WHAT IS COVERED – MEDICAL and in the SUMMARY OF BENEFITS. Either the Subscriber or Provider of service must claim benefits by sending Xxxxx properly completed claims forms itemizing the services or supplies received and the charges. These claim forms must be received by Xxxxx within one hundred eighty (180) from the date of services or supplies are received. If the claim is for an Out-of-Network Emergency Center or Urgent Care Center, these claim forms must be received by Oscar within one hundred eighty (180) days from the date of services. Xxxxx will not be liable for benefits if a completed claim form is not furnished to Oscar within this time period, except in the absence of legal capacity. Claims forms must be used, canceled checks or receipts are not acceptable.

Authorized Referrals. In some circumstances, We may authorize In-Network Provider Cost Share amounts (Deductible, Copayment, and/or Coinsurance) to apply to a claim for a Covered Service You receive from an Out-of-Network Provider. In such circumstance, You or Your Physician or Provider must request Precertification and contact Us in advance of obtaining the Covered Service and obtain Our written approval to have the services provided by Out-of-Network Provider. It is Your responsibility to ensure that We have been contacted. If We certify an In-Network Provider Cost Share amount to apply to a Covered Service received from an Out-of-Network Provider, You will only be responsible for any Copayments, Coinsurance, and/or Deductibles stated in this Agreement. Please contact Us at 1-855-Oscar-55 for Authorized Referral information or to request authorization. Approvals of authorizations to Out-of- of-Network Providers will not be made for the convenience of You or another treating Provider and may not necessarily be to the specific Out-Out- of-Network Provider You requested. The written authorization (the certification letter) will indicate the specific service that is approved and the specific provider that is approved to provide it. If We approve the authorization, all services performed by the Out-of-Network Provider are subject to a treatment plan approved by Us in consultation with Your In-Network Provider, the Out-of-Network Provider and You. Xxxxx can help You find an In-Network Provider specific to Your Plan by calling customer service at 1-855-Oscar-55 or visit Us at xxx.xxxxxxx.xxx. Your Oscar ID card identifies You and contains important health care coverage information. Carrying Your ID card at all times will ensure You always have access to this coverage information when You need it. Make sure You show Your ID card to Your doctor, Hospital, pharmacist, or other health care Provider so they know You are covered by Xxxxx. Out-of-Area Services and Out-of-Network Providers Outside Oscar’s Service Area Outside of Our Service area, Oscar covers only Emergency or Urgent Care services. If You need to go to an Out-of-Network out-of-area Provider for an Emergency or Urgent Care, the charges for that care are covered. Additionally, subject to Our prior approval, We may cover transplant services, or other highly specialized services through an Oscar designated Provider which is Out-of-Area. To the extent that the services of Out-of-of- Network or out-of-area Providers are covered, You are liable for the applicable Copayments, Coinsurance and/or Deductibles stated in this Agreement. When You are traveling abroad and need medical care You can call the Oscar Service Center at 1-855-Oscar-55. They are available 8am-8pm PST, Monday through Friday and 8am-6pm PST on Saturday. If You need inpatient Hospital care, Your Provider should contact Us for Precertification. If You need Emergency medical care, go to the nearest Hospital. There is no need to call before You receive Emergency care. Refer to the section titled GETTING APPROVAL FOR BENEFITS to learn how to get Authorization when You need to be admitted to the Hospital for non-Emergency care. For care obtained when You are traveling outside of the United States, You may need to pay for the following services up front: • ● Doctor services; • ● Inpatient Hospital care; and • ● Outpatient services. You will need to file a claim form for any payments made up front. You can obtain filing forms as well as further information by calling customer service at 1-855-Oscar-55 or by visiting xxx.xxxxxxx.xxx. Additional information on claims for services received while traveling abroad: • ● You are responsible, at Your expense, for obtaining an English language translation of foreign country Provider claims and medicalrecordsmedical records. • ● The exchange rate utilized for: o Inpatient Hospital care is based on the date of admission. o Outpatient and professional services are based on the date of service. o You will find the address for mailing the claim on the form. A claim is incurred on the date the service is provided to You. This is important because You must be enrolled and eligible to receive benefits on the date the service is provided. A claim must be submitted in order for Us to record the services and consider them for benefits. We will record claims in Our records in the order in which Your claims are processed, not necessarily in the order in which You receive the service or supply. We only provide benefits for Covered Services that are Medically Necessary. Benefits and benefit limits are described in WHAT IS COVERED – MEDICAL and in the SUMMARY OF BENEFITS. Either the Subscriber or Provider of service must claim benefits by sending Xxxxx properly completed claims forms itemizing the services or supplies received and the charges. These claim forms must be received by Xxxxx within one hundred eighty (180) from the date of services or supplies are received. If the claim is for an Out-of-Network Emergency Center or Urgent Care Center, these claim forms must be received by Oscar within one hundred eighty (180) days from the date of services. Xxxxx will not be liable for benefits if a completed claim form is not furnished to Oscar within this time period, except in the absence of legal capacity. Claims forms must be used, canceled checks or receipts are not acceptable.

Authorized Referrals. In some circumstances, We may authorize In-Network Provider Cost Share amounts (Deductible, Copayment, and/or Coinsurance) to apply to a claim for a Covered Service You receive from an Out-of-Network Provider. In such circumstance, You or Your Physician or Provider must request Precertification and contact Us in advance of obtaining the Covered Service and obtain Our written approval to have the services provided by Out-of-Network Provider. It is Your responsibility to ensure that We have been contacted. If We certify an In-In- Network Provider Cost Share amount to apply to a Covered Service received from an Out-of-of- Network Provider, You will only be responsible for any Copayments, Coinsurance, and/or Deductibles stated in this Agreement. Please contact Us at 1-855-Oscar-55 for Authorized Referral information or to request authorization. Approvals of authorizations to Out-of- of-Network Providers will not be made for the convenience of You or another treating Provider and may not necessarily be to the specific Out-of-Network Provider You requested. The written authorization (the certification letter) will indicate the specific service that is approved and the specific provider that is approved to provide it. If We approve the authorization, all services performed by the Out-of-Network Provider are subject to a treatment plan approved by Us in consultation with Your In-Network Provider, the Out-of-Network Provider and You. Xxxxx can help You find an In-Network Provider specific to Your Plan by calling customer service at 1-855-Oscar-55 or visit Us at xxx.xxxxxxx.xxx. Your Oscar ID card identifies You and contains important health care coverage information. Carrying Your ID card at all times will ensure You always have access to this coverage information when You need it. Make sure You show Your ID card to Your doctor, Hospital, pharmacist, or other health care Provider so they know You are covered by Xxxxx. Out-of-Area Services and Out-of-Network Providers Outside Oscar’s Service Area Outside of Our Service area, Oscar covers only Emergency or Urgent Care services. If You need to go to an Out-of-Network out-of-area Provider for an Emergency or Urgent Care, the charges for that care are covered. Additionally, subject to Our prior approval, We may cover transplant services, or other highly specialized services through an Oscar designated Provider which is Out-of-Area. To the extent that the services of Out-of-of- Network or out-of-area Providers are covered, You are liable for the applicable Copayments, Coinsurance and/or Deductibles stated in this Agreement. When You are traveling abroad and need medical care You can call the Oscar Service Center at 1-855-Oscar-55. They are available 8am-8pm PST, Monday through Friday and 8am-6pm PST on Saturday. If You need inpatient Hospital care, Your Provider should contact Us for Precertification. If You need Emergency medical care, go to the nearest Hospital. There is no need to call before You receive Emergency care. Refer to the section titled GETTING APPROVAL FOR BENEFITS to learn how to get Authorization when You need to be admitted to the Hospital for non-Emergency care. For care obtained when You are traveling outside of the United States, You may need to pay for the following services up front: • ● Doctor services; • ● Inpatient Hospital care; and • ● Outpatient services. You will need to file a claim form for any payments made up front. You can obtain filing forms as well as further information by calling customer service at 1-855-Oscar-55 or by visiting xxx.xxxxxxx.xxx. Additional information on claims for services received while traveling abroad: • ● You are responsible, at Your expense, for obtaining an English language translation of foreign country Provider claims and medicalrecordsmedical records. • ● The exchange rate utilized for: o Inpatient Hospital care is based on the date of admission. o Outpatient and professional services are based on the date of service. o You will find the address for mailing the claim on the form. A claim is incurred on the date the service is provided to You. This is important because You must be enrolled and eligible to receive benefits on the date the service is provided. A claim must be submitted in order for Us to record the services and consider them for benefits. We will record claims in Our records in the order in which Your claims are processed, not necessarily in the order in which You receive the service or supply. We only provide benefits for Covered Services that are Medically Necessary. Benefits and benefit limits are described in WHAT IS COVERED – MEDICAL and in the SUMMARY OF BENEFITS. Either the Subscriber or Provider of service must claim benefits by sending Xxxxx properly completed claims forms itemizing the services or supplies received and the charges. These claim forms must be received by Xxxxx within one hundred eighty (180) from the date of services or supplies are received. If the claim is for an Out-of-Network Emergency Center or Urgent Care Center, these claim forms must be received by Oscar within one hundred eighty (180) days from the date of services. Xxxxx will not be liable for benefits if a completed claim form is not furnished to Oscar within this time period, except in the absence of legal capacity. Claims forms must be used, canceled checks or receipts are not acceptable.