Certification Failure. When certification is required and the Utilization Review Agent does not grant such certification, expenses incurred which have not been certified by the Utilization Review Agent will be considered as non-covered and out-of-pocket expenses to the patient. The maximum amount of out-of-pocket expense described in this Section V.A.1. in any calendar year will be $250 per individual. This penalty will not apply towards the In-Network or Out-of-Network Deductible and Stop-Loss regardless of whether the In-Network or Out-of-Network Deductible or Stop-Loss provision has been satisfied during the calendar year.
Appears in 5 contracts
Samples: Pension & Insurance Agreement, Pension and Insurance Agreement, Pension & Insurance Agreement
