Common use of Certification Failure Clause in Contracts

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.2. in any calendar year will be $250 per individual unless the procedure is done on an emergency basis or is done during a Hospital confinement for another primary unrelated medical condition. 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 had been satisfied during the calendar year.

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.2. in any calendar year will be $250 per individual unless the procedure is done on an emergency basis or is done during a Hospital confinement for another primary unrelated medical condition. This penalty will not apply towards the In-In- Network or Out-of-Network Deductible and Stop-Loss regardless of whether the In-In- Network or Out-of-Network Deductible or Stop-Loss provision had been satisfied during the calendar year.