Coverage Determinations. Certain services are covered pursuant to HMO medical policies and clinical procedure and coding policies, which are updated throughout the Calendar Year. The medical policies are guides considered by HMO when making coverage determinations and lay out the procedure and criteria to determine whether a procedure, treatment, facility, equipment, drug or device is Medically Necessary and is eligible as a Covered Service or is Experimental /Investigational, cosmetic, or a convenience item. The clinical procedure and coding policies provide information about what services are reimbursable under the Certificate of Coverage. The most up-to-date medical and clinical procedure and coding policies are available at xxx.xxxxxx.xxx or call customer service at the toll-free telephone number on the back of Your identification card. Selecting a PCP At the time You enroll, You must choose a PCP. If any Member is a minor or otherwise incapable of selecting a PCP, the Subscriber should select a PCP on Member’s behalf. If Your Dependents enroll, You and Your Dependents must choose a PCP from HMO’s directory of Participating Providers in order to receive Covered Services. For the most current list of Participating Providers visit the website at xxx.xxxxxx.xxx. You may also refer to Your Provider directory or call customer service at the toll-free telephone number on the back of Your identification card. You may also request a written copy of the Participating Provider directory, which is updated quarterly, by calling customer service. Each directory identifies those Providers who are accepting existing patients only. HMO may assign a PCP if one has not been selected. Until a PCP is selected or assigned, benefits will be limited to coverage for Emergency Care. In addition to a PCP, female members may also select a Participating Obstetrician/Gynecologist (OB/GYN Care) for gynecological and obstetric conditions, including annual well-woman exam and maternity care, without first obtaining a Referral from a PCP or calling HMO. Members who have been diagnosed with a chronic, disabling or Life-Threatening illness may request approval to choose a Participating Specialist as a PCP using the process described in Specialist as PCP. Your PCP Your PCP coordinates Your medical care, as appropriate, either by providing treatment or by issuing Referrals to direct You to Participating Providers. Except for Emergency Care/medical emergencies or certain direct-access Specialist benefits described...
Coverage Determinations. A Payor or its Designated Representative shall have sole authority to determine: (i) what is a Covered Service; (ii) who is a Member; (iii) the amount and application of Co-payments; and (iv) the network or panel of providers that will provide Covered Services to Members. Group acknowledges that such determinations of Covered Services, Members, Co-payments and participation panel status may vary by Payor and within a particular Payor’s Health
Coverage Determinations. If LME determines that services, supplies, or other items are covered under LME’s health benefit plan or dental plan, including any determination under North Carolina G.S. § 58-50-61, LME shall not subsequently retract its determination after the services, supplies, or other items have been provided, or reduce payments for a service, supply, or other item furnished in reliance on such a determination, unless the determination was based on a material misrepresentation about the Enrollee’s health condition that was knowingly made by the LME or the provider of the service, supply, or other item. For purposes of this Section, a pretreatment estimate means a voluntary request for a projection of dental benefits or payment that does not require authorization and a pretreatment estimate for dental services shall not be considered a coverage determination.
Coverage Determinations. PLAN or its designated representative shall have sole authority to determine:
