Common use of Description of Covered Services Clause in Contracts

Description of Covered Services. Subject to the Exclusions, conditions and limitations specified in this Agreement, a Member shall be entitled to receive the Covered Services listed below. A Member may be required to make a Copayment or there may be limits on services and other cost sharing requirements as specified in the Section SC - Schedule Of Cost Sharing of this Agreement. Most Covered Services are provided or arranged by a Member’s Primary Care Physician. In the event there is no Participating Provider to provide the specialty or subspecialty services that a Member needs, a Referral to a Non- Participating Provider will be arranged by the Member’s Primary Care Physician, with approval by the HMO. See Section ACC - Access to Primary, Specialist and Hospital Care Network for procedures for obtaining Preauthorization for use of a Non-Participating Provider. If a Member should have questions about any information in this Agreement or need assistance at any time, they should contact Keystone by calling the telephone number shown on their ID Card. Some Covered Services must be Preauthorized before a Member receives the services. The Primary Care Physician or Participating Specialist must seek the HMO's approval and confirm that coverage is provided for certain services. Preauthorization of services is a vital program feature that reviews Medical Necessity of certain procedures and/or admissions. In certain cases, Preauthorization helps determine whether a different treatment may be available that is equally effective yet less traumatic. Preauthorization also helps determine the most appropriate setting for certain services. If a Primary Care Physician or Participating Specialist provides Covered Services or Referrals without obtaining such Preauthorization, the Member will not be responsible for payment. More information on Preauthorization is found in Section MC - Using the HMO System of this Agreement and the Medical Care Preauthorization Schedule attached to this Agreement.

Description of Covered Services. ‌ Subject to the Exclusions, conditions and limitations specified in this Agreement, a Member shall be entitled to receive the Covered Services listed below. A Member may be required to make a Copayment or there may be limits on services and other cost sharing requirements as specified in the Section SC - Schedule Of Cost Sharing of this Agreement. Most Covered Services are provided or arranged by a Member’s Primary Care Physician. In the event there is no Participating Provider to provide the specialty or subspecialty services that a Member needs, a Referral to a Non- Participating Provider will be arranged by the Member’s Primary Care Physician, with approval by the HMO. See Section ACC - Access to Primary, Specialist and Hospital Care Network for procedures for obtaining Preauthorization for use of a Non-Participating Provider. If a Member should have questions about any information in this Agreement or need assistance at any time, they should contact Keystone by calling the telephone number shown on their ID Card. Some Covered Services must be Preauthorized before a Member receives the services. The Primary Care Physician or Participating Specialist must seek the HMO's approval and confirm that coverage is provided for certain services. Preauthorization of services is a vital program feature that reviews Medical Necessity of certain procedures and/or admissions. In certain cases, Preauthorization helps determine whether a different treatment may be available that is equally effective yet less traumatic. Preauthorization also helps determine the most appropriate setting for certain services. If a Primary Care Physician or Participating Specialist provides Covered Services or Referrals without obtaining such Preauthorization, the Member will not be responsible for payment. More information on Preauthorization is found in Section MC - Using the HMO System of this Agreement and the Medical Care Preauthorization Schedule attached to this Agreement. PRIMARY AND PREVENTIVE CARE‌ Members are entitled to benefits for Primary and Preventive Care Covered Services. These Covered Services are provided or arranged by the Member’s Primary Care Physician, as noted. The Primary Care Physician will provide a Referral, when one is required, to a Participating Professional Provider when the Member’s condition requires a Specialist's Services. Services resulting from Referrals to Non-Participating Providers will be covered when the Referral is issued by a Member’s Primary Care Physician and Preauthorized by Keystone. The Referral is valid for ninety (90) days from date of issue so long as the Member is still enrolled in this plan. Self-Referrals are excluded, except for Emergency Care. Additional Covered Services recommended by the Referred Specialist will require another Referral from the Member’s Primary Care Physician. "Preventive Care" services generally describe health care services performed to catch the early warning signs of health problems. These services are performed when a Member has no symptoms of disease. "Primary Care" services generally describe health care services performed to treat an illness or injury. Keystone periodically reviews the Primary and Preventive Care Covered Services based on recommendations from organizations such as The American Academy of Pediatrics, The American College of Physicians, the U.S. Preventive Services Task Force and The American Cancer Society. Accordingly, the frequency and eligibility of Covered Services are subject to change. Keystone reserves the right to modify coverage for these Covered Services at any time after written notice of the change has been given to the Member.