Designated Facilities and Other Providers. If an Insured has a medical condition that SHL determines to need special services, SHL may direct the Insured to a Designated Facility and/or a Designated Provider selected by SHL. If the Insured requires certain complex Covered Health Services for which expertise is limited, SHL may direct the Insured to a Network facility or provider that is outside the Insured’s local geographic area. If the Insured is required to travel to obtain such Covered Health Services from a Designated Facility or Designated Provider, SHL may reimburse certain travel expenses at its discretion. In both cases, Network Benefits will only be paid if the Insured’s Covered Health Services for that condition are provided by or arranged by the Designated Facility, Designated Provider or other provider chosen by SHL. It is the responsibility of the Insured or of the Network Provider to notify SHL of special service needs (such as transplants or cancer treatment) that might warrant referral to a Designated Facility or Designated Provider. Benefits payable for expenses incurred in connection with Covered Services from a Network facility or Provider (regardless of whether it is a Designated Facility or Provider) which are not Prior Authorized by SHL’s Managed Care Program will be reduced to 50% of what the Insured would have received if the services had been Prior Authorized.
