Common use of Emergency Services Clause in Contracts

Emergency Services. AvMed will cover all Medically Necessary Physician and Hospital services for an Emergency Medical Condition. In the event Hospital inpatient services are provided following Emergency Medical Services and Care, AvMed should be notified by the Hospital, Member or a designee, within 24 hours of the inpatient admission if reasonably possible. AvMed may recommend and elect to transfer the Member to an In-Network Hospital after the Member’s Condition has been stabilized, and as soon as it is medically appropriate to do so. a. Any Member requiring medical, Hospital or ambulance services for an Emergency Medical Condition while temporarily outside the Service Area, or within the Service Area but before they can reach a Participating Provider, may receive the emergency benefits specified herein. When emergency services are rendered by an Out-of-Network Provider to treat an Emergency Medical Condition, any Copayment or Coinsurance amount applicable to In-Network Providers for emergency services will also apply to such Out-of-Network Provider. b. For out-of-network emergency services, AvMed will pay an amount equal to the greater of the three amounts specified below: i. The median of the amount negotiated with Participating Providers for the emergency services furnished; ii. The amount for the emergency services calculated using AvMed’s Maximum Allowable Payment, which is the same method the Plan generally uses to determine payments for out-of-network services, and applying in-network cost-sharing; or iii. The amount that would be paid under Medicare for the Emergency Medical Services and Care. c. Any request for reimbursement of payment made by a Member for services received must be filed within 90 days after the emergency or as soon as reasonably possible but not later than one year unless the Member was legally incapacitated; otherwise such a Claim will be considered to have been waived. If Emergency Medical Services and Care are required while outside the continental United States, Alaska or Hawaii, it is the Member’s responsibility to pay for such services at the time they are received. For information on filing a Claim for such services see Part XIII. REVIEW PROCEDURES AND HOW TO APPEAL A CLAIM (BENEFIT) DENIAL.

Emergency Services. AvMed will cover all Medically Necessary Physician and Hospital services for an Emergency Medical Condition. In the event Hospital inpatient services are provided following Emergency Medical Services and Care, AvMed should be notified by the Hospital, Member or a designee, within 24 hours of the inpatient admission if reasonably possible. AvMed may recommend and elect to transfer the Member to an Inin-Network network Hospital after the Member’s Condition has been stabilized, and as soon as it is medically appropriate to do so. a. Any Member requiring medical, Hospital or ambulance services for an Emergency Medical Condition while temporarily outside the Service Area, or within the Service Area but before they can reach a Participating an In-Network Provider, may receive the emergency benefits specified herein. When emergency services are rendered by an Out-of-Network Provider to treat an Emergency Medical Condition, any Copayment or Coinsurance amount applicable to In-Network Providers for emergency services will also apply to such Out-of-Network Provider. b. For out-of-network emergency services, AvMed will pay an amount equal to the greater of the three amounts specified below: i. The median of the amount negotiated with Participating In-Network Providers for the emergency services furnished; ii. The amount for the emergency services calculated using AvMed’s Maximum Allowable Payment, which is the same method the Plan generally uses to determine payments for out-of-network services, and applying in-network cost-sharing; or iii. The amount that would be paid under Medicare for the Emergency Medical Services and Care. c. Any request for reimbursement of payment made by a Member for services received must be filed within 90 days after the emergency or as soon as reasonably possible but not later than one year unless the Member was legally incapacitated; otherwise such a Claim will be considered to have been waived. If Emergency Medical Services and Care are required while outside the continental United States, Alaska or Hawaii, it is the Member’s responsibility to pay for such services at the time they are received. For information on filing a Claim for such services see Part XIII. REVIEW PROCEDURES AND HOW TO APPEAL A CLAIM (BENEFIT) DENIAL.

Emergency Services. AvMed will cover all Medically Necessary Physician and Hospital services for an Emergency Medical Condition. In the event Hospital inpatient services are provided following Emergency Medical Services and Care, AvMed should be notified by the Hospital, Member or a designee, within 24 hours of the inpatient admission if reasonably possible. AvMed may recommend and elect to transfer the Member to an In-Network Hospital after the Member’s Condition has been stabilized, and as soon as it is medically appropriate to do so. a. Any Member requiring medical, Hospital or ambulance services for an Emergency Medical Condition while temporarily outside the Service Area, or within the Service Area but before they can reach a Participating Provider, may receive the emergency benefits specified herein. When emergency services are rendered by an Out-of-Network Provider to treat an Emergency Medical Condition, any Copayment or Coinsurance amount applicable to In-Network Providers for emergency services will also apply to such Out-of-Network Provider. b. For out-of-network emergency services, AvMed will pay an amount equal to the greater of the three amounts specified below: i. The median of the amount negotiated with Participating Providers for the emergency services furnished; ii. The amount for the emergency services calculated using AvMed’s Maximum Allowable Payment, which is the same method the Plan generally uses to determine payments for out-of-network services, and applying in-network cost-sharing; or iii. The amount that would be paid under Medicare for the Emergency Medical Services and Careemergency services. c. Any request for reimbursement of payment made by a Member for services received must be filed within 90 days after the emergency or as soon as reasonably possible but not later than one year unless the Member was legally incapacitated; otherwise such a Claim will be considered to have been waived. If Emergency Medical Services and Care are required while outside the continental United States, Alaska or and Hawaii, it is the Member’s responsibility to pay for such services at the time they are received. For information on filing a Claim for such services see Part XIII. REVIEW PROCEDURES AND HOW TO APPEAL A CLAIM (BENEFIT) DENIAL.

Emergency Services. AvMed will cover all Medically Necessary Physician and Hospital services for an Emergency Medical Condition. In the event Hospital inpatient services are provided following Emergency Medical Services and Care, AvMed should be notified by the Hospital, Member or a designee, within 24 hours of the inpatient admission if reasonably possible. AvMed may recommend and elect to transfer the Member to an In-Network Hospital after the Member’s Condition has been stabilized, and as soon as it is medically appropriate to do so. If the Member chooses to stay in a non-participating Hospital after the date AvMed decides a transfer is medically appropriate, services will be paid as out-of-network benefits if the continued stay is determined to be a Covered Service. a. Any Member requiring medical, Hospital or ambulance services for an Emergency Medical Condition while temporarily outside the Service Area, or within the Service Area but before they can reach a Participating Provider, may receive the emergency benefits specified herein. When emergency services are rendered by an Out-of-Network Provider to treat an Emergency Medical Condition, any Copayment or Coinsurance amount applicable to In-Network Providers for emergency services will also apply to such Out-of-Network Provider. b. For out-of-network emergency services, AvMed will pay an amount equal to the greater of the three amounts specified below: i. The median of the amount negotiated with Participating Providers for the emergency services furnished; ii. The amount for the emergency services calculated using AvMed’s Maximum Allowable Payment, which is the same method the Plan generally uses to determine payments for out-of-network services, and applying in-network cost-sharing; or iii. The amount that would be paid under Medicare for the Emergency Medical Services and Careemergency services. c. Any request for reimbursement of payment made by a Member for services received must be filed within 90 days after the emergency or as soon as reasonably possible but not later than one year unless the Member was legally incapacitated; otherwise such a Claim will be considered to have been waived. If Emergency Medical Services and Care are required while outside the continental United States, Alaska or and Hawaii, it is the Member’s responsibility to pay for such services at the time they are received. For information on filing a Claim for such services see Part XIII. REVIEW PROCEDURES AND HOW TO APPEAL A CLAIM (BENEFIT) DENIAL.

Emergency Services. AvMed will cover all Medically Necessary Physician and Hospital services for an Emergency Medical Condition. In the event Hospital inpatient services are provided following Emergency Medical Services and Care, AvMed should be notified by the Hospital, Member or a designee, within 24 hours of the inpatient admission if reasonably possible. AvMed may recommend and elect to transfer the Member to an In-Network Hospital after the Member’s Condition has been stabilized, and as soon as it is medically appropriate to do so. If the Member chooses to stay in a non-participating Hospital after the date AvMed decides a transfer is medically appropriate, services will be paid as out-of-network benefits if the continued stay is determined to be a Covered Service. a. Any Member requiring medical, Hospital or ambulance services for an Emergency Medical Condition while temporarily outside the Service Area, or within the Service Area but before they can reach a Participating Provider, may receive the emergency benefits specified herein. When emergency services are rendered by an Out-of-Network Provider to treat an Emergency Medical Condition, any Copayment or Coinsurance amount applicable to In-Network Providers for emergency services will also apply to such Out-of-Network Provider. b. For out-of-network emergency services, AvMed will pay an amount equal to the greater of the three amounts specified below: i. The median of the amount negotiated with Participating Providers for the emergency services furnished; ii. The amount for the emergency services calculated using AvMed’s Maximum Allowable Payment, which is the same method the Plan generally uses to determine payments for out-of-network services, and applying in-network cost-sharing; or iii. The amount that would be paid under Medicare for the Emergency Medical Services and Care. c. Any request for reimbursement of payment made by a Member for services received must be filed within 90 days after the emergency or as soon as reasonably possible but not later than one year unless the Member was legally incapacitated; otherwise such a Claim will be considered to have been waived. If Emergency Medical Services and Care are required while outside the continental United States, Alaska or Hawaii, it is the Member’s responsibility to pay for such services at the time they are received. For information on filing a Claim for such services see Part XIII. REVIEW PROCEDURES AND HOW TO APPEAL A CLAIM (BENEFIT) DENIAL.

Emergency Services. AvMed will cover all Medically Necessary Physician and Hospital services for an Emergency Medical Condition. In the event Hospital inpatient services are provided following Emergency Medical Services and Care, AvMed should be notified by the Hospital, Member or a designee, within 24 hours of the inpatient admission if reasonably possible. AvMed We may recommend and elect to transfer the Member to an In-Network a Hospital that is a Participating Provider after the Member’s Condition has been stabilized, and as soon as it is medically appropriate to do so. a. Any Member requiring medical, Hospital or ambulance services for an Emergency Medical Condition while temporarily outside the Service Area, or within the Service Area but before they can reach a Participating Provider, may receive the emergency benefits specified hereinin this Contract. When emergency services are rendered by an Outa Non-of-Network Participating Provider to treat an Emergency Medical Condition, any Copayment or Coinsurance amount applicable to In-Network Participating Providers for emergency services will also apply to such OutNon-of-Network Participating Provider. b. For outemergency services from Non-of-network emergency servicesParticipating Providers, AvMed will pay an amount equal to the greater of the three amounts specified below: i. The median of the amount negotiated with Participating Providers for the emergency services furnished; ii. The amount for the emergency services calculated using AvMed’s Maximum Allowable Payment, which is the same method the Plan generally uses to determine payments for outNon-of-network Participating] Provider services, and applying in-network Participating Provider cost-sharing; or iii. The amount that would be paid under Medicare for the Emergency Medical Services and Care. c. Any request for reimbursement of payment made by a Member for emergency services received must be filed within 90 days after the emergency or as soon as reasonably possible possible, but not later than one year unless the Member was legally incapacitated; otherwise such a Claim will be considered to have been waived. If Emergency Medical Services and Care are required while outside the continental United States, Alaska or Hawaii, it is the Member’s responsibility to pay for such services at the time they are received. For information on filing a Claim for such services see Part XIII. REVIEW PROCEDURES AND HOW TO APPEAL A CLAIM (BENEFIT) DENIAL.

Emergency Services. AvMed will cover all Medically Necessary Physician and Hospital services for an Emergency Medical Condition. In the event Hospital inpatient services are provided following Emergency Medical Services and Care, AvMed should be notified by the Hospital, Member Member, or a designee, designee within 24 hours of the inpatient admission if reasonably possible. AvMed may recommend and elect to transfer the Member to an In-Network a participating Hospital after the Member’s Condition has been stabilized, stabilized and as soon as it is medically appropriate to do so. a. Any Member requiring medical, Hospital or ambulance services for an Emergency Medical Condition emergencies as described in Sections 2.28 and 2.29, while temporarily outside the Service Area, or within the Service Area but before they can reach a Participating Provider, may receive the emergency benefits specified herein. When emergency services Emergency Services for an Emergency Medical Condition are rendered by an Out-of-Network Provider to treat an Emergency Medical ConditionProvider, any Copayment or Coinsurance amount applicable to In-Network Providers for emergency services Emergency Services will also apply to such Out-of-Network Provider. b. For out-of-network emergency servicesEmergency Medical Services and Care, AvMed will pay an amount equal to the greater of the three amounts specified below: i. The median of the amount negotiated with Participating Providers for the emergency services Emergency Medical Services and Care furnished; ii. The amount for the emergency services service calculated using AvMed’s Maximum Allowable Payment, which is the same method the Plan generally uses to determine payments for out-of-network services, and applying in-network cost-sharing; or iii. The amount that would be paid under Medicare for the Emergency Medical Services and Care. c. Any request for reimbursement of payment made by a Member for services received must be filed within 90 days after the emergency or as soon as reasonably possible but not later than one year unless the Member was legally incapacitated; otherwise such a Claim will be considered to have been waived. If Emergency Medical Services and Care are required while outside the continental United States, Alaska or and Hawaii, it is the Member’s responsibility to pay for such services at the time they are received. For information on filing a Claim for such services see Part XIII. REVIEW PROCEDURES AND HOW TO APPEAL A CLAIM (BENEFIT) DENIALSection 13.3d.

Emergency Services. AvMed will cover all Medically Necessary Physician and Hospital services for an Emergency Medical Condition. In the event Hospital inpatient services are provided following Emergency Medical Services and Care, AvMed should be notified by the Hospital, Member or a designee, within 24 hours of the inpatient admission if reasonably possible. AvMed may recommend and elect to transfer the Member to an In-Network Tier A Hospital after the Member’s Condition has been stabilized, and as soon as it is medically appropriate to do so. If the Member chooses to stay in a an In-Network Tier B, or non-participating Hospital after the date AvMed decides a transfer to a Tier A Hospital is medically appropriate, services will be paid at the middle Benefit Level for a Tier B hospital, and as out-of-network benefits for a non-participating Hospital if the continued stay is determined to be a Covered Service. a. Any Member requiring medical, Hospital or ambulance services for an Emergency Medical Condition while temporarily outside the Service Area, or within the Service Area but before they can reach a Participating Provider, may receive the emergency benefits specified herein. When emergency services are rendered by an Out-of-Network Provider to treat an Emergency Medical Condition, any Copayment or Coinsurance amount applicable to In-Network Providers for emergency services will also apply to such Out-of-Network Provider. b. For out-of-network emergency services, AvMed will pay an amount equal to the greater of the three amounts specified below: i. The median of the amount negotiated with Participating Providers for the emergency services furnished; ii. The amount for the emergency services calculated using AvMed’s Maximum Allowable Payment, which is the same method the Plan generally uses to determine payments for out-of-network services, and applying in-network cost-sharing; or iii. The amount that would be paid under Medicare for the Emergency Medical Services and Careemergency services. c. Any request for reimbursement of payment made by a Member for services received must be filed within 90 days after the emergency or as soon as reasonably possible but not later than one year unless the Member was legally incapacitated; otherwise such a Claim will be considered to have been waived. If Emergency Medical Services and Care are required while outside the continental United States, Alaska or and Hawaii, it is the Member’s responsibility to pay for such services at the time they are received. For information on filing a Claim for such services see Part XIII. REVIEW PROCEDURES AND HOW TO APPEAL A CLAIM (BENEFIT) DENIAL.

Emergency Services. AvMed will cover all Medically Necessary Physician and Hospital services for an Emergency Medical Condition. In the event Hospital inpatient services are provided following Emergency Medical Services and Care, AvMed should be notified by the Hospital, Member or a designee, within 24 hours of the inpatient admission if reasonably possible. AvMed We may recommend and elect to transfer the Member to an In-Network a Hospital that is a Participating Provider after the Member’s Condition has been stabilized, and as soon as it is medically appropriate to do so. If the Member chooses to stay in a Hospital that is not a Participating Provider after the date AvMed decides a transfer is medically appropriate, services will be paid at the Non-Participating Provider low Benefit Level if the continued stay is determined to be a Covered Service. a. Any Member requiring medical, Hospital or ambulance services for an Emergency Medical Condition while temporarily outside the Service Area, or within the Service Area but before they can reach a Participating Provider, may receive the emergency benefits specified hereinin this Contract. When emergency services are rendered by an Outa Non-of-Network Participating Provider to treat an Emergency Medical Condition, any Copayment or Coinsurance amount applicable to In-Network Participating Providers for emergency services will also apply to such OutNon-of-Network Participating Provider. b. For outemergency services from Non-of-network emergency servicesParticipating Providers, AvMed will pay an amount equal to the greater of the three amounts specified below: i. The median of the amount negotiated with Participating Providers for the emergency services furnished; ii. The amount for the emergency services calculated using AvMed’s Maximum Allowable Payment, which is the same method the Plan generally uses to determine payments for outNon-of-network Participating Provider services, and applying in-network Participating Provider cost-sharing; or iii. The amount that would be paid under Medicare for the Emergency Medical Services and Care. c. Any request for reimbursement of payment made by a Member for emergency services received must be filed within 90 days after the emergency or as soon as reasonably possible possible, but not later than one year unless the Member was legally incapacitated; otherwise such a Claim will be considered to have been waived. If Emergency Medical Services and Care are required while outside the continental United States, Alaska or Hawaii, it is the Member’s responsibility to pay for such services at the time they are received. For information on filing a Claim for such services see Part XIII. REVIEW PROCEDURES AND HOW TO APPEAL A CLAIM (BENEFIT) DENIAL.

Emergency Services. AvMed will cover all Medically Necessary Physician and Hospital services for an Emergency Medical Condition. In the event Hospital inpatient services are provided following Emergency Medical Services and Care, AvMed should be notified by the Hospital, Member or a designee, within 24 hours of the inpatient admission if reasonably possible. AvMed may recommend and elect to transfer the Member to an In-Network Tier A Hospital after the Member’s Condition has been stabilized, and as soon as it is medically appropriate to do so. If the Member chooses to stay in a an In-Network Tier B, or non-participating Hospital after the date AvMed decides a transfer to a Tier A Hospital is medically appropriate, services will be paid at the middle Benefit Level for a Tier B Hospital, and as out-of-network benefits for a non-participating Hospital if the continued stay is determined to be a Covered Service. a. Any Member requiring medical, Hospital or ambulance services for an Emergency Medical Condition while temporarily outside the Service Area, or within the Service Area but before they can reach a Participating Provider, may receive the emergency benefits specified herein. When emergency services are rendered by an Out-of-Network Provider to treat an Emergency Medical Condition, any Copayment or Coinsurance amount applicable to In-Network Providers for emergency services will also apply to such Out-of-Network Provider. b. For out-of-network emergency services, AvMed will pay an amount equal to the greater of the three amounts specified below: i. The median of the amount negotiated with Participating Providers for the emergency services furnished; ii. The amount for the emergency services calculated using AvMed’s Maximum Allowable Payment, which is the same method the Plan generally uses to determine payments for out-of-network services, and applying in-network cost-sharing; or iii. The amount that would be paid under Medicare for the Emergency Medical Services and Care. c. Any request for reimbursement of payment made by a Member for services received must be filed within 90 days after the emergency or as soon as reasonably possible but not later than one year unless the Member was legally incapacitated; otherwise such a Claim will be considered to have been waived. If Emergency Medical Services and Care are required while outside the continental United States, Alaska or Hawaii, it is the Member’s responsibility to pay for such services at the time they are received. For information on filing a Claim for such services see Part XIII. REVIEW PROCEDURES AND HOW TO APPEAL A CLAIM (BENEFIT) DENIAL.

Emergency Services. AvMed will cover all Medically Necessary Physician and Hospital services for an Emergency Medical Condition. In the event Hospital inpatient services are provided following Emergency Medical Services and Care, AvMed should be notified by the Hospital, Member or a designee, within 24 hours of the inpatient admission if reasonably possible. AvMed may recommend and elect to transfer the Member to a Hospital that is an In-Network Hospital Provider or a PHCS provider after the Member’s Condition has been stabilized, and as soon as it is medically appropriate to do so. If the Member chooses to stay in an out-of-network Hospital after the date AvMed decides a transfer is medically appropriate, services will be paid as out-of-network benefits if the continued stay is determined to be a Covered Service. a. Any Member requiring medical, Hospital or ambulance services for an Emergency Medical Condition while temporarily outside the Service Area, or within the Service Area but before they can reach a Participating an In-Network Provider, may receive the emergency benefits specified herein. When emergency services are rendered by an Out-of-Network Provider to treat an Emergency Medical Condition, any Copayment or Coinsurance amount applicable to In-Network Providers for emergency services will also apply to such Out-of-Network Provider. b. For out-of-network emergency services, AvMed will pay an amount equal to the greater of the three amounts specified below: i. The median of the amount negotiated with Participating In-Network Providers for the emergency services furnished; ii. The amount for the emergency services calculated using AvMed’s Maximum Allowable Payment, which is the same method the Plan generally uses to determine payments for out-of-network services, and applying in-network cost-sharing; or iii. The amount that would be paid under Medicare for the Emergency Medical Services and Care. c. Any request for reimbursement of payment made by a Member for services received must be filed within 90 days after the emergency or as soon as reasonably possible but not later than one year unless the Member was legally incapacitated; otherwise such a Claim will be considered to have been waived. If Emergency Medical Services and Care are required while outside the continental United States, Alaska or Hawaii, it is the Member’s responsibility to pay for such services at the time they are received. For information on filing a Claim for such services see Part XIII. REVIEW PROCEDURES AND HOW TO APPEAL A CLAIM (BENEFIT) DENIAL.

Emergency Services. AvMed will cover all Medically Necessary Physician and Hospital services for an Emergency Medical Condition. In the event Hospital inpatient services are provided following Emergency Medical Services and Care, AvMed should be notified by the Hospital, Member or a designee, designee within 24 hours of the inpatient admission if reasonably possible. AvMed may recommend and elect to transfer the Member to an In-Network a participating Hospital after the Member’s Condition has been stabilized, stabilized and as soon as it is medically appropriate to do so. a. Any Member requiring medical, Hospital or ambulance services for an Emergency Medical Condition emergencies as described in Sections 2.27 and 2.28, while temporarily outside the Service Area, or within the Service Area but before they can reach a Participating Provider, may receive the emergency benefits specified herein. When emergency services Emergency Services for an Emergency Medical Condition are rendered by an Out-of-Network Provider to treat an Emergency Medical ConditionProvider, any Copayment or Coinsurance amount applicable to In-Network Providers for emergency services Emergency Services will also apply to such Out-of-Network Provider. b. For out-of-network emergency servicesEmergency Medical Services and Care, AvMed will pay an amount equal to the greater of the three amounts specified below: i. The median of the amount negotiated with Participating Providers for the emergency services Emergency Medical Services and Care furnished; ii. The amount for the emergency services service calculated using AvMed’s Maximum Allowable Payment, which is the same method the Plan generally uses to determine payments for out-of-network services, and applying in-network cost-sharing; or iii. The amount that would be paid under Medicare for the Emergency Medical Services and Care. c. Any request for reimbursement of payment made by a Member for services received must be filed within 90 days after the emergency or as soon as reasonably possible but not later than one year unless the Member was legally incapacitated; otherwise such a Claim will be considered to have been waived. If Emergency Medical Services and Care are required while outside the continental United States, Alaska or and Hawaii, it is the Member’s responsibility to pay for such services at the time they are received. For information on filing a Claim for such services see Part XIII. REVIEW PROCEDURES AND HOW TO APPEAL A CLAIM (BENEFIT) DENIALSection 13.3d.

Emergency Services. AvMed will cover all Medically Necessary Physician and Hospital services for an Emergency Medical Condition. In the event Hospital inpatient services are provided following Emergency Medical Services and Care, AvMed should be notified by the Hospital, Member or a designee, within 24 hours of the inpatient admission if reasonably possible. AvMed may recommend and elect to transfer the Member to an In-Network Hospital after the Member’s Condition has been stabilized, and as soon as it is medically appropriate to do so. a. Any Member requiring medical, Hospital or ambulance services for an Emergency Medical Condition while temporarily outside the Service Area, or within the Service Area but before they can reach a Participating an In-Network Provider, may receive the emergency benefits specified herein. When emergency services are rendered by an Out-of-Network Provider to treat an Emergency Medical Condition, any Copayment or Coinsurance amount applicable to In-Network Providers for emergency services will also apply to such Out-of-Network Provider. b. For out-of-network emergency services, AvMed will pay an amount equal to the greater of the three amounts specified below: i. The median of the amount negotiated with Participating In-Network Providers for the emergency services furnished; ii. The amount for the emergency services calculated using AvMed’s Maximum Allowable Payment, which is the same method the Plan generally uses to determine payments for out-of-network services, and applying in-network cost-sharing; or iii. The amount that would be paid under Medicare for the Emergency Medical Services and Care. c. Any request for reimbursement of payment made by a Member for services received must be filed within 90 days after the emergency or as soon as reasonably possible but not later than one year unless the Member was legally incapacitated; otherwise such a Claim will be considered to have been waived. If Emergency Medical Services and Care are required while outside the continental United States, Alaska or Hawaii, it is the Member’s responsibility to pay for such services at the time they are received. For information on filing a Claim for such services see Part XIII. REVIEW PROCEDURES AND HOW TO APPEAL A CLAIM (BENEFIT) DENIAL.

Emergency Services. AvMed will cover all Medically Necessary Physician and Hospital services for an Emergency Medical Condition. In the event Hospital inpatient services are provided following Emergency Medical Services and Care, AvMed should be notified by the Hospital, Member or a designee, within 24 hours of the inpatient admission admission, if reasonably possible. AvMed may recommend and elect to transfer the Member to an In-Network a participating Hospital after the Member’s Condition has been stabilized, stabilized and as soon as it is medically appropriate to do so. If the Member chooses to stay in a Participating Tier B facility after the date AvMed decides a transfer to a Tier A facility is medically appropriate, services will be paid at the middle Benefit Level. If the Member chooses to stay in a Non-Participating facility after the date AvMed decides a transfer to a Tier A facility is medically appropriate, services will be paid as out-of-network benefits if the continued stay is determined to be a Covered Service. a. Any Member requiring medical, Hospital or ambulance services for an Emergency Medical Condition emergencies as described in Sections 2.29 and 2.75, while temporarily outside the Service Area, or within the Service Area but before they can reach a Participating Provider, may receive the emergency benefits specified hereinbelow. When emergency services Emergency Services for an Emergency Medical Condition are rendered by an Out-of-Network Provider to treat an Emergency Medical ConditionProvider, any Copayment or Coinsurance amount applicable to In-Network Providers for emergency services Emergency Services will also apply to such Out-of-Network Provider. b. For out-of-network emergency servicesEmergency Medical Services and Care, AvMed will pay an amount equal to the greater of the three amounts specified below: i. The median of the amount negotiated with Participating Providers for the emergency services Emergency Medical Services and Care furnished; ii. The amount for the emergency services service calculated using AvMed’s Maximum Allowable Payment, which is the same method the Plan generally uses to determine payments for out-of-network services, and applying in-network cost-sharing; or iii. The amount that would be paid under Medicare for the Emergency Medical Services and Care. c. Any request for reimbursement of payment made by a Member for services received must be filed within 90 days after the emergency or as soon as reasonably possible but not later than one year unless the Member was legally incapacitated; otherwise such a Claim will be considered to have been waived. If Emergency Medical Services and Care are required while outside the continental United States, Alaska or and Hawaii, it is the Member’s responsibility to pay for such services at the time they are received. For information on filing a Claim for such services see Part XIII. REVIEW PROCEDURES AND HOW TO APPEAL A CLAIM (BENEFIT) DENIALSection 13.3d.

Emergency Services. AvMed will cover all Medically Necessary Physician and Hospital services for an Emergency Medical Condition. In the event Hospital inpatient services are provided following Emergency Medical Services and Care, AvMed should be notified by the Hospital, Member or a designee, within 24 hours of the inpatient admission if reasonably possible. AvMed may recommend and elect to transfer the Member to an Agility Plan In-Network Hospital after the Member’s Condition has been stabilized, and as soon as it is medically appropriate to do so. If the Member chooses to stay in a non-participating Hospital after the date XxXxx decides a transfer is medically appropriate, services will be paid as out-of-network benefits if the continued stay is determined to be a Covered Service. a. Any Member requiring medical, Hospital or ambulance services for an Emergency Medical Condition while temporarily outside the Service Area, or within the Service Area but before they can reach a Participating Provider, may receive the emergency benefits specified herein. When emergency services are rendered by an Outa Non-of-Network Participating Provider to treat an Emergency Medical Condition, any Copayment or Coinsurance amount applicable to In-Network Participating Providers for emergency services will also apply to such OutNon-of-Network Participating Provider. b. For out-of-network emergency services, AvMed will pay an amount equal to the greater of the three amounts specified below: i. The median of the amount negotiated with Participating Providers for the emergency services furnished; ii. The amount for the emergency services calculated using AvMed’s Maximum Allowable Payment, which is the same method the Plan generally uses to determine payments for out-of-network services, and applying in-network cost-sharing; or iii. The amount that would be paid under Medicare for the Emergency Medical Services and Care. c. Any request for reimbursement of payment made by a Member for services received must be filed within 90 days after the emergency or as soon as reasonably possible but not later than one year unless the Member was legally incapacitated; otherwise such a Claim will be considered to have been waived. If Emergency Medical Services and Care are required while outside the continental United States, Alaska or Hawaii, it is the Member’s responsibility to pay for such services at the time they are received. For information on filing a Claim for such services see Part XIII. REVIEW PROCEDURES AND HOW TO APPEAL A CLAIM (BENEFIT) DENIAL.

Emergency Services. AvMed will cover all Medically Necessary Physician and Hospital services for an Emergency Medical Condition. In the event Hospital inpatient services are provided following Emergency Medical Services and Care, AvMed should be notified by the Hospital, Member or a designee, within 24 hours of the inpatient admission if reasonably possible. AvMed may recommend and elect to transfer the Member to an AvMed Choice In-Network Hospital after the Member’s Condition has been stabilized, and as soon as it is medically appropriate to do so. If the Member chooses to stay in a non-participating Hospital after the date AvMed decides a transfer is medically appropriate, services will be paid as out-of-network benefits if the continued stay is determined to be a Covered Service. a. Any Member requiring medical, Hospital or ambulance services for an Emergency Medical Condition while temporarily outside the Service Area, or within the Service Area but before they can reach a Participating Provider, may receive the emergency benefits specified herein. When emergency services are rendered by an Out-of-Network Provider to treat an Emergency Medical Condition, any Copayment or Coinsurance amount applicable to In-Network Providers for emergency services will also apply to such Out-of-Network Provider. b. For out-of-network emergency services, AvMed will pay an amount equal to the greater of the three amounts specified below: i. The median of the amount negotiated with Participating Providers for the emergency services furnished; ii. The amount for the emergency services calculated using AvMed’s Maximum Allowable Payment, which is the same method the Plan generally uses to determine payments for out-of-network services, and applying in-network cost-sharing; or iii. The amount that would be paid under Medicare for the Emergency Medical Services and Careemergency services. c. Any request for reimbursement of payment made by a Member for services received must be filed within 90 days after the emergency or as soon as reasonably possible but not later than one year unless the Member was legally incapacitated; otherwise such a Claim will be considered to have been waived. If Emergency Medical Services and Care are required while outside the continental United States, Alaska or and Hawaii, it is the Member’s responsibility to pay for such services at the time they are received. For information on filing a Claim for such services see Part XIII. REVIEW PROCEDURES AND HOW TO APPEAL A CLAIM (BENEFIT) DENIAL.

Emergency Services. AvMed will cover all Medically Necessary Physician and Hospital services for an Emergency Medical Condition. In the event Hospital inpatient services are provided following Emergency Medical Services and Care, AvMed should be notified by the Hospital, Member or a designee, designee within 24 hours of the inpatient admission admission, if reasonably possible. AvMed may recommend and elect to transfer the Member to an In-Network a participating Hospital after the Member’s Condition has been stabilized, stabilized and as soon as it is medically appropriate to do so. a. Any Member requiring medical, Hospital or ambulance services for an Emergency Medical Condition emergencies as described in Sections 2.27 and 2.73, while temporarily outside the Service Area, or within the Service Area but before they can reach a Participating Provider, may receive the emergency benefits specified hereinbelow. When emergency services Emergency Services for an Emergency Medical Condition are rendered by an Out-of-Network Provider to treat an Emergency Medical ConditionProvider, any Copayment or Coinsurance amount applicable to In-Network Providers for emergency services Emergency Services will also apply to such Out-of-Network Provider. b. For out-of-network emergency servicesEmergency Medical Services and Care, AvMed will pay an amount equal to the greater of the three amounts specified below: i. The median of the amount negotiated with Participating Providers for the emergency services Emergency Medical Services and Care furnished; ii. The amount for the emergency services service calculated using AvMed’s Maximum Allowable Payment, which is the same method the Plan generally uses to determine payments for out-of-network services, and applying in-network cost-sharing; or iii. The amount that would be paid under Medicare for the Emergency Medical Services and Care. c. Any request for reimbursement of payment made by a Member for services received must be filed within 90 days after the emergency or as soon as reasonably possible but not later than one year unless the Member was legally incapacitated; otherwise such a Claim will be considered to have been waived. If Emergency Medical Services and Care are required while outside the continental United States, Alaska or and Hawaii, it is the Member’s responsibility to pay for such services at the time they are received. For information on filing a Claim for such services see Part XIII. REVIEW PROCEDURES AND HOW TO APPEAL A CLAIM (BENEFIT) DENIALSection 13.3d.

Emergency Services. AvMed will cover all Medically Necessary Physician and Hospital services for an Emergency Medical Condition. In the event Hospital inpatient services are provided following Emergency Medical Services and Care, AvMed should be notified by the Hospital, Member or a designee, within 24 hours of the inpatient admission if reasonably possible. AvMed may recommend and elect to transfer the Member to an Achieve Plan In-Network Hospital after the Member’s Condition has been stabilized, and as soon as it is medically appropriate to do so. a. Any Member requiring medical, Hospital or ambulance services for an Emergency Medical Condition while temporarily outside the Service Area, or within the Service Area but before they can reach a Participating Provider, may receive the emergency benefits specified herein. When emergency services are rendered by an Outa Non-of-Network Participating Provider to treat an Emergency Medical Condition, any Copayment or Coinsurance amount applicable to In-Network Participating Providers for emergency services will also apply to such OutNon-of-Network Participating Provider. b. For out-of-network emergency services, AvMed will pay an amount equal to the greater of the three amounts specified below: i. The median of the amount negotiated with Participating Providers for the emergency services furnished; ii. The amount for the emergency services calculated using AvMed’s Maximum Allowable Payment, which is the same method the Plan generally uses to determine payments for out-of-network services, and applying in-network cost-sharing; or iii. The amount that would be paid under Medicare for the Emergency Medical Services and Care. c. Any request for reimbursement of payment made by a Member for services received must be filed within 90 days after the emergency or as soon as reasonably possible but not later than one year unless the Member was legally incapacitated; otherwise such a Claim will be considered to have been waived. If Emergency Medical Services and Care are required while outside the continental United States, Alaska or Hawaii, it is the Member’s responsibility to pay for such services at the time they are received. For information on filing a Claim for such services see Part XIII. REVIEW PROCEDURES AND HOW TO APPEAL A CLAIM (BENEFIT) DENIAL.

Emergency Services. AvMed will cover all Medically Necessary Physician and Hospital services for an Emergency Medical Condition. In the event Hospital inpatient services are provided following Emergency Medical Services and Care, AvMed should be notified by the Hospital, Member or a designee, within 24 hours of the inpatient admission if reasonably possible. AvMed may recommend and elect to transfer the Member to an In-Network a Hospital after the Member’s Condition has been stabilized, and as soon as it is medically appropriate to do so. If the Member chooses to stay in an out-of- network Hospital after the date AvMed decides a transfer is medically appropriate, services will be paid as out-of-network benefits if the continued stay is determined to be a Covered Service. a. Any Member requiring medical, Hospital or ambulance services for an Emergency Medical Condition while temporarily outside the Service Area, or within the Service Area but before they can reach a Participating an In-Network Provider, may receive the emergency benefits specified herein. When emergency services are rendered by an Out-of-Network Provider to treat an Emergency Medical Condition, any Copayment or Coinsurance amount applicable to In-Network Providers for emergency services will also apply to such Out-of-Network Provider. b. For out-of-network emergency services, AvMed will pay an amount equal to the greater of the three amounts specified below: i. The median of the amount negotiated with Participating In-Network Providers for the emergency services furnished; ii. The amount for the emergency services calculated using AvMed’s Maximum Allowable Payment, which is the same method the Plan generally uses to determine payments for out-of-network services, and applying in-network cost-sharing; or iii. The amount that would be paid under Medicare for the Emergency Medical Services and Care. c. Any request for reimbursement of payment made by a Member for services received must be filed within 90 days after the emergency or as soon as reasonably possible but not later than one year unless the Member was legally incapacitated; otherwise such a Claim will be considered to have been waived. If Emergency Medical Services and Care are required while outside the continental United States, Alaska or Hawaii, it is the Member’s responsibility to pay for such services at the time they are received. For information on filing a Claim for such services see Part XIII. REVIEW PROCEDURES AND HOW TO APPEAL A CLAIM (BENEFIT) DENIAL.

Emergency Services. AvMed will cover all Medically Necessary Physician and Hospital services for an Emergency Medical Condition. In the event Hospital inpatient services are provided following Emergency Medical Services and Care, AvMed should be notified by the Hospital, Member or a designee, within 24 hours of the inpatient admission if reasonably possible. AvMed may recommend and elect to transfer the Member to an Engage Plan In-Network Hospital after the Member’s Condition has been stabilized, and as soon as it is medically appropriate to do so. a. Any Member requiring medical, Hospital or ambulance services for an Emergency Medical Condition while temporarily outside the Service Area, or within the Service Area but before they can reach a Participating Provider, may receive the emergency benefits specified herein. When emergency services are rendered by an Outa Non-of-Network Participating Provider to treat an Emergency Medical Condition, any Copayment or Coinsurance amount applicable to In-Network Participating Providers for emergency services will also apply to such OutNon-of-Network Participating Provider. b. For out-of-network emergency services, AvMed will pay an amount equal to the greater of the three amounts specified below: i. The median of the amount negotiated with Participating Providers for the emergency services furnished; ii. The amount for the emergency services calculated using AvMed’s Maximum Allowable Payment, which is the same method the Plan generally uses to determine payments for out-of-network services, and applying in-network cost-sharing; or iii. The amount that would be paid under Medicare for the Emergency Medical Services and Care. c. Any request for reimbursement of payment made by a Member for services received must be filed within 90 days after the emergency or as soon as reasonably possible but not later than one year unless the Member was legally incapacitated; otherwise such a Claim will be considered to have been waived. If Emergency Medical Services and Care are required while outside the continental United States, Alaska or Hawaii, it is the Member’s responsibility to pay for such services at the time they are received. For information on filing a Claim for such services see Part P art XIII. REVIEW PROCEDURES AND HOW TO APPEAL A CLAIM (BENEFIT) DENIAL.

Emergency Services. AvMed will cover all Medically Necessary Physician and Hospital services for an Emergency Medical Condition. In the event Hospital inpatient services are provided following Emergency Medical Services and Care, AvMed should be notified by the Hospital, Member Member, or a designee, designee within 24 hours of the inpatient admission if reasonably possible. AvMed may recommend and elect to transfer the Member to an AvMed Choice In-Network Hospital after the Member’s Condition has been stabilized, stabilized and as soon as it is medically appropriate to do so. If the Member chooses to stay in a non-participating facility after the date AvMed decides a transfer is medically appropriate, services will be paid as out-of-network benefits if the continued stay is determined to be a Covered Service. a. Any Member requiring medical, Hospital or ambulance services for an Emergency Medical Condition emergencies as described in Sections 2.29 and 2.30, while temporarily outside the Service Area, or within the Service Area but before they can reach a Participating Provider, may receive the emergency benefits specified herein. When emergency services Emergency Services for an Emergency Medical Condition are rendered by an Out-of-Network Provider to treat an Emergency Medical ConditionProvider, any Copayment or Coinsurance amount applicable to In-Network Providers for emergency services Emergency Services will also apply to such Out-of-Network Provider. b. For out-of-network emergency servicesEmergency Medical Services and Care, AvMed will pay an amount equal to the greater of the three amounts specified below: i. The median of the amount negotiated with Participating Providers for the emergency services Emergency Medical Services and Care furnished; ii. The amount for the emergency services service calculated using AvMed’s Maximum Allowable Payment, which is the same method the Plan generally uses to determine payments for out-of-network services, and applying in-network cost-sharing; or iii. The amount that would be paid under Medicare for the Emergency Medical Services and Care. c. Any request for reimbursement of payment made by a Member for services received must be filed within 90 days after the emergency or as soon as reasonably possible but not later than one year unless the Member was legally incapacitated; otherwise such a Claim will be considered to have been waived. If Emergency Medical Services and Care are required while outside the continental United States, Alaska or and Hawaii, it is the Member’s responsibility to pay for such services at the time they are received. For information on filing a Claim for such services see Part XIII. REVIEW PROCEDURES AND HOW TO APPEAL A CLAIM (BENEFIT) DENIALSection 13.3d.

Emergency Services. AvMed will cover all Medically Necessary Physician and Hospital services for an Emergency Medical Condition. In the event Hospital inpatient services are provided following Emergency Medical Services and Care, AvMed should be notified by the Hospital, Member or a designee, within 24 hours of the inpatient admission if reasonably possible. AvMed may recommend and elect to transfer the Member to an AvMed Choice Plan In-Network Hospital or a PHCS Network Hospital after the Member’s Condition has been stabilized, and as soon as it is medically appropriate to do so. If the Member chooses to stay in a non-participating Hospital after the date AvMed decides a transfer is medically appropriate, services will be paid as out-of-network benefits if the continued stay is determined to be a Covered Service. a. Any Member requiring medical, Hospital or ambulance services for an Emergency Medical Condition while temporarily outside the Service Area, or within the Service Area but before they can reach a Participating Provider, may receive the emergency benefits specified herein. When emergency services are rendered by an Outa Non-of-Network Participating Provider to treat an Emergency Medical Condition, any Copayment or Coinsurance amount applicable to In-Network Participating Providers for emergency services will also apply to such OutNon-of-Network Participating Provider. b. For out-of-network emergency services, AvMed will pay an amount equal to the greater of the three amounts specified below: i. The median of the amount negotiated with Participating Providers for the emergency services furnished; ii. The amount for the emergency services calculated using AvMed’s Maximum Allowable Payment, which is the same method the Plan generally uses to determine payments for out-of-network services, and applying in-network cost-sharing; or iii. The amount that would be paid under Medicare for the Emergency Medical Services and Care. c. Any request for reimbursement of payment made by a Member for services received must be filed within 90 days after the emergency or as soon as reasonably possible but not later than one year unless the Member was legally incapacitated; otherwise such a Claim will be considered to have been waived. If Emergency Medical Services and Care are required while outside the continental United States, Alaska or Hawaii, it is the Member’s responsibility to pay for such services at the time they are received. For information on filing a Claim for such services see Part XIII. REVIEW PROCEDURES AND HOW TO APPEAL A CLAIM (BENEFIT) DENIAL.

Emergency Services. AvMed will cover all Medically Necessary Physician and Hospital services for an Emergency Medical Condition. In the event Hospital inpatient services are provided following Emergency Medical Services and Care, AvMed should be notified by the Hospital, Member Member, or a designee, designee within 24 hours of the inpatient admission if reasonably possible. AvMed may recommend and elect to transfer the Member to an In-Network a participating Hospital after the Member’s Condition has been stabilized, stabilized and as soon as it is medically appropriate to do so. If the Member chooses to stay in a non-participating facility after the date AvMed decides a transfer is medically appropriate, services will be paid as out-of-network benefits if the continued stay is determined to be a Covered Service. a. Any Member requiring medical, Hospital or ambulance services for an Emergency Medical Condition emergencies as described in Sections 2.28 and 2.29, while temporarily outside the Service Area, or within the Service Area but before they can reach a Participating Provider, may receive the emergency benefits specified herein. When emergency services Emergency Services for an Emergency Medical Condition are rendered by an Out-of-Network Provider to treat an Emergency Medical ConditionProvider, any Copayment or Coinsurance amount applicable to In-Network Providers for emergency services Emergency Services will also apply to such Out-of-Network Provider. b. For out-of-network emergency servicesEmergency Medical Services and Care, AvMed will pay an amount equal to the greater of the three amounts specified below: i. The median of the amount negotiated with Participating Providers for the emergency services Emergency Medical Services and Care furnished; ii. The amount for the emergency services service calculated using AvMed’s Maximum Allowable Payment, which is the same method the Plan generally uses to determine payments for out-of-network services, and applying in-network cost-sharing; or iii. The amount that would be paid under Medicare for the Emergency Medical Services and Care. c. Any request for reimbursement of payment made by a Member for services received must be filed within 90 days after the emergency or as soon as reasonably possible but not later than one year unless the Member was legally incapacitated; otherwise such a Claim will be considered to have been waived. If Emergency Medical Services and Care are required while outside the continental United States, Alaska or and Hawaii, it is the Member’s responsibility to pay for such services at the time they are received. For information on filing a Claim for such services see Part XIII. REVIEW PROCEDURES AND HOW TO APPEAL A CLAIM (BENEFIT) DENIALSection 13.3d.

Emergency Services. AvMed will cover all Medically Necessary Physician and Hospital services for an Emergency Medical Condition. In the event Hospital inpatient services are provided following Emergency Medical Services and Care, AvMed should be notified by the Hospital, Member or a designee, within 24 hours of the inpatient admission if reasonably possible. AvMed may recommend and elect to transfer the Member to an Empower Plan In-Network Tier A Hospital after the Member’s Condition has been stabilized, and as soon as it is medically appropriate to do so. If the Member chooses to stay in a an In-Network Tier B, or non-participating Hospital after the date AvMed decides a transfer to a Tier A Hospital is medically appropriate, services will be paid at the middle Benefit Level for a Tier B Hospital, and as out-of-network benefits for a non-participating Hospital if the continued stay is determined to be a Covered Service. a. Any Member requiring medical, Hospital or ambulance services for an Emergency Medical Condition while temporarily outside the Service Area, or within the Service Area but before they can reach a Participating Provider, may receive the emergency benefits specified herein. When emergency services are rendered by an Outa Non-of-Network Participating Provider to treat an Emergency Medical Condition, any Copayment or Coinsurance amount applicable to In-Network Participating Providers for emergency services will also apply to such OutNon-of-Network Participating Provider. b. For out-of-network emergency services, AvMed will pay an amount equal to the greater of the three amounts specified below: i. The median of the amount negotiated with Participating Providers for the emergency services furnished; ii. The amount for the emergency services calculated using AvMed’s Maximum Allowable Payment, which is the same method the Plan generally uses to determine payments for out-of-network services, and applying in-network cost-sharing; or iii. The amount that would be paid under Medicare for the Emergency Medical Services and Care. c. Any request for reimbursement of payment made by a Member for services received must be filed within 90 days after the emergency or as soon as reasonably possible but not later than one year unless the Member was legally incapacitated; otherwise such a Claim will be considered to have been waived. If Emergency Medical Services and Care are required while outside the continental United States, Alaska or Hawaii, it is the Member’s responsibility to pay for such services at the time they are received. For information on filing a Claim for such services see Part P art XIII. REVIEW PROCEDURES AND HOW TO APPEAL A CLAIM (BENEFIT) DENIAL.

Emergency Services. AvMed will cover all Medically Necessary Physician and Hospital services for an Emergency Medical Condition. In the event Hospital inpatient services are provided following Emergency Medical Services and Care, AvMed should be notified by the Hospital, Member or a designee, designee within 24 hours of the inpatient admission if reasonably possible. AvMed may recommend and elect to transfer the Member to an In-Network a participating Hospital after the Member’s Condition has been stabilized, stabilized and as soon as it is medically appropriate to do so. If the Member chooses to stay in a non-participating facility after the date AvMed decides a transfer is medically appropriate, services will be paid as out-of-network benefits if the continued stay is determined to be a Covered Service. a. Any Member requiring medical, Hospital or ambulance services for an Emergency Medical Condition emergencies as described in Sections 2.28 and 2.79, while temporarily outside the Service Area, or within the Service Area but before they can reach a Participating Provider, may receive the emergency benefits specified herein. When emergency services Emergency Services for an Emergency Medical Condition are rendered by an Out-of-Network Provider to treat an Emergency Medical ConditionProvider, any Copayment or Coinsurance amount applicable to In-Network Providers for emergency services Emergency Services will also apply to such Out-of-Network Provider. b. For out-of-network emergency servicesEmergency Medical Services and Care, AvMed will pay an amount equal to the greater of the three amounts specified below: i. The median of the amount negotiated with Participating Providers for the emergency services Emergency Medical Services and Care furnished; ii. The amount for the emergency services service calculated using AvMed’s Maximum Allowable Payment, which is the same method the Plan generally uses to determine payments for out-of-network services, and applying in-network cost-sharing; or iii. The amount that would be paid under Medicare for the Emergency Medical Services and Care. c. Any request for reimbursement of payment made by a Member for services received must be filed within 90 days after the emergency or as soon as reasonably possible but not later than one year unless the Member was legally incapacitated; otherwise such a Claim will be considered to have been waived. If Emergency Medical Services and Care are required while outside the continental United States, Alaska or and Hawaii, it is the Member’s responsibility to pay for such services at the time they are received. For information on filing a Claim for such services see Part XIII. REVIEW PROCEDURES AND HOW TO APPEAL A CLAIM (BENEFIT) DENIALSection 13.3d.

Emergency Services. AvMed will cover all Medically Necessary Physician and Hospital services for an Emergency Medical Condition. In the event Hospital inpatient services are provided following Emergency Medical Services and Care, AvMed should be notified by the Hospital, Member Member, or a designee, designee within 24 hours of the inpatient admission if reasonably possible. AvMed may recommend and elect to transfer the Member to an a Tier A In-Network Hospital after the Member’s Condition has been stabilized, stabilized and as soon as it is medically appropriate to do so. If the Member chooses to stay in a Tier B Hospital after the date XxXxx decides a transfer to a Tier A Hospital is medically appropriate, services will be paid at the middle Benefit Level. If the Member chooses to stay in a Non-Participating Hospital after the date AvMed decides a transfer to a Tier A facility is medically appropriate, services will be paid as out-of-network benefits if the continued stay is determined to be a Covered Service. a. Any Member requiring medical, Hospital or ambulance services for an Emergency Medical Condition emergencies as described in Sections 2.29 and 2.30, while temporarily outside the Service Area, or within the Service Area but before they can reach a Participating Provider, may receive the emergency benefits specified herein. When emergency services Emergency Services for an Emergency Medical Condition are rendered by an Out-of-Network Provider to treat an Emergency Medical ConditionProvider, any Copayment or Coinsurance amount applicable to In-Network Providers for emergency services Emergency Services will also apply to such Out-of-Network Provider. b. For out-of-network emergency servicesEmergency Medical Services and Care, AvMed will pay an amount equal to the greater of the three amounts specified below: i. The median of the amount negotiated with Participating Providers for the emergency services Emergency Medical Services and Care furnished; ii. The amount for the emergency services service calculated using AvMed’s Maximum Allowable Payment, which is the same method the Plan generally uses to determine payments for out-of-network services, and applying in-network cost-sharing; or iii. The amount that would be paid under Medicare for the Emergency Medical Services and Care. c. Any request for reimbursement of payment made by a Member for services received must be filed within 90 days after the emergency or as soon as reasonably possible but not later than one year unless the Member was legally incapacitated; otherwise such a Claim will be considered to have been waived. If Emergency Medical Services and Care are required while outside the continental United States, Alaska or and Hawaii, it is the Member’s responsibility to pay for such services at the time they are received. For information on filing a Claim for such services see Part XIII. REVIEW PROCEDURES AND HOW TO APPEAL A CLAIM (BENEFIT) DENIALSection 13.3d.