Common use of HEALTH CARE MANAGEMENT SERVICES Clause in Contracts

HEALTH CARE MANAGEMENT SERVICES. A Member is entitled to benefits for Covered Services under this Agreement, subject to exclusions, conditions and limitations of this Agreement, and subject to Health Care Management Services administered by the Plan. When Precertification/Certification, as set forth in this Agreement, is required, Medical Necessity and Appropriateness for Covered Services will be determined prior to the Covered Service being rendered. However, when Precertification/Certification is not required, the Plan may determine that a Covered Service was not Medically Necessary and Appropriate after the Covered Service has been rendered. When a Member seeks Covered Services from an Out-of-Network Provider or outside the Network Service Area, the Member is required to call the Precertification toll-free number on the back of his/her Identification Card, prior to the receipt of the Covered Services, to determine what, if any, Precertification requirements they must follow. 1. Pre-Admission Certification a. In-Area Network Services b. Out-of-Area Network Services In the event of a proposed Inpatient stay to a Network Facility Provider located Out- of-Area, for other than an emergency, it shall be the responsibility of the Network Facility Provider to contact the Plan prior to a proposed admission to obtain Precertification of the admission. In addition, the Member must contact the Plan to confirm the Plan’s determination of Medical Necessity and Appropriateness prior to the admission. i) If Precertification for a Medically Necessary and Appropriate Inpatient admission has been obtained, as required under this Agreement, benefits will be paid in accordance with this Agreement. ii) If a Member elects to be admitted after receiving written notification from the Plan that any portion of the proposed admission is not Medically Necessary and Appropriate, the Member will be financially responsible for all charges associated with care that has been determined not to be Medically Necessary and Appropriate. iii) If a Network Facility Provider DOES NOT CONTACT the Plan for Precertification, as required under this Agreement, any claim for benefits will be reviewed for Medical Necessity and Appropriateness. It is important that the Member confirm the Plan’s determination of Medical Necessity and Appropriateness, otherwise if such admission is determined not to be Medically Necessary and Appropriate, no benefits will be provided and the Member will be financially responsible for the difference between the Plan’s payment and the full amount of the Network Facility Provider’s charge. If the admission is determined to be Medically Necessary and Appropriate, benefits will be paid in accordance with this Agreement. c. Out-of-Network Services In the event of a proposed admission to an Out-of-Network Provider, for other than an emergency, the Member is responsible for contacting the Plan prior to a proposed admission to obtain Precertification of the admission. i) If Precertification for a Medically Necessary and Appropriate Inpatient admission has been obtained, as required under this Agreement, benefits will be paid in accordance with this Agreement. The Member will be financially responsible for the difference between the Plan’s payment and the Out-of-Network Provider’s full charge. ii) If a Member elects to be admitted after receiving written notification from the Plan that any portion of the proposed admission is not Medically Necessary and Appropriate, the Member will be financially responsible for all charges associated with care that has been determined not to be Medically Necessary and Appropriate. iii) If a Member DOES NOT CONTACT the Plan for Precertification, as required under this Agreement, any claim for benefits will be reviewed for Medical Necessity and Appropriateness. If the admission is determined to be Medically Necessary and Appropriate, benefits will be paid in accordance with this Agreement. The Member will be financially responsible for the difference between the Plan’s payment and the full amount of the Out-of-Network Provider’s charge. If such admission is determined not to be Medically Necessary and Appropriate, no benefits will be provided, and the Member will be financially responsible for the full amount of the Out-of-Network Provider’s charge.

HEALTH CARE MANAGEMENT SERVICES. A Member is entitled to benefits for Covered Services under this Agreement, subject to exclusions, conditions and limitations of this Agreement, and subject to Health Care Management Services administered by the Plan. When Precertification/Certification, as set forth in this Agreement, is required, Medical Necessity and Appropriateness for Covered Services will be determined prior to the Covered Service being rendered. However, when Precertification/Certification is not required, the Plan may determine that a Covered Service was not Medically Necessary and Appropriate after the Covered Service has been rendered. When a Member seeks Covered Services from an a Network Provider located Out-of-Network Provider or outside the Network Service Area, the Member is required to call the Precertification toll-free number on the back of his/her Identification Card, prior to the receipt of the Covered Services, to determine what, if any, Precertification requirements they must follow. 1. Pre-Admission Certification a. In-Area Network Services b. Out-of-Area Network Services In the event of a proposed Inpatient stay to a Network Facility Provider located Out- of-Area, for other than an emergency, it shall be the responsibility of the Network Facility Provider to contact the Plan prior to a proposed admission to obtain Precertification of the admission. In addition, the Member must contact the Plan to confirm the Plan’s determination of Medical Necessity and Appropriateness prior to the admission. i) If Precertification for a Medically Necessary and Appropriate Inpatient admission has been obtained, as required under this Agreement, benefits will be paid in accordance with this Agreement. ii) If a Member elects to be admitted after receiving written notification from the Plan that any portion of the proposed admission is not Medically Necessary and Appropriate, the Member will be financially responsible for all charges associated with care that has been determined not to be Medically Necessary and Appropriate. iii) If a Network Facility Provider DOES NOT CONTACT the Plan for Precertification, as required under this Agreement, any claim for benefits will be reviewed for Medical Necessity and Appropriateness. It is important that the Member confirm the Plan’s determination of Medical Necessity and Appropriateness, otherwise if such admission is determined not to be Medically Necessary and Appropriate, no benefits will be provided and the Member will be financially responsible for the difference between the Plan’s payment and the full amount of the Network Facility Provider’s charge. If the admission is determined to be Medically Necessary and Appropriate, benefits will be paid in accordance with this Agreement. c. Out-of-Network Services In the event of a proposed admission to an Out-of-Network Provider, for other than an emergency, the Member is responsible for contacting the Plan prior to a proposed admission to obtain Precertification of the admission. i) If Precertification for a Medically Necessary and Appropriate Inpatient admission has been obtained, as required under this Agreement, benefits will be paid in accordance with this Agreement. The Member will be financially responsible for the difference between the Plan’s payment and the Out-of-Network Provider’s full charge. ii) If a Member elects to be admitted after receiving written notification from the Plan that any portion of the proposed admission is not Medically Necessary and Appropriate, the Member will be financially responsible for all charges associated with care that has been determined not to be Medically Necessary and Appropriate. iii) If a Member DOES NOT CONTACT the Plan for Precertification, as required under this Agreement, any claim for benefits will be reviewed for Medical Necessity and Appropriateness. If the admission is determined to be Medically Necessary and Appropriate, benefits will be paid in accordance with this Agreement. The Member will be financially responsible for the difference between the Plan’s payment and the full amount of the Out-of-Network Provider’s charge. If such admission is determined not to be Medically Necessary and Appropriate, no benefits will be provided, and the Member will be financially responsible for the full amount of the Out-of-Network Provider’s charge.

HEALTH CARE MANAGEMENT SERVICES. A Member is entitled to benefits for Covered Services under this Agreement, subject to exclusions, conditions and limitations of this Agreement, and subject to Health Care Management Services administered by the Plan. When Precertification/Certification, as set forth in this Agreement, is required, Medical Necessity and Appropriateness for Covered Services will be determined prior to the Covered Service being rendered. However, when Precertification/Certification is not required, the Plan may determine that a Covered Service was not Medically Necessary and Appropriate after the Covered Service has been rendered. When a Member seeks Covered Services from an Out-of-Network Provider or outside the Network Plan Service Area, the Member is required to call the Precertification toll-free number on the back of his/her Identification Card, prior to the receipt of the Covered Services, to determine what, if any, Precertification requirements they must follow. 1. Pre-Admission Certification a. In-Area Network Services b. Out-of-Area Network Services In the event of a proposed Inpatient stay to a Network Facility Provider located Out- of-Area, for other than an emergency, it shall be the responsibility of the Network Facility Provider to contact the Plan prior to a proposed admission to obtain Precertification of the admission. In addition, the Member must contact the Plan to confirm the Plan’s determination of Medical Necessity and Appropriateness prior to the admission. i) If Precertification for a Medically Necessary and Appropriate Inpatient admission has been obtained, as required under this Agreement, benefits will be paid in accordance with this Agreement. ii) If a Member elects to be admitted after receiving written notification from the Plan that any portion of the proposed admission is not Medically Necessary and Appropriate, the Member will be financially responsible for all charges associated with care that has been determined not to be Medically Necessary and Appropriate. iii) If a Network Facility Provider DOES NOT CONTACT the Plan for Precertification, as required under this Agreement, any claim for benefits will be reviewed for Medical Necessity and Appropriateness. It is important that the Member confirm the Plan’s determination of Medical Necessity and Appropriateness, otherwise if such admission is determined not to be Medically Necessary and Appropriate, no benefits will be provided and the Member will be financially responsible for the difference between the Plan’s payment and the full amount of the Network Facility Provider’s charge. If the admission is determined to be Medically Necessary and Appropriate, benefits will be paid in accordance with this Agreement. c. Out-of-Network Services In the event of a proposed admission to an Out-of-Network Provider, for other than an emergency, the Member is responsible for contacting the Plan prior to a proposed admission to obtain Precertification of the admission. i) If Precertification for a Medically Necessary and Appropriate Inpatient admission has been obtained, as required under this Agreement, benefits will be paid in accordance with this Agreement. The Member will be financially responsible for the difference between the Plan’s payment and the Out-of-Network Provider’s full charge. ii) If a Member elects to be admitted after receiving written notification from the Plan that any portion of the proposed admission is not Medically Necessary and Appropriate, the Member will be financially responsible for all charges associated with care that has been determined not to be Medically Necessary and Appropriate. iii) If a Member DOES NOT CONTACT the Plan for Precertification, as required under this Agreement, any claim for benefits will be reviewed for Medical Necessity and Appropriateness. If the admission is determined to be Medically Necessary and Appropriate, benefits will be paid in accordance with this Agreement. The Member will be financially responsible for the difference between the Plan’s payment and the full amount of the Out-of-Network Provider’s charge. If such admission is determined not to be Medically Necessary and Appropriate, no benefits will be provided, and the Member will be financially responsible for the full amount of the Out-of-Network Provider’s charge.