Common use of How the Plan Works Clause in Contracts

How the Plan Works. Provider Information You are entitled to medical care and services from Participating Providers including Medically Necessary medical, surgical, diagnostic, therapeutic and preventive services that are generally and customarily provided in the Service Area. Some services may not be covered. To be covered, a service that is Medically Necessary must also be described in COVERED SERVICES AND BENEFITS. Even though a Physician or other Health Care Professional has performed, prescribed or recommended a service does not mean it is Medically Necessary or that it is covered under COVERED SERVICES AND BENEFITS. Some Covered Services may also require Preauthorization by HMO. Preauthorization processes will be conducted in accordance with Texas Insurance Code, chapter 4201, or in accordance with the laws in the state of Texas. Only services that are performed, prescribed, directed or authorized in advance by the PCP or HMO are covered benefits under this Certificate except Emergency Care or Covered Services provided to female Members, who may directly access an Obstetrician/Gynecologist in the same Limited Provider Network as their PCP for: 1) well woman exams; 2) obstetrical care; 3) care for all active gynecological conditions; and

How the Plan Works. Provider Information You are entitled to medical care and services from Participating Providers including Medically Necessary medical, surgical, diagnostic, therapeutic and preventive services that are generally and customarily provided in the Service Area. Some services may not be covered. To be covered, a service that is Medically Necessary must also be described in COVERED SERVICES AND BENEFITSCovered Services and Benefits. Even though a Physician or other Health Care Professional has performed, prescribed or recommended a service does not mean it is Medically Necessary or that it is covered under COVERED SERVICES AND BENEFITSCovered Services and Benefits. Some Covered Services may also require Preauthorization by HMO. Preauthorization processes will be conducted in accordance with Texas Insurance Code, chapter 4201, or in accordance with the laws in the state of Texas. Only services that are performed, prescribed, directed or authorized in advance by the PCP or HMO are covered benefits under this Certificate except Emergency Care or Covered Services provided to female Members, who may directly access an Obstetrician/Gynecologist in the same Limited Provider Network as their PCP for: 1) well woman exams; 2) obstetrical care; 3) care for all active gynecological conditions; and