Common use of Limitation on Services Clause in Contracts

Limitation on Services. Except in cases of Emergency, services are available only from Network Providers. We shall have no liability or obligation whatsoever on account of any service or benefit sought or received by a [Member] from any Provider or other person, entity, institution or organization unless prior arrangements are made by Us. PROVIDER PAYMENT [[Different] providers in Our Network have agreed to be paid [in different ways by Us. A Member’s Provider may be paid] [each time he or she treats the Member (“fee for service”] [, or may be paid] [a set fee for each month for each Member whether or not the Member actually receives services (“capitation”)] [ , or may receive] [ a salary]. [These payment methods may include financial incentive agreements to pay some providers more (“bonuses”) or less (“withholds”) based on many factors: Member satisfaction, quality of care, and control of costs and use of services among them.] If a Member desires additional information about how Our Primary Care Physicians or any other Provider in Our Network are compensated, please call Us at [telephone number] or write [address]. The laws of the state of New Jersey, at N.J.S.A. 45:9-22.4 et seq., mandate that a physician, chiropractor or podiatrist who is permitted to make Referrals to other health care Providers in which he or she has a significant financial interest inform his or her patients of any significant financial interest he or she may have in a health care Provider or Facility when making a Referral to that health care Provider or Facility. If a Member wants more information about this the [Member], the [Member] should contact his or her physician, chiropractor or podiatrist. If a Member believes he or she is not receiving the information to which the Member is entitled, contact the Division of Consumer Affairs in the New Jersey Department of Law and Public Safety at (000) 000-0000 OR (000) 000-0000.] APPEAL PROCEDURE NOTE TO CARRIERS: Insert Appeals Procedure text here. The Appeal Procedure text must satisfy the requirements of N.J.A.C. 11:24-8.5 et seq. The text must include specific information regarding the Stage 1 and External Appeals process.

Limitation on Services. Except in cases of Emergency, services are available only from Network Providers. We shall have no liability or obligation whatsoever on account of any service or benefit sought or received by a [Member] Member from any Provider or other person, entity, institution or organization unless prior arrangements are made by Us. PROVIDER PAYMENT [[Different] Different providers in Our Network have agreed to be paid [in different ways by Us. A Member’s Provider may be paid] [paid each time he or she treats the Member (“fee for service”] [), or may be paid] [paid a set fee for each month for each Member whether or not the Member actually receives services (“capitation”)] [ , or may receive] [ receive a salary]. [These payment methods may include financial incentive agreements to pay some providers more (“bonuses”) or less (“withholds”) based on many factors: Member satisfaction, quality of care, and control of costs and use of services among them.] . If a Member desires additional information about how Our Primary Care Physicians Providers or any other Provider in Our Network are compensated, please call Us at [telephone number] 0-000-000-0000 or write [address]Cigna HealthCare of New Jersey, Inc., 000 Xxxxxxxxxx Xxxx., Xxxxxx Xxxx, XX 00000. The laws of the state of New Jersey, at N.J.S.A. 45:9-22.4 et seq., mandate that a physician, chiropractor or podiatrist who is permitted to make Referrals to other health care Providers in which he or she has a significant financial interest inform his or her patients of any significant financial interest he or she may have in a health care Provider or Facility when making a Referral to that health care Provider or Facility. If a Member wants more information about this the [Member], the [Member] Member should contact his or her physician, chiropractor or podiatrist. If a Member believes he or she is not receiving the information to which the Member is entitled, contact the Division of Consumer Affairs in the New Jersey Department of Law and Public Safety at (000) 000-0000 OR (000) 000-0000.] APPEAL PROCEDURE NOTE TO CARRIERS: Insert Appeals Procedure text here. The Appeal Procedure text must satisfy the requirements of N.J.A.C. 11:24-8.5 et seq. The text must include specific information regarding the Stage 1 and External Appeals process.

Limitation on Services. Except in cases of Emergency, services are available only from Network Providers. We shall have no liability or obligation whatsoever on account of any service or benefit sought or received by a [Member] from any Provider or other person, entity, institution or organization unless prior arrangements are made by Us. PROVIDER PAYMENT [[Different] providers in Our Network have agreed to be paid [in different ways by Us. A Member’s Provider may be paid] [each time he or she treats the Member (“fee for service”] [, or may be paid] [a set fee for each month for each Member whether or not the Member actually receives services (“capitation”)] [ , or may receive] [ a salary]. [These payment methods may include financial incentive agreements to pay some providers more (“bonuses”) or less (“withholds”) based on many factors: Member satisfaction, quality of care, and control of costs and use of services among them.] If a Member desires additional information about how Our Primary Care Physicians Providers or any other Provider in Our Network are compensated, please call Us at [telephone number] or write [address]. The laws of the state of New Jersey, at N.J.S.A. 45:9-22.4 et seq., mandate that a physician, chiropractor or podiatrist who is permitted to make Referrals to other health care Providers in which he or she has a significant financial interest inform his or her patients of any significant financial interest he or she may have in a health care Provider or Facility when making a Referral to that health care Provider or Facility. If a Member wants more information about this the [Member], the [Member] should contact his or her physician, chiropractor or podiatrist. If a Member believes he or she is not receiving the information to which the Member is entitled, contact the Division of Consumer Affairs in the New Jersey Department of Law and Public Safety at (000) 000-0000 OR (000) 000-0000.] APPEAL PROCEDURE NOTE TO CARRIERS: Insert Appeals Procedure text here. The Appeal Procedure text must satisfy the requirements of N.J.A.C. 11:24-8.5 et seq. The text must include specific information regarding the Stage 1 and External Appeals process.

Limitation on Services. Except in cases of Emergency, services are available only from Network Providers. We shall have no liability or obligation whatsoever on account of any service or benefit sought or received by a [Member] from any Provider or other person, entity, institution or organization unless prior arrangements are made by Us. PROVIDER PAYMENT [[Different] providers in Our Network have agreed to be paid [in different ways by Us. A Member’s Provider may be paid] [each time he or she treats the Member (“fee for service”] [, or may be paid] [a set fee for each month for each Member whether or not the Member actually receives services (“capitation”)] [ , or may receive] [ a salary]. [These payment methods may include financial incentive agreements to pay some providers more (“bonuses”) or less (“withholds”) based on many factors: Member satisfaction, quality of care, and control of costs and use of services among them.] If a Member desires additional information about how Our Primary Care Physicians or any other Provider in Our Network are compensated, please call Us at [telephone number] or write [address]. The laws of the state of New Jersey, at N.J.S.A. 45:9-22.4 et seq., mandate that a physician, chiropractor or podiatrist who is permitted to make Referrals to other health care Providers in which he or she has a significant financial interest inform his or her patients of any significant financial interest he or she may have in a health care Provider or Facility when making a Referral to that health care Provider or Facility. If a Member wants more information about this the [Member], the [Member] should contact his or her physician, chiropractor or podiatrist. If a Member believes he or she is not receiving the information to which the Member is entitled, contact the Division of Consumer Affairs in the New Jersey Department of Law and Public Safety at (000) 000-0000 OR (000) 000-0000.] APPEAL PROCEDURE NOTE TO CARRIERS: Insert Appeals Procedure text here. The Appeal Procedure text must satisfy the requirements of N.J.A.C. 11:24-8.5 et seq. The text must include specific information regarding the Stage 1 1, Stage 2 and External Appeals process. CONTINUATION OF CARE We shall provide written notice to each [Member] at least 30 business days prior to the termination or withdrawal from Our Provider Network of a [Member’s] PCP and any other Provider from which the [Member] is currently receiving a course of treatment, as reported to Us. The 30-day prior notice may be waived in cases of immediate termination of a health care professional based on a breach of contract by the health care professional, a determination of fraud, or where Our medical director is of the opinion that the health care professional is an imminent danger to the patient or the public health, safety or welfare. We shall assure continued coverage of covered services at the contract rate by a terminated health care professional for up to four months in cases where it is Medically Necessary and Appropriate for the [Member] to continue treatment with the terminated health care professional. In case of pregnancy of a [Member], coverage of services for the terminated health care professional shall continue to the postpartum evaluation of the [Member], up to six weeks after the delivery. With respect to pregnancy, Medical Necessity and Appropriateness shall be deemed to have been demonstrated.

Limitation on Services. Except in cases of Emergency, services are available only from Network Providers. We shall have no liability or obligation whatsoever on account of any service or benefit sought or received by a [Member] from any Provider or other person, entity, institution or organization unless prior arrangements are made by Us. PROVIDER PAYMENT [[Different] providers in Our Network have agreed to be paid [in different ways by Us. A Member’s Provider may be paid] [each time he or she treats the Member (“fee for service”] [, or may be paid] [a set fee for each month for each Member whether or not the Member actually receives services (“capitation”)] [ , or may receive] [ a salary]. [These payment methods may include financial incentive agreements to pay some providers more (“bonuses”) or less (“withholds”) based on many factors: Member satisfaction, quality of care, and control of costs and use of services among them.] If a Member desires additional information about how Our Primary Care Physicians Providers or any other Provider in Our Network are compensated, please call Us at [telephone number] or write [address]. The laws of the state of New Jersey, at N.J.S.A. 45:9-22.4 et seq., mandate that a physician, chiropractor or podiatrist who is permitted to make Referrals to other health care Providers in which he or she has a significant financial interest inform his or her patients of any significant financial interest he or she may have in a health care Provider or Facility when making a Referral to that health care Provider or Facility. If a Member wants more information about this the [Member], the [Member] should contact his or her physician, chiropractor or podiatrist. If a Member believes he or she is not receiving the information to which the Member is entitled, contact the Division of Consumer Affairs in the New Jersey Department of Law and Public Safety at (000) 000-0000 OR (000) 000-0000.] APPEAL PROCEDURE NOTE TO CARRIERS: Insert Appeals Procedure text here. The Appeal Procedure text must satisfy the requirements of N.J.A.C. 11:24-8.5 et seq. The text must include specific information regarding the Stage 1 and External Appeals process. The text must address the specific appeals process and in-plan exception required by P.L. 2017, c.28.

Limitation on Services. Except in cases of Emergency, services are available only from Network Providers. We shall have no liability or obligation whatsoever on account of any service or benefit sought or received by a [Member] from any Provider or other person, entity, institution or organization unless prior arrangements are made by Us. PROVIDER PAYMENT [[Different] providers in Our Network have agreed to be paid [in different ways by Us. A Member’s Provider may be paid] [each time he or she treats the Member (“fee for service”] [, or may be paid] [a set fee for each month for each Member whether or not the Member actually receives services (“capitation”)] [ , or may receive] [ a salary]. [These payment methods may include financial incentive agreements to pay some providers more (“bonuses”) or less (“withholds”) based on many factors: Member satisfaction, quality of care, and control of costs and use of services among them.] If a Member desires additional information about how Our Primary Care Physicians Providers or any other Provider in Our Network are compensated, please call Us at [telephone number] or write [address]. The laws of the state of New Jersey, at N.J.S.A. 45:9-22.4 et seq., mandate that a physician, chiropractor or podiatrist who is permitted to make Referrals to other health care Providers in which he or she has a significant financial interest inform his or her patients of any significant financial interest he or she may have in a health care Provider or Facility when making a Referral to that health care Provider or Facility. If a Member wants more information about this the [Member], the [Member] should contact his or her physician, chiropractor or podiatrist. If a Member believes he or she is not receiving the information to which the Member is entitled, contact the Division of Consumer Affairs in the New Jersey Department of Law and Public Safety at (000) 000-0000 OR (000) 000-0000.] APPEAL PROCEDURE NOTE TO CARRIERS: Insert Appeals Procedure text here. The Appeal Procedure text must satisfy the requirements of N.J.A.C. 11:24-8.5 et seq. The text must include specific information regarding the Stage 1 and External Appeals process.PROCEDURE

Limitation on Services. Except in cases of Emergency, services are available only from Network Providers. We shall have no liability or obligation whatsoever on account of any service or benefit sought or received by a [Member] Member from any Provider or other person, entity, institution or organization unless prior arrangements are made by Us. PROVIDER PAYMENT [[Different] Different providers in Our Network have agreed to be paid [in different ways by Us. A Member’s Provider may be paid] [paid each time he or she treats the Member (“fee for service”] [), or may be paid] [paid a set fee for each month for each Member whether or not the Member actually receives services (“capitation”)] [ , or may receive] [ receive a salary]. [These payment methods may include financial incentive agreements to pay some providers more (“bonuses”) or less (“withholds”) based on many factors: Member satisfaction, quality of care, and control of costs and use of services among them.] . If a Member desires additional information about how Our Primary Care Physicians or any other Provider in Our Network are compensated, please call Us at [telephone number] 0-000-000-0000 or write [address]Cigna HealthCare of New Jersey, Inc., 000 Xxxxxxxxxx Xxxx., Xxxxxx Xxxx, XX 00000. The laws of the state of New Jersey, at N.J.S.A. 45:9-22.4 et seq., mandate that a physician, chiropractor or podiatrist who is permitted to make Referrals to other health care Providers in which he or she has a significant financial interest inform his or her patients of any significant financial interest he or she may have in a health care Provider or Facility when making a Referral to that health care Provider or Facility. If a Member wants more information about this the [Member], the [Member] Member should contact his or her physician, chiropractor or podiatrist. If a Member believes he or she is not receiving the information to which the Member is entitled, contact the Division of Consumer Affairs in the New Jersey Department of Law and Public Safety at (000) 000-0000 OR (000) 000-0000.] APPEAL PROCEDURE NOTE TO CARRIERS: Insert Appeals Procedure text here. The Appeal Procedure text must satisfy the requirements of N.J.A.C. 11:24-8.5 et seq. The text must include specific information regarding the Stage 1 and External Appeals process.

Limitation on Services. Except in cases of Emergency, services are available only from Network Providers. We shall have no liability or obligation whatsoever on account of any service or benefit sought or received by a [Member] from any Provider or other person, entity, institution or organization unless prior arrangements are made by Us. PROVIDER PAYMENT [[Different] providers in Our Network have agreed to be paid [in different ways by Us. A Member’s Provider may be paid] [each time he or she treats the Member (“fee for service”] [, or may be paid] [a set fee for each month for each Member whether or not the Member actually receives services (“capitation”)] [ , or may receive] [ a salary]. [These payment methods may include financial incentive agreements to pay some providers more (“bonuses”) or less (“withholds”) based on many factors: Member satisfaction, quality of care, and control of costs and use of services among them.] If a Member desires additional information about how Our Primary Care Physicians or any other Provider in Our Network are compensated, please call Us at [telephone number] or write [address]. The laws of the state of New Jersey, at N.J.S.A. 45:9-22.4 et seq., mandate that a physician, chiropractor or podiatrist who is permitted to make Referrals to other health care Providers in which he or she has a significant financial interest inform his or her patients of any significant financial interest he or she may have in a health care Provider or Facility when making a Referral to that health care Provider or Facility. If a Member wants more information about this the [Member], the [Member] should contact his or her physician, chiropractor or podiatrist. If a Member believes he or she is not receiving the information to which the Member is entitled, contact the Division of Consumer Affairs in the New Jersey Department of Law and Public Safety at (000) 000-0000 OR (000) 000-0000.] APPEAL PROCEDURE NOTE TO CARRIERS: Insert Appeals Procedure text here. The Appeal Procedure text must satisfy the requirements of N.J.A.C. 11:248:38-8.5 et seq. The text must include specific information regarding the Stage 1 1, Stage 2 and External Appeals process. CONTINUATION OF CARE We shall provide written notice to each [Member] at least 30 business days prior to the termination or withdrawal from Our Provider Network of a [Member’s] PCP and any other Provider from which the [Member] is currently receiving a course of treatment, as reported to Us. The 30-day prior notice may be waived in cases of immediate termination of a health care professional based on a breach of contract by the health care professional, a determination of fraud, or where Our medical director is of the opinion that the health care professional is an imminent danger to the patient or the public health, safety or welfare. We shall assure continued coverage of covered services at the contract rate by a terminated health care professional for up to four months in cases where it is Medically Necessary and Appropriate for the [Member] to continue treatment with the terminated health care professional. In case of pregnancy of a [Member], coverage of services for the terminated health care professional shall continue to the postpartum evaluation of the [Member], up to six weeks after the delivery. With respect to pregnancy, Medical Necessity and Appropriateness shall be deemed to have been demonstrated.