Local Community Needs. Where a Member’s treating Physician believes that a Member requires certain medical services and the Department of Health has determined that such services are not available from another source locally other than from a UPMC Provider that is an Out-of-Network Provider under this Agreement, the Member may receive Covered Services from such UPMC Provider. Covered Services shall be available at the Standard Value level of benefits.
Local Community Needs. Highmark members will continue to have ongoing access to unique UPMC providers and services where the patient’s treating physician believes the patient needs such services and the Department of Health (DOH) determines that they are not available from another source, and the member is out-of-network. UPMC will not balance bill the member and Highmark and UPMC will negotiate a payment that is not greater than out-of-network rates established by the Consent Decree. Highmark members will have ongoing access to UPMC services, providers facilities and physicians for cancer treatment, as if in-network, if a patient’s treating physician makes the determination that a patient who is diagnosed with cancer should be treated by a UPMC oncologist and the patient agrees. UPMC and Highmark shall negotiate an agreement for treatment of illnesses which result from cancer treatment. That may include mental health, endocrinology, orthopedics and cardiology. This includes all UPMC joint ventures, physician services provided at or on behalf of independent hospitals (whether related to oncology or not), including services provided through Hillman and at Magee. Services shall be considered in-network and UPMC shall not balance bill consumers until this agreement is resolved. (Note: Last Friday, UPMC released a statement that UPMC Xxxxxxx Cancer Center is not in-network. We will contact you when this is resolved).
