Managed Care Program Requirements. SHL's Managed Care Program requires the Insured, Plan Providers and SHL to work together. All Plan Providers have agreed to participate in SHL’s Managed Care Program. Plan Providers have agreed to accept SHL’s Reimbursement Schedule amount as payment in full for Covered Services, less the Insured’s payment of any applicable Calendar Year Deductible, Copayment or Coinsurance amount, whereas Non-Plan Providers have not. Insureds enrolled under SHL’s Exclusive Provider Organization (EPO) Plans who use the services of Non-Plan Providers will receive no benefit payments or reimbursement for amounts for any Covered Service, except in the case of Emergency Services or Urgently Needed Services or other Covered Services provided by a Non-Plan Provider that are Prior Authorized by SHL’s Managed Care Program. This includes any Prior Authorized Covered Services obtained from a Non-Plan outpatient facility, such as a laboratory, radiological facility (x-ray), or any complex diagnostic or therapeutic services. In no event will SHL pay more than the maximum payment allowance established in the SHL Reimbursement Schedule. It is the Insured's responsibility to verify that the Provider selected is a Plan Provider before receiving any non-Emergency Services and to comply with all other rules of SHL’s Managed Care Program. Failure of the Insured to comply with the requirements of SHL’s Managed Care Program will result in a reduction of benefits. Benefits payable for Covered Services from Plan Providers which are not Prior Authorized by SHL’s Managed Care Program will be reduced to 50% of what the Insured would have received with Prior Authorization.
Managed Care Program Requirements. SHL's Managed Care Program requires the Insured, Plan Providers and SHL to work together. All Plan Providers have agreed to participate in SHL’s Managed Care Program. Plan Providers have agreed to accept SHL’s Reimbursement Schedule amount as payment in full for Covered Services, less the Insured’s payment of any applicable Calendar Year Deductible, Copayment or Coinsurance amount, whereas Non-Plan Providers have not. In no event will SHL pay more than the maximum payment allowance established in the SHL Reimbursement Schedule. It is the Insured's responsibility to verify that the Provider selected is a Plan Provider before receiving any non-Emergency Services and to comply with all other rules of SHL’s Managed Care Program. Benefits payable for expenses incurred in connection with Covered Services which are not Prior Authorized by SHL’s Managed Care Program will be reduced to 50% of what the Insured would have received if the services had been Prior Authorized.
Managed Care Program Requirements. HPN's Managed Care Program requires the Member, Plan Providers and HPN to work together. All Plan Providers have agreed to participate in HPN’s Managed Care Program. Plan Providers have agreed to accept HPN’s Reimbursement Schedule amount as payment in full for Covered Services, less the Member’s payment of any applicable Calendar Year Deductible, Copayment or Coinsurance amount, whereas Non-Plan Providers have not. Members enrolled under HPN’s HMO Plans who use the services of Non-Plan Providers will receive no benefit payments or reimbursement for amounts for any Covered Service, except in the case of Emergency Services or Urgently Needed Services; or for other Covered Services, as defined in this AOC, provided by a Non-Plan Provider that are Prior Authorized by HPN’s Managed Care Program. This includes any Prior Authorized Covered Services obtained from a Non-Plan outpatient facility, such as a laboratory, radiological facility (x-ray), or any complex diagnostic or therapeutic services. In no event will HPN pay more than the maximum payment allowance established in the HPN Reimbursement Schedule.
Managed Care Program Requirements. HPN's Managed Care Program requires the Member, Plan Providers and HPN to work together. All Plan Providers have agreed to participate in HPN’s Managed Care Program. Plan Providers have agreed to accept HPN’s Reimbursement Schedule amount as payment in full for Covered Services, less the Member’s payment of any applicable Calendar Year Deductible, Copayment or Coinsurance amount, whereas Non-Plan Providers have not.
Managed Care Program Requirements. SHL's Managed Care Program requires the Insured, Plan Providers and SHL to work together. All Plan Providers have agreed to participate in SHL’s Managed Care Program. Plan Providers have agreed to accept SHL’s Reimbursement Schedule amount as payment in full for Covered Services, less the Insured’s payment of any applicable Calendar Year Deductible, Copayment or Coinsurance amount, whereas Non-Plan Providers have not. Insureds enrolled under SHL’s Exclusive Provider Organization (EPO) Plans who use the services of Non-Plan Providers will receive no benefit payments or reimbursement for amounts for any Covered Service, except in the case of Emergency Services or Urgently Needed Services or other Covered Services provided by a Non-Plan Provider that are Prior Authorized by SHL’s Managed Care Program. This includes any Prior Authorized Covered Services obtained from a Non-Plan outpatient facility, such as a laboratory, radiological facility (x-ray), or any complex diagnostic or therapeutic services. In no event will SHL pay more than the maximum payment allowance established in the SHL Reimbursement Schedule.
Managed Care Program Requirements. Following review, HPN will complete the Prior Authorization form and send a copy to the Provider and the Member. The form will specify approved services and supplies. Prior Authorization is not a guarantee of payment. The final decision as to whether any care should be received is between the Member and the Provider. If HPN denies a request by a Member and/or Provider for Prior Authorization of a service or supply, the Member or Provider may appeal the denial to the Grievance Review Committee (see Section 10, Appeals Procedures).
Managed Care Program Requirements the most appropriate setting to provide healthcare in a cost-effective manner. Benefits payable for expenses incurred in connection with Covered Services, which are not Prior Authorized by the Managed Care Program, will be reduced as shown in the Attachment A Benefit Schedule. SHL's Managed Care Program requires the Insured, Plan Providers and SHL to work together. All Plan Providers have agreed to participate in SHL’s Managed Care Program. Plan Providers have agreed to accept SHL’s Reimbursement Schedule amount as payment in full for Covered Services, less the Insured’s payment of any applicable Copayment, Deductible or Coinsurance amount, whereas Non- Plan Providers have not. In no event will SHL pay more than the maximum payment allowance established in the SHL Reimbursement Schedule.
Managed Care Program Requirements. SHL's Managed Care Program requires the Insured, Plan Providers and SHL to work together. • All Plan Providers have agreed to participate in SHL’s Managed Care Program. Plan Providers have agreed to accept SHL’s Reimbursement Schedule amount as payment in full for Covered Services, less the Insured’s payment of any applicable Copayment, Deductible or Coinsurance amount, whereas Non-Plan Providers have not. In no event will SHL pay more than the maximum payment allowance established in the SHL Reimbursement Schedule. • It is the Insured's responsibility to verify Prior Authorization has been obtained for any Covered Services requiring Prior Authorization and to comply with all other rules of SHL’s Managed Care Program.
Managed Care Program Requirements. The final decision as to whether any care should be received is between the Member and the Provider. If HPN denies a request by a Member and/or Provider for Prior Authorization of a service or supply, the Member or Provider may appeal the denial to the Grievance Review Committee (see Section 10, Appeals Procedures).
Managed Care Program Requirements. SHL's Managed Care Program requires the Insured, Plan Providers and SHL to work together. • All Plan Providers have agreed to participate in SHL’s Managed Care Program. Plan Providers have agreed to accept SHL’s Reimbursement Schedule amount as payment in full for Covered Services, less the Insured’s payment of any applicable Copayment, Deductible or Coinsurance amount, whereas Non-Plan Providers have not. In no event will SHL pay more than the maximum payment allowance established in the SHL Reimbursement Schedule. Form No. SHL-Ind_AOC(2015) Page 6 • It is the Insured's responsibility to verify Prior Authorization has been obtained for any Covered Services requiring Prior Authorization and to comply with all other rules of SHL’s Managed Care Program.
