Common use of Member Responsibility Clause in Contracts

Member Responsibility. If the Member receives Covered Services outside of the service area, or care is rendered by a Non- Preferred Provider, the Member is responsible for all utilization management requirements. It is the Member’s responsibility to ensure that providers associated with the Member’s care cooperate with utilization management requirements. This includes initial notification in a timely manner, responding to CareFirst inquiries and, if requested, allowing CareFirst representatives to review medical records on-site or in CareFirst offices. If CareFirst is unable to conduct utilization reviews, Member benefits may be reduced or excluded from coverage.