Member’s Responsibility in Seeking Covered Benefits and Services Sample Clauses

Member’s Responsibility in Seeking Covered Benefits and Services. Members are solely responsible for selecting a provider when obtaining Health Care Services and for verifying whether that provider is a Participating Provider at the time Health Care Services are rendered. Members are also responsible for determining any corresponding payment options at the time the Health Care Services are rendered. It is the Member's responsibility when seeking benefits under this Contract to identify himself as a Member of AvMed.
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Member’s Responsibility in Seeking Covered Benefits and Services. You are solely responsible for selecting a provider when obtaining Health Care Services and for verifying whether that provider is a Participating Provider at the time Health Care Services are rendered. You are also responsible for determining any corresponding payment options at the time the Health Care Services are rendered. If a Member does not follow these access rules, he risks having the services and supplies received not covered under this Contract. In such a circumstance, any payment that AvMed may make will not exceed the Maximum Allowable Payment and the Member will be responsible for reimbursing AvMed for the services and supplies received. It is the Member's responsibility when seeking benefits under this Contract to identify himself as a Member of AvMed.

Related to Member’s Responsibility in Seeking Covered Benefits and Services

  • Covered Benefits and Services The Contractor shall provide to its Hoosier Healthwise members, at a minimum, all benefits and services deemed “medically reasonable and necessary” and covered by the IHCP, and included in the Indiana Administrative Code and under the Contract with the State. A covered service is considered medically necessary if it meets the definition as set forth in 405 IAC 5-2-17. The Contractor shall deliver covered services sufficient in amount, duration or scope to reasonably expect that provision of such services would achieve the purpose of the furnished services. Costs for these services are the basis of the Contractor’s capitation rate and are, therefore, the responsibility of the Contractor. Coverage may not be arbitrarily denied or reduced and is subject to certain limitations in accordance with CFR 438.210(a)(4), which specifies when Contractors may place appropriate limits on services:  On the basis of criteria applied under the State plan, such as medical necessity; or  For the purpose of utilization control, provided the services furnished are sufficient in amount, duration or scope to reasonably be expected to achieve the purpose for which the services are furnished.

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