Network Authorization. For services that cannot be provided by a network provider, you can request a network authorization to seek services from a non-network provider. With an approved network authorization, the network benefit level will apply to the authorized covered healthcare service. If we approve a network authorization for you to receive services from a non- network provider, our reimbursement will be based on the lesser of our allowance, the non-network provider’s charge, or the benefit limit. For more information, please see the How Non-Network Providers Are Paid section.
Network Authorization. For services that cannot be provided by a network provider, you can request a network authorization to seek services from a non-network provider. With an approved network authorization, the network benefit level will apply to the authorized covered healthcare service. If we approve a network authorization for you to receive services from a non- network provider, our reimbursement will be based on the lesser of our allowance, the non-network provider’s charge, or the benefit limit. For more information, please see the How Non-Network Providers Are Paid section. If you are in active treatment for pregnancy or a serious health condition with a network provider and there is a change to the network so that this provider is no longer in the network, please contact us for more information about whether that provider’s services to treat your pregnancy or serious health condition can continue to be covered at the network benefit level.
Network Authorization. For services that cannot be provided by an in-network provider, you can request a network authorization to seek services from an out-of-network provider. With an approved network authorization, the in-network benefit level will apply to the authorized covered health care service. If we approve a network authorization for you to receive services from an out-of-network provider, we will reimburse you or the out-of-network provider up to the maximum benefit or our allowance, less any copayments and deductibles. Please see Section 8.0 for the definition of Network Authorization. Expedited Preauthorization Review You may request an expedited preauthorization review if the circumstances are an emergency. If an expedited preauthorization review is received by us, we will respond to you with a determination within seventy-two (72) hours or in less than seventy two (72) hours (taking into consideration medical exigencies) following receipt of the request. Services for which Prescription Drug Preauthorization is required are marked with the symbol (+) in the Summary of Pharmacy Benefits. To obtain the required Prescription Drug Preauthorization for certain covered prescription drugs please request your prescribing physician to call our pharmacy benefits administrator, using the number listed for the “Pharmacist” on the back of your ID card. You can call our Customer Service Department at (000) 000-0000 or 0-000-000-0000 or visit our Web site at XXXXXX.xxx to see if a prescription drug requires Prescription Drug Preauthorization. Prescription drug preauthorization is defined in Section 3.27.
