Common use of NMAC Clause in Contracts

NMAC. Current patients are covered persons who have a claim with Presbyterian Health Plan (PHP) related to the provider's services within the past year, or who have received a pre-authorization prior to termination to use the provider's services at a future time. PHP will assist such affected covered persons in locating and transferring to another similarly qualified provider. A covered person may not be held financially liable for services received from the provider in good faith between the effective date of the suspension or termination and the receipt of notice provided to the covered person, if the covered person has not received comparable notice during this time from the provider. We do not require our In-network Practitioners/Providers to comply with any specified numbers, targeted averages, or maximum duration of patient visits. Presbyterian does not discriminate against any health care provider who is acting within the scope of their license or certification under applicable State law. Out-of-network (outside of the 5-county area) Practitioners/Providers Out-of-network (outside of the 5-county area) Practitioners/Providers are healthcare Practitioners/Providers, including non-medical facilities, who have not entered into an agreement with us to provide Healthcare Services to PHP Members on this plan. Covered Healthcare Services obtained from an Out-of-network (outside of the 5-county area) Practitioner/Provider or outside the Service Area will not be Covered unless such services are not reasonably available from an In-network Practitioner/Provider or in cases of urgent or an emergency. You will not pay higher or additional Cost Sharing amounts under such circumstances. These provisions also apply to Telehealth services. If you pay a non-participating Provider more than the in-network cost-sharing amount for services provided under circumstances giving rise to a surprise bill, the non-participating Provider must refund to you within 45 days of receipt of payment from Presbyterian any amount paid in excess of the in-network cost-sharing amount. In accordance with the hearing procedures established pursuant to the Patient Protection Act [Chapter 59, Article 57 NMSA 1978], you may appeal Presbyterian’s determination made regarding a surprise bill. Services provided by an Out-of-network (outside of the 5-county area) Practitioner/Provider, except for urgent or Emergency services, require that your Primary Care Physician request and obtain written approval (Authorization) from our Medical Director BEFORE services are rendered. Otherwise, you may be responsible for payment. Please refer to the Prior Authorization Section for more information on Prior Authorization requirements. If the services of an Out-of-network (outside of the 5-county area) Practitioner/Provider are required, your In-network Practitioner/Provider must request and obtain Prior Authorization from our Medical Director BEFORE services are performed, otherwise, we may not Cover the services and you may be responsible for payment. Before the Medical Director may deny a request for specialist services that are unavailable from an In-Network Practitioner/Provider, the request must be reviewed by a specialist similar to the type of specialist to whom the Prior Authorization is requested. In determining whether a Prior Authorization to an Out-of-network (outside of the 5-county area) Practitioner/Provider is reasonable, we will consider the following circumstances: Availability – The In-network Practitioner/Provider is not reasonably available to see you in a timely fashion as dictated by the clinical situation.

NMAC. Current patients are covered persons who have a claim with Presbyterian Health Plan (PHP) PHP)/PIC related to the provider's services within the past year, or who have received a pre-authorization prior to termination to use the provider's services at a future time. PHP PHP/PIC will assist such affected covered persons in locating and transferring to another similarly qualified provider. A covered person may not be held financially liable for services received from the provider in good faith between the effective date of the suspension or termination and the receipt of notice provided to the covered person, if the covered person has not received comparable notice during this time from the provider. We do not require our In-network Practitioners/Providers to comply with any specified numbers, targeted averages, or maximum duration of patient visits. Presbyterian does not discriminate against any health care provider who is acting within the scope of their license or certification under applicable State law. Out-of-network (outside of the 5-county area) Practitioners/Providers Out-of-network (outside of the 5-county area) Practitioners/Providers are healthcare Practitioners/Providers, including non-non- medical facilities, who have not entered into an agreement with us to provide Healthcare Services to PHP Members on this planMembers. Covered Healthcare Services obtained from an Out-of-network (outside of the 5-county area) Practitioner/Provider or outside the Service Area will not be Covered unless such services are not reasonably available from an In-network Practitioner/Provider or in cases of urgent or an emergency. You will not pay higher or additional Cost Cost-Sharing amounts under such circumstances. These provisions also apply to Telehealth services. If you pay a non-participating Provider more than the inIn-network cost-sharing Cost Sharing amount for services provided under circumstances giving rise to a surprise bill, the non-participating Provider must refund to you within 45 days of receipt of payment from Presbyterian any amount paid in excess of the inIn-network cost-sharing Cost Sharing amount. In accordance with the hearing procedures established pursuant to the Patient Protection Act [Chapter 59, Article 57 NMSA 1978], you may appeal Presbyterian’s determination made regarding a surprise bill. Services provided by an Out-of-network (outside of the 5-county area) Practitioner/Provider, except for urgent or Emergency services, require that your Primary Care Physician PCP request and obtain written approval (Authorization) from our Medical Director BEFORE services are rendered. Otherwise, you may be responsible for payment. Please refer to the Prior Authorization Section for more information on Prior Authorization requirements. If the services of an Out-of-network (outside of the 5-county area) Practitioner/Provider are required, your In-network Practitioner/Provider must request and obtain Prior Authorization from our Medical Director BEFORE services are performed, otherwise, we may not Cover the services and you may be responsible for payment. Before the Medical Director may deny a request for specialist services that are unavailable from an In-Network Practitioner/Provider, the request must be reviewed by a specialist similar to the type of specialist to whom the Prior Authorization is requested. In determining whether a Prior Authorization to an Out-of-network (outside of the 5-county area) Practitioner/Provider is reasonable, we will consider the following circumstances: • Availability – The In-network Practitioner/Provider is not reasonably available to see you in a timely fashion as dictated by the clinical situation. • Competency – The In-network Practitioner/Provider does not have the necessary training or expertise required to render the service or treatment.

NMAC. Current patients are covered persons who have a claim with Presbyterian Health Plan (PHP) PHP)/PIC related to the provider's services within the past year, or who have received a pre-authorization prior to termination to use the provider's services at a future time. PHP PHP/PIC will assist such affected covered persons in locating and transferring to another similarly qualified provider. A covered person may not be held financially liable for services received from the provider in good faith between the effective date of the suspension or termination and the receipt of notice provided to the covered person, if the covered person has not received comparable notice during this time from the provider. We do not require our In-network Practitioners/Providers to comply with any specified numbers, targeted averages, or maximum duration of patient visits. Presbyterian does not discriminate against any health care provider who is acting within the scope of their license or certification under applicable State law. Out-of-network (outside of the 5-county area) Network Practitioners/Providers Out-of-network (outside of the 5-county area) Practitioners/Providers are healthcare Practitioners/Providers, including non-non- medical facilities, who have not entered into an agreement with us to provide Healthcare Services to PHP Members on this planMembers. Covered Healthcare Services obtained from an Out-of-network (outside of the 5-county area) Practitioner/Provider or outside the Service Area will not be Covered unless such services are not reasonably available from an In-network Practitioner/Provider or in cases of urgent or an emergency. You will not pay higher or additional Cost Sharing amounts under such circumstances. These provisions also apply to Telehealth services. If you pay a non-participating Provider more than the inIn-network cost-sharing Cost Sharing amount for services provided under circumstances giving rise to a surprise bill, the non-participating Provider provider must refund to you within 45 days of receipt of payment from Presbyterian any amount paid in excess of the inIn-network costCost-sharing Sharing amount. In accordance with the hearing procedures established pursuant to the Patient Protection Act [Chapter 59, Article 57 NMSA 1978], you may appeal Presbyterian’s determination made regarding a surprise bill. Services provided by an Out-of-network (outside of the 5-county area) Practitioner/Provider, except for urgent or Emergency services, require that your Primary Care Physician PCP request and obtain written approval (Authorization) from our Medical Director BEFORE services are rendered. Otherwise, you may be responsible for payment. Please refer to the Prior Authorization Section for more information on Prior Authorization requirements. If the services of an Out-of-network (outside of the 5-county area) Practitioner/Provider are required, your In-network Practitioner/Provider must request and obtain Prior Authorization from our Medical Director BEFORE services are performed, otherwise, we may not Cover the services and you may be responsible for payment. Before the Medical Director may deny a request for specialist services that are unavailable from an In-Network Practitioner/Provider, the request must be reviewed by a specialist similar to the type of specialist to whom the Prior Authorization is requested. In determining whether a Prior Authorization to an Out-of-network (outside of the 5-county area) Practitioner/Provider is reasonable, we will consider the following circumstances: · Availability – The In-network Practitioner/Provider is not reasonably available to see you in a timely fashion as dictated by the clinical situation. · Competency – The In-network Practitioner/Provider does not have the necessary training or expertise required to render the service or treatment. · Geography – The In-network Practitioner/Provider is not located within a reasonable distance from your residence. A “reasonable distance” is defined as travel Where the distance to the service is no more than 60 miles. · Continuity – If the requested Out-of-network Practitioner/Provider has a well-established professional relationship with you and is providing ongoing treatment of a specific medical problem, you will be allowed to continue seeing that specialist for a minimum of 30 days as needed to ensure continuity of care. · Any Prior Authorization requested simply for your convenience will not be considered to be reasonable. Services of an Out-of-network Practitioner/Provider will not be Covered unless this Prior Authorization is obtained prior to receiving the services. You may be liable for the charges resulting from failure to obtain Prior Authorization for services provided by the Out-of- network Practitioner/Provider. Out-of-network Practitioners/Providers may require you to pay them in full at the time of service. You may have to pay them and then file your claim for reimbursement with us. We will only pay this claim if the service provided was Authorized by us or was due to an Urgent or Emergency Healthcare situation.

NMAC. Current patients are covered persons who have a claim with Presbyterian Health Plan (PHP) PHP)/PIC related to the provider's services within the past year, or who have received a pre-authorization prior to termination to use the provider's services at a future time. PHP PHP/PIC will assist such affected covered persons in locating and transferring to another similarly qualified provider. A covered person may not be held financially liable for services received from the provider in good faith between the effective date of the suspension or termination and the receipt of notice provided to the covered person, if the covered person has not received comparable notice during this time from the provider. We do not require our In-network Practitioners/Providers to comply with any specified numbers, targeted averages, or maximum duration of patient visits. Presbyterian does not discriminate against any health care provider who is acting within the scope of their license or certification under applicable State law. Out-of-network (outside of the 5-county area) Network Practitioners/Providers Out-of-network (outside of the 5-county area) Practitioners/Providers are healthcare Practitioners/Providers, including non-non- medical facilities, who have not entered into an agreement with us to provide Healthcare Services to PHP Members on this planMembers. Covered Healthcare Services obtained from an Out-of-network (outside of the 5-county area) Practitioner/Provider or outside the Service Area will not be Covered unless such services are not reasonably available from an In-network Practitioner/Provider or in cases of urgent or an emergency. You will not pay higher or additional Cost Cost-Sharing amounts under such circumstances. These provisions also apply to Telehealth services. If you pay a non-participating Provider more than the inIn-network cost-sharing Cost Sharing amount for services provided under circumstances giving rise to a surprise bill, the non-participating Provider provider must refund to you within 45 days of receipt of payment from Presbyterian any amount paid in excess of the inIn-network cost-sharing Cost Sharing amount. In accordance with the hearing procedures established pursuant to of the Patient Protection Act [Chapter 59, Article 57 NMSA 1978], you may appeal Presbyterian’s determination made regarding a surprise bill. Services provided by an Out-of-network (outside of the 5-county area) Practitioner/Provider, except for urgent or Emergency services, require that your Primary Care Physician PCP request and obtain written approval (Authorization) from our Medical Director BEFORE services are rendered. Otherwise, you may be responsible for payment. Please refer to the Prior Authorization Section for more information on Prior Authorization requirements. If the services of an Out-of-network (outside of the 5-county area) Practitioner/Provider are required, your In-network Practitioner/Provider must request and obtain Prior Authorization from our Medical Director BEFORE services are performed, otherwise, we may not Cover the services and you may be responsible for payment. Before the Medical Director may deny a request for specialist services that are unavailable from an In-Network Practitioner/Provider, the request must be reviewed by a specialist similar to the type of specialist to whom the Prior Authorization is requested. In determining whether a Prior Authorization to an Out-of-network (outside of the 5-county area) Practitioner/Provider is reasonable, we will consider the following circumstances: • Availability – The In-network Practitioner/Provider is not reasonably available to see you in a timely fashion as dictated by the clinical situation. • Competency – The In-network Practitioner/Provider does not have the necessary training or expertise required to render the service or treatment.

NMAC. Current patients are covered persons who have a claim with Presbyterian Health Plan (PHP) related to the provider's services within the past year, or who have received a pre-authorization prior to termination to use the provider's services at a future time. PHP will assist such affected covered persons in locating and transferring to another similarly qualified provider. A covered person may not be held financially liable for services received from the provider in good faith between the effective date of the suspension or termination and the receipt of notice provided to the covered person, if the covered person has not received comparable notice during this time from the provider. We do not require our In-network Practitioners/Providers to comply with any specified numbers, targeted averages, or maximum duration of patient visits. Presbyterian does not discriminate against any health care provider who is acting within the scope of their license or certification under applicable State law. Out-of-network (outside of the 5-county area) Practitioners/Providers Out-of-network (outside of the 5-county area) Practitioners/Providers are healthcare Practitioners/Providers, including non-non- medical facilities, who have not entered into an agreement with us to provide Healthcare Services to PHP Members on this planMembers. Covered Healthcare Services obtained from an Out-of-network (outside of the 5-county area) Practitioner/Provider or outside the Service Area will not be Covered unless such services are not reasonably available from an In-network Practitioner/Provider or in cases of urgent or an emergency. You will not pay higher or additional Cost Cost-Sharing amounts under such circumstances. These provisions also apply to Telehealth services. If you pay a non-participating Provider more than the inIn-network cost-sharing Cost Sharing amount for services provided under circumstances giving rise to a surprise bill, the non-participating Provider must refund to you within 45 days of receipt of payment from Presbyterian any amount paid in excess of the inIn-network cost-sharing Cost Sharing amount. In accordance with the hearing procedures established pursuant to the Patient Protection Act [Chapter 59, Article 57 NMSA 1978], you may appeal Presbyterian’s determination made regarding a surprise bill. Services provided by an Out-of-network (outside of the 5-county area) Practitioner/Provider, except for urgent or Emergency services, require that your Primary Care Physician PCP request and obtain written approval (Authorization) from our Medical Director BEFORE services are rendered. Otherwise, you may be responsible for payment. Please refer to the Prior Authorization Section for more information on Prior Authorization requirements. If the services of an Out-of-network (outside of the 5-county area) Practitioner/Provider are required, your In-network Practitioner/Provider must request and obtain Prior Authorization from our Medical Director BEFORE services are performed, otherwise, we may not Cover the services and you may be responsible for payment. Before the Medical Director may deny a request for specialist services that are unavailable from an In-Network Practitioner/Provider, the request must be reviewed by a specialist similar to the type of specialist to whom the Prior Authorization is requested. In determining whether a Prior Authorization to an Out-of-network (outside of the 5-county area) Practitioner/Provider is reasonable, we will consider the following circumstances: Availability – The In-network Practitioner/Provider is not reasonably available to see you in a timely fashion as dictated by the clinical situation.

NMAC. Current patients are covered persons who have a claim with Presbyterian Health Plan (PHP) PHP)/PIC related to the provider's services within the past year, or who have received a pre-authorization prior to termination to use the provider's services at a future time. PHP PHP/PIC will assist such affected covered persons in locating and transferring to another similarly qualified provider. A covered person may not be held financially liable for services received from the provider in good faith between the effective date of the suspension or termination and the receipt of notice provided to the covered person, if the covered person has not received comparable notice during this time from the provider. We do not require our In-network Practitioners/Providers to comply with any specified numbers, targeted averages, or maximum duration of patient visits. Presbyterian does not discriminate against any health care provider who is acting within the scope of their license or certification under applicable State law. Out-of-network (outside of the 5-county area) Network Practitioners/Providers Out-of-network (outside of the 5-county area) Practitioners/Providers are healthcare Practitioners/Providers, including non-non- medical facilities, who have not entered into an agreement with us to provide Healthcare Services to PHP Members on this planMembers. Covered Healthcare Services obtained from an Out-of-network (outside of the 5-county area) Practitioner/Provider or outside the Service Area will not be Covered unless such services are not reasonably available from an In-network Practitioner/Provider or in cases of urgent or an emergency. You will not pay higher or additional Cost Cost-Sharing amounts under such circumstances. These provisions also apply to Telehealth services. If you pay a non-participating Provider more than the inIn-network cost-sharing Cost Sharing amount for services provided under circumstances giving rise to a surprise bill, the non-participating Provider provider must refund to you within 45 calendar days of or receipt of payment from Presbyterian any amount paid in excess of the inIn-network cost-sharing Cost Sharing amount. In accordance with the hearing procedures established pursuant to the Patient Protection Act [Chapter 5959A, Article 57 NMSA 1978XXXX 0000], you may appeal Presbyterian’s determination made regarding a surprise bill. Services provided by an Out-of-network (outside of the 5-county area) Practitioner/Provider, except for urgent or Emergency services, require that your Primary Care Physician PCP request and obtain written approval (Authorization) from our Medical Director BEFORE services are rendered. Otherwise, you may be responsible for payment. Please refer to the Prior Authorization Section for more information on Prior Authorization requirements. If the services of an Out-of-network (outside of the 5-county area) Practitioner/Provider are required, your In-network Practitioner/Provider must request and obtain Prior Authorization from our Medical Director BEFORE services are performed, otherwise, we may not Cover the services and you may be responsible for payment. Before the Medical Director may deny a request for specialist services that are unavailable from an In-Network Practitioner/Provider, the request must be reviewed by a specialist similar to the type of specialist to whom the Prior Authorization is requested. In determining whether a Prior Authorization to an Out-of-network (outside of the 5-county area) Practitioner/Provider is reasonable, we will consider the following circumstances: · Availability – The In-network Practitioner/Provider is not reasonably available to see you in a timely fashion as dictated by the clinical situation. · Competency – The In-network Practitioner/Provider does not have the necessary training or expertise required to render the service or treatment. · Geography – The In-network Practitioner/Provider is not located within a reasonable distance from your residence. A “reasonable distance” is defined as travel where the distance to the service is no more than 60 miles. · Continuity – If the requested Out-of-network Practitioner/Provider has a well-established professional relationship with you and is providing ongoing treatment of a specific medical problem, you will be allowed to continue seeing that specialist for a minimum of 30 days as needed to ensure continuity of care. · Any Prior Authorization requested simply for your convenience will not be considered to be reasonable. Services of an Out-of-network Practitioner/Provider will not be Covered unless this Prior Authorization is obtained prior to receiving the services. You may be liable for the charges resulting from failure to obtain Prior Authorization for services provided by the Out-of- network Practitioner/Provider. Out-of-network Practitioners/Providers may require you to pay them in full at the time of service. You may have to pay them and then file your claim for reimbursement with us. We will only pay this claim if the service provided was Authorized by us or was due to an Urgent or Emergency Healthcare situation.

NMAC. Current patients are covered persons who have a claim with Presbyterian Health Plan (PHP) related to the provider's services within the past year, or who have received a pre-authorization prior to termination to use the provider's services at a future time. PHP will assist such affected covered persons in locating and transferring to another similarly qualified provider. A covered person may not be held financially liable for services received from the provider in good faith between the effective date of the suspension or termination and the receipt of notice provided to the covered person, if the covered person has not received comparable notice during this time from the provider. We do not require our In-network Practitioners/Providers to comply with any specified numbers, targeted averages, or maximum duration of patient visits. Presbyterian does not discriminate against any health care provider who is acting within the scope of their license or certification under applicable State law. Out-of-network (outside of the 5-county area) Network Practitioners/Providers Out-of-network (outside of the 5-county area) Practitioners/Providers are healthcare Practitioners/Providers, including non-non- medical facilities, who have not entered into an agreement with us to provide Healthcare Services to PHP Members on this planMembers. Covered Healthcare Services obtained from an Out-of-network (outside of the 5-county area) Practitioner/Provider or outside the Service Area will not be Covered unless such services are not reasonably available from an In-network Practitioner/Provider or in cases of urgent or an emergency. You will not pay higher or additional Cost Sharing amounts under such circumstances. These provisions also apply to Telehealth services. If you pay a non-participating Provider more than the inIn-network cost-sharing Cost Sharing amount for services provided under circumstances giving rise to a surprise bill, the non-participating Provider provider must refund to you within 45 days of receipt of payment from Presbyterian any amount paid in excess of the inIn-network costCost-sharing Sharing amount. In accordance with the hearing procedures established pursuant to the Patient Protection Act [Chapter 59, Article 57 NMSA 1978], you may appeal Presbyterian’s determination made regarding a surprise bill. Services provided by an Out-of-network (outside of the 5-county area) Practitioner/Provider, except for urgent or Emergency services, require that your Primary Care Physician PCP request and obtain written approval (Authorization) from our Medical Director BEFORE services are rendered. Otherwise, you may be responsible for payment. Please refer to the Prior Authorization Section for more information on Prior Authorization requirements. If the services of an Out-of-network (outside of the 5-county area) Practitioner/Provider are required, your In-network Practitioner/Provider must request and obtain Prior Authorization from our Medical Director BEFORE services are performed, otherwise, we may not Cover the services and you may be responsible for payment. Before the Medical Director may deny a request for specialist services that are unavailable from an In-Network Practitioner/Provider, the request must be reviewed by a specialist similar to the type of specialist to whom the Prior Authorization is requested. In determining whether a Prior Authorization to an Out-of-network (outside of the 5-county area) Practitioner/Provider is reasonable, we will consider the following circumstances:  Availability – The In-network Practitioner/Provider is not reasonably available to see you in a timely fashion as dictated by the clinical situation.  Competency – The In-network Practitioner/Provider does not have the necessary training or expertise required to render the service or treatment.  Geography – The In-network Practitioner/Provider is not located within a reasonable distance from your residence.  Continuity – If the requested Out-of-network Practitioner/Provider has a well-established professional relationship with you and is providing ongoing treatment of a specific medical problem, you will be allowed to continue seeing that specialist for a minimum of 30 days as needed to ensure continuity of care.  Any Prior Authorization requested simply for your convenience will not be considered to be reasonable. Services of an Out-of-network Practitioner/Provider will not be Covered unless this Prior Authorization is obtained prior to receiving the services. You may be liable for the charges resulting from failure to obtain Prior Authorization for services provided by the Out-of- network Practitioner/Provider. Out-of-network Practitioners/Providers may require you to pay them in full at the time of service. You may have to pay them and then file your claim for reimbursement with us. We will only pay this claim if the service provided was Authorized by us or was due to an Urgent or Emergency Healthcare situation.

NMAC. Current patients are covered persons who have a claim with Presbyterian Health Plan (PHP) PHP)/PIC related to the provider's services within the past year, or who have received a pre-authorization prior to termination to use the provider's services at a future time. PHP will assist such affected covered persons in locating and transferring to another similarly qualified provider. A covered person may not be held financially liable for services received from the provider in good faith between the effective date of the suspension or termination and the receipt of notice provided to the covered person, if the covered person has not received comparable notice during this time from the provider. We do not require our In-network Practitioners/Providers to comply with any specified numbers, targeted averages, or maximum duration of patient visits. Presbyterian does not discriminate against any health care provider who is acting within the scope of their license or certification under applicable State law. Out-of-network (outside of the 5-county area) Practitioners/Providers Out-of-network (outside of the 5-county area) Practitioners/Providers are healthcare Practitioners/Providers, including non-medical facilities, who have not entered into an agreement with us to provide Healthcare Services to PHP Members on this plan. Covered Healthcare Services obtained from an Out-of-network (outside of the 5-county area) Practitioner/Provider or outside the Service Area will not be Covered unless such services are not reasonably available from an In-network Practitioner/Provider or in cases of urgent or an emergency. You will not pay higher or additional Cost Sharing amounts under such circumstances. These provisions also apply to Telehealth services. If you pay a non-participating Provider more than the in-network cost-sharing amount for services provided under circumstances giving rise to a surprise bill, the non-participating Provider must refund to you within 45 days of receipt of payment from Presbyterian any amount paid in excess of the in-network cost-sharing amount. In accordance with the hearing procedures established pursuant to the Patient Protection Act [Chapter 59, Article 57 NMSA 1978], you may appeal Presbyterian’s determination made regarding a surprise bill. Services provided by an Out-of-network (outside of the 5-county area) Practitioner/Provider, except for urgent or Emergency services, require that your Primary Care Physician request and obtain written approval (Authorization) from our Medical Director BEFORE services are rendered. Otherwise, you may be responsible for payment. Please refer to the Prior Authorization Section for more information on Prior Authorization requirements. If the services of an Out-of-network (outside of the 5-county area) Practitioner/Provider are required, your In-network Practitioner/Provider must request and obtain Prior Authorization from our Medical Director BEFORE services are performed, otherwise, we may not Cover the services and you may be responsible for payment. Before the Medical Director may deny a request for specialist services that are unavailable from an In-Network Practitioner/Provider, the request must be reviewed by a specialist similar to the type of specialist to whom the Prior Authorization is requested. In determining whether a Prior Authorization to an Out-of-network (outside of the 5-county area) Practitioner/Provider is reasonable, we will consider the following circumstances: · Availability – The In-network Practitioner/Provider is not reasonably available to see you in a timely fashion as dictated by the clinical situation. · Competency – The In-network Practitioner/Provider does not have the necessary training or expertise required to render the service or treatment. · Geography – The In-network Practitioner/Provider is not located within a reasonable distance from your residence. A “reasonable distance” is defined as travel where the distance to the service is no more than 60 miles. · Continuity – If the requested Out-of-network (outside of the 5-county area) Practitioner/Provider has a well-established professional relationship with you and is providing ongoing treatment of a specific medical problem, you will be allowed to continue seeing that specialist for a minimum of 30 days as needed to ensure continuity of care. · Any Prior Authorization requested simply for your convenience will not be considered to be reasonable. Services of an Out-of-network (outside of the 5-county area) Practitioner/Provider will not be Covered unless in an urgent or emergent situation as defined by your benefits. this Prior Authorization is obtained prior to receiving the services. You may be liable for the charges resulting from failure to obtain Prior Authorization for services provided by the Out-of- network (outside of the 5-county area) Practitioner/Provider. Out-of-network (outside of the 5-county area) Practitioners/Providers may require you to pay them in full at the time of service. You may have to pay them and then file your claim for reimbursement with us. We will only pay this claim if the service provided was Authorized by us or was due to an Urgent or Emergency Healthcare situation.

NMAC. Current patients are covered persons who have a claim with Presbyterian Health Plan (PHP) /PIC related to the provider's services within the past year, or who have received a pre-authorization prior to termination to use the provider's services at a future time. PHP PHP/PIC will assist such affected covered persons in locating and transferring to another similarly qualified provider. A covered person may not be held financially liable for services received from the provider in good faith between the effective date of the suspension or termination and the receipt of notice provided to the covered person, if the covered person has not received comparable notice during this time from the provider. We do not require our In-network Practitioners/Providers to comply with any specified numbers, targeted averages, or maximum duration of patient visits. Presbyterian does not discriminate against any health care provider who is acting within the scope of their license or certification under applicable State law. Out-of-network (outside of the 5-county area) Practitioners/Providers Out-of-network (outside of the 5-county area) Practitioners/Providers are healthcare health care Practitioners/Providers, including non-medical facilities, who have not entered into an agreement with us to provide Healthcare Health Care Services to PHP Members on this planMembers. Covered Healthcare Health Care Services obtained from an Out-of-network (outside of the 5-county area) Practitioner/Provider or outside the Service Area will not be Covered unless such services are not reasonably available from an In-network Practitioner/Provider or in cases of urgent or an emergency. You will not pay higher or additional Cost Sharing amounts under such circumstances. These provisions also apply to Telehealth services. If you pay a non-participating Provider provider more than the in-network cost-sharing amount for services provided under circumstances giving rise to a surprise bill, the non-participating Provider provider must refund to you within 45 calendar days of receipt of payment from Presbyterian any amount paid in excess of the in-network cost-sharing amount. In accordance with the hearing procedures established pursuant to the Patient Protection Act [Chapter 59, Article 57 NMSA 1978XXXX 0000], you may appeal Presbyterian’s determination made regarding a surprise bill. Services provided by an Out-of-network (outside of the 5-county area) Practitioner/Provider, except for urgent or Emergency services, require that your Primary Care Physician request and obtain written approval (Authorization) from our Medical Director BEFORE services are rendered. Otherwise, you may be responsible for payment. Please refer to the Prior Authorization Section for more information on Prior Authorization requirements. If the services of an Out-of-network (outside of the 5-county area) Practitioner/Provider are required, your In-network Practitioner/Provider must request and obtain Prior Authorization from our Medical Director BEFORE services are performed, otherwise, we may not Cover the services and you may be responsible for payment. Before the Medical Director may deny a request for specialist services that are unavailable from an In-Network Practitioner/Provider, the request must be reviewed by a specialist similar to the type of specialist to whom the Prior Authorization is requested. In determining whether a Prior Authorization to an Out-of-network (outside of the 5-county area) Practitioner/Provider is reasonable, we will consider the following circumstances: • Availability – The In-network Practitioner/Provider is not reasonably available to see you in a timely fashion as dictated by the clinical situation. • Competency – The In-network Practitioner/Provider does not have the necessary training or expertise required to render the service or treatment.

NMAC. Current patients are covered persons who have a claim with Presbyterian Health Plan (PHP) /PIC related to the provider's services within the past year, or who have received a pre-authorization prior to termination to use the provider's services at a future time. PHP PHP/PIC will assist such affected covered persons in locating and transferring to another similarly qualified provider. A covered person may not be held financially liable for services received from the provider in good faith between the effective date of the suspension or termination and the receipt of notice provided to the covered person, if the covered person has not received comparable notice during this time from the provider. We do not require our In-network Practitioners/Providers to comply with any specified numbers, targeted averages, or maximum duration of patient visits. Presbyterian does not discriminate against any health care provider who is acting within the scope of their license or certification under applicable State law. Out-of-network (outside of the 5-county area) Practitioners/Providers Out-of-network (outside of the 5-county area) Practitioners/Providers are healthcare health care Practitioners/Providers, including non-medical facilities, who have not entered into an agreement with us to provide Healthcare Health Care Services to PHP Members on this planMembers. Covered Healthcare Health Care Services obtained from an Out-of-network (outside of the 5-county area) Practitioner/Provider or outside the Service Area will not be Covered unless such services are not reasonably available from an In-network Practitioner/Provider or in cases of urgent or an emergency. You will not pay higher or additional Cost Sharing amounts under such circumstances. These provisions also apply to Telehealth services. If you pay a non-participating Provider more than the inIn-network cost-sharing amount for services provided under circumstances giving rise to a surprise bill, the non-participating Provider must refund to you within 45 calendar days of receipt of payment from Presbyterian any amount paid in excess of the inIn-network cost-sharing amount. In accordance with the hearing procedures established pursuant to the Patient Protection Act [Chapter 59, Article 57 NMSA 1978], you may appeal Presbyterian’s determination made regarding a surprise bill. Services provided by an Out-of-network (outside of the 5-county area) Practitioner/Provider, except for urgent or Emergency services, require that your Primary Care Physician PCP request and obtain written approval (Authorization) from our Medical Director BEFORE services are rendered. Otherwise, you may be responsible for payment. Please refer to the Prior Authorization Section for more information on Prior Authorization requirements. If the services of an Out-of-network (outside of the 5-county area) Practitioner/Provider are required, your In-network Practitioner/Provider must request and obtain Prior Authorization from our Medical Director BEFORE services are performed, otherwise, we may not Cover the services and you may be responsible for payment. Before the Medical Director may deny a request for specialist services that are unavailable from an In-Network Practitioner/Provider, the request must be reviewed by a specialist similar to the type of specialist to whom the Prior Authorization is requested. In determining whether a Prior Authorization to an Out-of-network (outside of the 5-county area) Practitioner/Provider is reasonable, we will consider the following circumstances: • Availability – The In-network Practitioner/Provider is not reasonably available to see you in a timely fashion as dictated by the clinical situation.. • Competency – The In-network Practitioner/Provider does not have the necessary training or expertise required to render the service or treatment.‌‌