Common use of Non-Participating Providers Clause in Contracts

Non-Participating Providers. Participating Provider acknowledges and agrees that a Member may not receive the maximum benefits under his/her Health Benefits Plan if he/she is referred or admitted to a non-Participating Provider. When a Referral is required: 5.13.1 Participating Provider shall refer Member to other Participating Providers unless such Participating Provider determines it would be medically inappropriate to do so or in the event the required medical services are not available through other Participating Providers. In the event Participating Provider engages in a pattern of referring Members to out-of-network or non-participating Providers, QualCare may terminate this Agreement in accordance with Article 10. 5.13.2 Participating Provider shall admit Member requiring Hospital Services to Participating Hospitals unless the necessary Hospital Services are not available at a Participating Hospital or in the case of an Emergency. Participating Provider shall obtain an appropriate Authorization prior to admitting any Member to a hospital, except in the case of an Emergency. In cases where an Emergency admission is required, Participating Provider shall notify QualCare or its designee of such Emergency admission within forty-eight (48) hours of such Emergency admission or the next business day, whichever is later.

Non-Participating Providers. Participating Provider acknowledges and agrees that a Member may not receive the maximum benefits under his/her Health Benefits Plan if he/she is referred or admitted to a non-Participating Provider. When a Referral is required: 5.13.1 Participating Provider shall refer Member to other Participating Providers unless such Participating Provider determines it would be medically inappropriate to do so or in the event the required medical services are not available through other Participating Providers. In the event Participating Provider engages in a pattern of referring Members to out-of-network or non-non- participating Providers, QualCare may terminate this Agreement in accordance with Article 10. 5.13.2 Participating Provider shall admit Member requiring Hospital Services to Participating Hospitals unless the necessary Hospital Services are not available at a Participating Hospital or in the case of an Emergency. Participating Provider shall obtain an appropriate Authorization prior to admitting any Member to a hospital, except in the case of an Emergency. In cases where an Emergency admission is required, Participating Provider shall notify QualCare or its designee of such Emergency admission within forty-eight (48) hours of such Emergency admission or the next business day, whichever is later.