Out-of-Network Service Denial Sample Clauses

Out-of-Network Service Denial. You also have the right to Appeal the denial of a Preauthorization request for an out-of-network health service when We determine that the out-of- network health service is not materially different from an available in-network health service. A denial of an out-of-network health service is a service provided by a Non-Participating Provider, but only when the service is not available from a Participating Provider. For a Utilization Review Appeal of denial of an out-of-network health service, You, or Your designee, must submit: • A written statement from Your attending Physician, who must be a licensed, board- certified or board-eligible Physician qualified to practice in the specialty area of practice appropriate to treat Your condition, that the requested out-of-network health service is materially different from the alternate health service available from a Participating Provider that We approved to treat Your condition; and • Two (2) documents from the available medical and scientific evidence that the out-of- network service: 1) is likely to be more clinically beneficial to You than the alternate in- network service; and 2) that the adverse risk of the out-of-network service would likely not be substantially increased over the in-network health service.