Common use of Out-of-Plan Use of Non-Emergency Services Clause in Contracts

Out-of-Plan Use of Non-Emergency Services. Unless otherwise specified in this Contract, where an Enrollee utilizes services available under the Health Plan other than emergency services from a non-contract provider, the Health Plan shall not be liable for the cost of such utilization unless the Health Plan referred the Enrollee to the non-contract provider or authorized such out-of-plan utilization. The Health Plan shall provide timely approval or denial of authorization of out-of-plan use through the assignment of a prior authorization number, which refers to and documents the approval. A Health Plan may not require paper authorization as a condition of receiving treatment if the plan has an automated authorization system. Written follow up documentation of the approval must be provided to the out-of-plan provider within one (1) Business Day from the request for approval. The Enrollee shall be liable for the cost of such unauthorized use of contract-covered services from non-contract providers. In accordance with section 409.912, F.S., the Health Plan shall reimburse any hospital or physician that is outside the Health Plan’s authorized geographic service area for Health Plan authorized services provided by the hospital or physician to plan members at a rate negotiated with the hospital or physician for the provision of services or according to the lesser of the following: a. The usual and customary charge made to the general public by the hospital or physician; or b. The Florida Medicaid reimbursement rate established for the hospital or physician. The plan shall reimburse all out-of-plan providers pursuant to section 641.3155, F.S.

Out-of-Plan Use of Non-Emergency Services. a. Unless otherwise specified in this Contract, where an Enrollee utilizes services available under the Health Plan other than emergency services Emergency Services from a non-contract participating provider, the Health Plan shall not be liable for the cost of such utilization unless the Health Plan referred the Enrollee to the non-contract participating provider or authorized such out-of-plan network utilization. The Health Plan shall provide timely approval or denial of authorization of out-of-plan network use through the assignment of a prior authorization number, which refers to and documents the approval. A The Health Plan may not require paper authorization as a condition of receiving treatment if the plan Health Plan has an automated authorization system. Written follow up documentation of the approval must be provided to the out-of-plan network provider within one (1) Business Day from the request for approval. The Enrollee shall be liable for the cost of such unauthorized use of contract-covered services Covered Services from non-contract participating providers. . b. In accordance with section Section 409.912, F.S., the Health Plan shall reimburse any hospital or physician that is outside the Health Plan’s authorized geographic service area Service Area for Health Plan authorized services provided by the hospital or physician to plan members Enrollees at a rate negotiated with the hospital or physician for the provision of services or according to the lesser of the following: a. (1) The usual and customary charge made to the general public by the hospital or physician; or b. (2) The Florida Medicaid reimbursement rate established for the hospital or physician. . c. The plan Health Plan shall reimburse all out-of-plan network providers pursuant to section Section 641.3155, F.S.