Common use of Outpatient Procedure or Covered Service Clause in Contracts

Outpatient Procedure or Covered Service. Precertification a. Network Services The Network Provider is responsible for the Precertification of such procedure or Covered Service. The Member will not be financially responsible whenever certification for such procedure or Covered Service is not obtained by the Network Provider. If the procedure or Covered Service is deemed not to be Medically Necessary and Appropriate, the Member will not be financially responsible, except when the Plan provides prior written notice to the Member that charges for the procedure or Covered Service will not be covered. In such case, the Member will be financially responsible for such procedure or Covered Service. b. Out-of-Area and Out-of-Network Services An Out-of-Area or Out-of-Network Provider is not responsible for the Precertification of any procedure or Covered Service. Whenever a Member utilizes an Out-of-Area or Out-of-Network Provider, the Member should contact the Plan prior to the receipt of a procedure or Covered Service to confirm the Medical Necessity and Appropriateness. However, the Plan may also review certain procedures or Covered Services after they are received to determine Medical Necessity and Appropriateness. If the procedure or Covered Service is determined to be Medically Necessary and Appropriate, benefits will be paid in accordance with this Agreement. The Member will be financially responsible for the difference between what is covered by the Agreement and the full amount of the Out-of-Area or Out-of-Network Provider’s charge. If the procedure or Covered Service is determined not to be Medically Necessary and Appropriate, no benefits will be provided. The Member will be financially responsible for the full amount of the Out-of-Area or Out-of-Network Provider’s charge.