Common use of Referrals and Access to Specialty Providers Clause in Contracts

Referrals and Access to Specialty Providers. (A) The Contractor shall ensure that there is access to appropriate specialty providers to provide Medically Necessary Covered Services for Adults and Children With Special Health Care Needs. If the Contractor does not employ or contract with a specialty provider to treat a special health care condition at the time the Enrollee needs such Covered Services, the Contractor shall have a process to allow the Enrollee to receive Covered Services from a qualified specialist who may not be affiliated with the Contractor. In such instances the Contractor shall be responsible for payment, even if the Provider is a Non-Network Provider. The process for requesting specialist care shall be clearly described by the Contractor in the Contractor’s Member Handbook, and explained to each Enrollee during the initial contact with the Enrollee.

Referrals and Access to Specialty Providers. (A) The Contractor shall ensure that there is access to appropriate specialty providers to provide Medically Necessary Covered Services for Adults and Children With Special Health Care Needs. If the Contractor does not employ or contract with a specialty provider to treat a special health care condition at the time the Enrollee needs such Covered Services, the Contractor shall have a process to allow the Enrollee to receive Covered Services from a qualified specialist who may not be affiliated with the Contractor. In such instances the Contractor shall be responsible for payment, even if the Specialty Provider is a Non-Network Provider. The process for requesting specialist care shall be clearly described by the Contractor in the Contractor’s Member Dental Plans Enrollee Handbook, and explained to each Enrollee during the initial contact with the Enrollee.

Referrals and Access to Specialty Providers. (A) The Contractor shall ensure that there is access to appropriate specialty providers to provide Medically Necessary Covered Services for Adults and Children With Enrollees with Special Health Care Needs. If the Contractor does not employ or contract with a specialty provider to treat a special health care condition at the time the Enrollee needs such Covered Services, the Contractor shall have a process to allow the Enrollee to receive Covered Services from a qualified specialist who may not be affiliated with the Contractor. In such instances the Contractor shall be responsible for payment, even if the Provider is a Non-Network Provider. The process for requesting specialist care shall be clearly described by the Contractor in the Contractor’s Member Handbookhandbook, and explained to each Enrollee during the initial contact with the Enrollee.

Referrals and Access to Specialty Providers. (A) The Contractor shall ensure that there is access to appropriate specialty providers Providers to provide Medically Necessary Covered Services for Adults and Children With Enrollees with Special Health Care Needs. If the Contractor does not employ or contract with a specialty provider Provider to treat a special health care condition at the time the Enrollee needs such Covered Services, the Contractor shall have a process to allow the Enrollee to receive Medically Necessary Covered Services from a qualified specialist who may not be affiliated with the Contractor. In such instances the Contractor shall be responsible for payment, even if the Provider is a Non-Network Provider. The process for requesting specialist care shall be clearly described by the Contractor in the Contractor’s Member Handbookhandbook, and explained to each Enrollee during the initial contact with the Enrollee.

Referrals and Access to Specialty Providers. (A) The Contractor shall ensure that there is access to appropriate specialty providers to provide Medically Necessary Covered Services for Adults and Children With Special Health Care Needs. If the Contractor does not employ or contract with a specialty provider to treat a special health care condition at the time the Enrollee needs such Covered Services, the Contractor shall have a process to allow the Enrollee to receive Covered Services from a qualified specialist who may not be affiliated with the Contractor. In such instances the Contractor shall be responsible for payment, even if the Provider is a Non-Network Participating Provider. The process for requesting specialist care shall be clearly described by the Contractor in the Contractor’s Member Handbook, and explained to each Enrollee during the initial contact with the Enrollee.

Referrals and Access to Specialty Providers. (A) The Contractor shall ensure that there is access to appropriate specialty providers to provide Medically Necessary Covered Services for Adults and Children With with Special Health Care Needs. If the Contractor does not employ or contract with a specialty provider to treat a special health care condition at the time the Enrollee needs such Covered Services, the Contractor shall have a process to allow the Enrollee to receive Covered Services from a qualified specialist who may not be affiliated with the Contractor. In such instances instances, the Contractor shall be responsible for payment, even if the Provider is a Non-Network Participating Provider. The process for requesting specialist care shall be clearly described by the Contractor in the Contractor’s Member HandbookEnrollee handbook, and explained to each Enrollee during the initial contact with the Enrollee.

Referrals and Access to Specialty Providers. (A) The Contractor shall ensure that there is access to appropriate specialty providers to provide Medically Necessary Covered Services for Adults and Children With Special Health Care Needs. If the Contractor does not employ or contract with a specialty provider to treat a special health care condition at the time the Enrollee needs such Covered Services, the Contractor shall have a process to allow the Enrollee to receive Covered Services from a qualified specialist who may not be affiliated with the Contractor. In such instances the Contractor shall be responsible for payment, even if the Provider is a Non-Network Participating Provider. The process for requesting specialist care shall be clearly described by the Contractor in the Contractor’s Member HandbookEnrollee handbook, and explained to each Enrollee during the initial contact with the Enrollee.

Referrals and Access to Specialty Providers. (A) The Contractor shall ensure that there is access to appropriate specialty providers to provide Medically Necessary Covered Services for Adults and Children With Special Health Care Needs. If the Contractor does not employ or contract with a specialty provider to treat a special health care condition at the time the Enrollee needs such Covered Services, the Contractor shall have a process to allow the Enrollee to receive Covered Services from a qualified specialist who may not be affiliated with the Contractor. In such instances the Contractor shall be responsible for payment, even if the Provider is a Non-Network Participating Provider. The process for requesting specialist care shall be clearly described by the Contractor in the Contractor’s Member Handbook, and explained to each Enrollee during the initial contact with the Enrollee.