Common use of Seeking Prior Approval Clause in Contracts

Seeking Prior Approval. If you use a Network Provider, he or she is responsible for obtaining Prior Approval for you. If your Network Provider fails to acquire Prior Approval for you, you will not be financially responsible for this failure. If you use a Non-Network Provider or your services are ordered by a Non-Network Provider, you (or your Designee) are responsible for ensuring Prior Approval is obtained for any services requiring Prior Approval. To seek Prior Approval, please have your Provider contact Health Options at 1-855-624-6463 (TTY/TDD: 711). Requests for Prior Approval require review of clinical information from your Provider. Health Options will not accept Prior Approval requests from Members or non-Provider Designees. Failure to obtain Prior Approval for your Covered Services received from Non-Network Providers will result in a benefit reduction penalty of $500 for each type of Covered Service, per occurrence, if the services are determined by Health Options to be Medically Necessary. The benefit reduction penalty is not a covered, and will not be applied to your Deductible amount or the Maximum Out- of-Pocket. If you seek services from a Non-Network Provider and fail to obtain Prior Approval for a service needing Prior Approval, or you fail to provide notification as required, you may not receive Benefits for that service and you may be responsible for the full cost of the service. Approved Covered Services provided by Non-Network Providers apply towards your Out-of-Network cost-sharing as described in your Schedule of Benefits. Health Options pays Benefits up to the Maximum Allowable Amount. The Out-of-Network Provider may balance bill you for submitted charges that exceed the Maximum Allowable Amount. When there is an inadequate network, balance billing does not apply. Services for Medical Emergencies do not need Prior Approval. In the event of an admission due to a Medical Emergency, you (or your Designee) must contact Health Options within 48 hours after you are admitted or as soon as reasonably possible. Failure to notify Health Options will result in a benefit reduction penalty of $500 for each occurrence, if the services are determined by Health Options to be Medically Necessary. The benefit reduction penalty is not covered, and will not be applied to your Deductible amount or the Maximum Out-of-Pocket.

Seeking Prior Approval. If you use a Network Provider, he or she is responsible for obtaining Prior Approval for you. If your Network Provider fails to acquire Prior Approval for you, you will not be financially responsible for this failure. If you use a Non-Network Non‐Network Provider or your services are ordered by a Non-Network Non‐Network Provider, you (or your Designee) are responsible for ensuring Prior Approval is obtained for any services requiring Prior Approval. To seek Prior Approval, please have your Provider contact Community Health Options at 1-855-624-6463 (TTY/TDD: 711)Options. Requests for Prior Approval require review of clinical information from your Provider. Community Health Options will not accept Prior Approval requests from Members or non-Provider non‐Provider Designees. Failure to obtain Prior Approval or provide required notification for your Covered Services received from Non-Non‐ Network Providers will result in a benefit reduction penalty of $500 for each type of Covered Service, per occurrence, if the services are determined by Community Health Options to be Medically Necessary. The benefit reduction penalty is not a covered, covered and will not be applied to your Deductible amount or the Maximum Out- of-PocketOut‐of‐Pocket. If you seek services from a Non-Network Non‐Network Provider and fail to obtain Prior Approval for a service needing Prior Approval, or you fail to provide notification as required, you may not receive Benefits for that service and you may be responsible for the full cost of the service. Approved Covered Services provided by Non-Network Non‐Network Providers apply towards your Out-of-Network cost-Out‐of‐Network cost‐ sharing as described in your Schedule of Benefits. Community Health Options pays Benefits up to the Maximum Allowable Amount. The Out-of-Network Out‐of‐Network Provider may balance bill you for submitted charges that exceed the Maximum Allowable Amount. When there is an inadequate network, balance billing does not apply. Services Members are encouraged to check Community Health Options website for Medical Emergencies do not need a current list of Prior Approval/Notification requirements. In the event of an admission due to a Medical Emergency, you (or your Designee) Members must contact notify Community Health Options within 48 hours after you are admitted or as soon as reasonably possibleof any Out‐of‐Network services that may require Prior Approval/Notification by calling 855‐624‐6463, Monday – Friday 8am – 6pm. Failure Out‐of‐Network providers must submit authorization requirements to notify Community Health Options will result in a benefit reduction penalty as noted on Prior Approval/Notification form located on the provider section of $500 for each occurrence, if the services are determined by Community Health Options to be Medically Necessary. The benefit reduction penalty is not covered, and will not be applied to your Deductible amount or the Maximum Out-of-Pocketwebsite.

Seeking Prior Approval. If you use a Network Provider, he or she is responsible for obtaining Prior Approval for you. If your Network Provider fails to acquire Prior Approval for you, you will not be financially responsible for this failure. If you use a Non-Network Provider or your services are ordered by a Non-Network Provider, you (or your Designee) are responsible for ensuring Prior Approval is obtained for any services requiring Prior Approval. To seek Prior Approval, please have your Provider contact Health Options at 1-855-624-6463 (TTY/TDD: 711). Requests for Prior Approval require review of clinical information from your Provider. Health Options will not accept Prior Approval requests from Members or non-non- Provider Designees. Failure to obtain Prior Approval or provide required notification for your Covered Services received from Non-Network Providers will result in a benefit reduction penalty of $500 for each type of Covered Service, per occurrence, if the services are determined by Health Options to be Medically Necessary. The benefit reduction penalty is not a covered, and will not be applied to your Deductible amount or the Maximum Out- Out-of-Pocket. If you seek services from a Non-Network Provider and fail to obtain Prior Approval for a service needing Prior Approval, or you fail to provide notification as required, you may not receive Benefits for that service and you may be responsible for the full cost of the service. Approved Covered Services provided by Non-Network Providers apply towards your Out-of-Network cost-cost- sharing as described in your Schedule of Benefits. Health Options pays Benefits up to the Maximum Allowable Amount. The Out-of-Network Provider may balance bill you for submitted charges that exceed the Maximum Allowable Amount. When there is an inadequate network, balance billing does not apply. Services Members are encouraged to check Health Options website for Medical Emergencies do not need a current list of Prior Approval/Notification requirements. In the event of an admission due to a Medical Emergency, you (or your Designee) Members must contact Health Options within 48 hours after you are admitted or as soon as reasonably possible. Failure to notify Health Options will result in a benefit reduction penalty of $500 for each occurrence, if the services are determined by Health Options to be Medically Necessary. The benefit reduction penalty is not covered, and will not be applied to your Deductible amount or the Maximum any Out-of-PocketNetwork services that may require Prior Approval/Notification by calling 000-000-0000, Monday – Friday 8am – 6pm. Out-of-Network providers must submit authorization requirements to Health Options as noted on Prior Approval/Notification form located on the provider section of the Health Options website.

Seeking Prior Approval. If you use a Network Provider, he or she is responsible for obtaining Prior Approval for you. If your Network Provider fails to acquire Prior Approval for you, you will not be financially responsible for this failure. If you use a Non-Network Provider or your services are ordered by a Non-Network Provider, you (or your Designee) are responsible for ensuring Prior Approval is obtained for any services requiring Prior Approval. To seek Prior Approval, please have your Provider contact Health Options at 1-855-624-6463 (TTY/TDD: 711). Requests for Prior Approval require review of clinical information from your Provider. Health Options will not accept Prior Approval requests from Members or non-Provider Designees. Failure to obtain Prior Approval or provide required notification for your Covered Services received from Non-Network Providers will result in a benefit reduction penalty of $500 for each type of Covered Service, per occurrence, if the services are determined by Health Options to be Medically Necessary. The benefit reduction penalty is not a covered, and will not be applied to your Deductible amount or the Maximum Out- Out-of-Pocket. If you seek services from a Non-Network Provider and fail to obtain Prior Approval for a service needing Prior Approval, or you fail to provide notification as required, you may not receive Benefits for that service and you may be responsible for the full cost of the service. Approved Covered Services provided by Non-Non- Network Providers apply towards your Out-of-Network cost-sharing as described in your Schedule of Benefits. Health Options pays Benefits up to the Maximum Allowable Amount. The Out-of-Network Provider may balance bill you for submitted charges that exceed the Maximum Allowable Amount. When there is an inadequate network, balance billing does not apply. Services Members are encouraged to check Health Options website for Medical Emergencies do not need a current list of Prior Approval/Notification requirements. In the event of an admission due to a Medical Emergency, you (or your Designee) Members must contact Health Options within 48 hours after you are admitted or as soon as reasonably possible. Failure to notify Health Options will result in a benefit reduction penalty of $500 for each occurrence, if the services are determined by Health Options to be Medically Necessary. The benefit reduction penalty is not covered, and will not be applied to your Deductible amount or the Maximum any Out-of-PocketNetwork services that may require Prior Approval/Notification by calling 000-000-0000, Monday – Friday 8am – 6pm. Out-of-Network providers must submit authorization requirements to Health Options as noted on Prior Approval/Notification form located on the provider section of the Health Options website.

Seeking Prior Approval. If you use a Network Provider, he or she is responsible for obtaining Prior Approval for you. If your Network Provider fails to acquire Prior Approval for you, you will not be financially responsible for this failure. If you use a Non-Network Provider or your services are ordered by a Non-Network Provider, you (or your Designee) are responsible for ensuring Prior Approval is obtained for any services requiring Prior Approval. To seek Prior Approval, please have your Provider contact Health Options at 1-855-624-6463 (TTY/TDD: 711). Requests for Prior Approval require review of clinical information from your Provider. Health Options will not accept Prior Approval requests from Members or non-Provider Designees. Failure to obtain Prior Approval or provide required notification for your Covered Services received from Non-Network Providers will result in a benefit reduction penalty of $500 for each type of Covered Service, per occurrence, if the services are determined by Health Options to be Medically Necessary. The benefit reduction penalty is not a covered, and will not be applied to your Deductible amount or the Maximum Out- Out-of-Pocket. If you seek services from a Non-Network Provider and fail to obtain Prior Approval for a service needing Prior Approval, or you fail to provide notification as required, you may not receive Benefits for that service and you may be responsible for the full cost of the service. Approved Covered Services provided by Non-Non- Network Providers apply towards your Out-of-Network cost-sharing as described in your Schedule of Benefits. Health Options pays Benefits up to the Maximum Allowable Amount. The Out-of-Network Provider may balance bill you for submitted charges that exceed the Maximum Allowable Amount. When there is an inadequate network, balance billing does not apply. Members are encouraged to check Health Options website for a current list of Prior Approval/Notification requirements. Members must notify Health Options of any Out-of-Network services that may require Prior Approval/Notification by calling 000-000-0000, Monday – Friday 8am – 6pm. Out-of-Network providers must submit authorization requirements to Health Options as noted on Prior Approval/Notification form located on the provider section of the Health Options website Services for Medical Emergencies do not need Prior Approval. In the event of an admission due to a Medical Emergency, you (or your Designee) must contact Health Options within 48 hours after you are admitted or as soon as reasonably possible. Failure to notify Health Options will result in a benefit reduction penalty of $500 for each occurrence, if the services are determined by Health Options to be Medically Necessary. The benefit reduction penalty is not covered, and will not be applied to your Deductible amount or the Maximum Out-of-Pocket.