Common use of Service Continuation Clause in Contracts

Service Continuation. a) New Enrollees i) If a new Enrollee has an existing relationship with a health care provider who is not a member of the Contractor's provider network, the Contractor shall permit the Enrollee to continue an ongoing course of treatment by the Non-Participating Provider during a transitional period of up to sixty (60) days from the Effective Date of Enrollment, if (1) the Enrollee has a life- threatening disease or condition or a degenerative and disabling disease or condition, or (2) the Enrollee has entered the second trimester of pregnancy at the Effective Date of Enrollment, in which case the transitional period shall include the provision of post-partum care directly related to the delivery up until sixty (60) days post partum. If the new Enrollee elects to continue to receive care from such Non-Participating Provider, such care shall be authorized by the Contractor for the transitional period only if the Non-Participating Provider agrees to: A) Accept reimbursement from the Contractor at rates established by the Contractor as payment in full, which rates shall be no more than the level of reimbursement applicable to similar providers within the Contractor's network for such services; and B) Adhere to the Contractor's quality assurance requirements and agrees to provide to the Contractor necessary medical information related to such care; and C) Otherwise adhere to the Contractor's policies and procedures including, but not limited to procedures regarding referrals and obtaining pre-authorization in a treatment plan approved by the Contractor. ii) In no event shall this requirement be construed to require the Contractor to provide coverage for benefits not otherwise covered.

Service Continuation. a) New Enrollees i) Enrollees If a new Enrollee has an existing relationship with a health care provider who is not a member of the Contractor's provider network, the Contractor contractor shall permit the Enrollee to continue an ongoing course of treatment by the Non-Participating Provider during a transitional period of up to sixty (60) days from the Effective Date of Enrollment, if if, (1) the Enrollee has a life- SECTION 15 (EQUALITY OF ACCESS AND TREATMENT) October 1, 2004 15-2 threatening disease or condition or a degenerative and disabling disease or condition, or (2) the Enrollee has entered the second trimester of pregnancy at the Effective Date of Enrollment, in which case the transitional period shall include the provision of post-partum care directly related to the delivery up until sixty (60) days post partum. If the new Enrollee elects to continue to receive care from such Non-Participating Provider, such care shall be authorized by the Contractor for the transitional period only if the Non-Participating Provider agrees to: Ai) Accept accept reimbursement from the Contractor at rates established by the Contractor as payment in full, which rates shall be no more than the level of reimbursement applicable to similar providers within the Contractor's network for such services; and Bii) Adhere adhere to the Contractor's quality assurance requirements and agrees to provide to the Contractor necessary medical information related to such care; and Ciii) Otherwise otherwise adhere to the Contractor's policies and procedures including, but not limited to procedures regarding referrals and obtaining pre-authorization in a treatment plan approved by the Contractor. ii) . In no event shall this requirement be construed to require the Contractor to provide coverage for benefits not otherwise covered.

Service Continuation. a) New Enrollees i) If a new Enrollee has an existing relationship with a health care provider who is not a member of the Contractor's provider network, the Contractor shall permit the Enrollee to continue an ongoing course of treatment by the Non-Participating Provider during a transitional period of up to sixty (60) days from the Effective Date of Enrollment, if if, (1) the Enrollee has a life- life-threatening disease or condition or a degenerative and disabling disease or condition, or (2) the Enrollee has entered the second trimester of pregnancy at the Effective Date of Enrollment, in which case the transitional period shall include the provision of post-partum care directly related to the delivery up until sixty (60) days post partum. If the new Enrollee elects to continue to receive care from such Non-Participating Provider, such care shall be authorized by the Contractor for the transitional period only if the Non-Participating Provider agrees to: A) Accept accept reimbursement from the Contractor at rates established by the Contractor as payment in full, which rates shall be no more than the level of reimbursement applicable to similar providers within the Contractor's network for such services; and B) Adhere adhere to the Contractor's quality assurance requirements and agrees to provide to the Contractor necessary medical information related to such care; and C) Otherwise otherwise adhere to the Contractor's policies and procedures including, but not limited to procedures regarding referrals and obtaining pre-authorization in a treatment plan approved by the Contractor. ii) In no event shall this requirement be construed to require the Contractor to provide coverage for benefits not otherwise covered.

Service Continuation. a) New Enrollees i) If a new Enrollee has an existing relationship with a health care provider who is not a member of the Contractor's provider network, the Contractor contractor shall permit the Enrollee to continue an ongoing course of treatment by the Non-Participating Provider during a transitional period of up to sixty (60) days from the Effective Date of Enrollment, if if, (1) the Enrollee has a life- life-threatening disease or condition or a degenerative and disabling disease or condition, or (2) the Enrollee has entered the second trimester of pregnancy at the Effective Date of Enrollment, in which case the transitional period shall include the provision of post-partum care directly related to the delivery up until sixty (60) days post partum. If the new Enrollee elects to continue to receive care from such Non-Participating Provider, such care shall be authorized by the Contractor for the transitional period only if the Non-Participating Provider agrees to: A) Accept accept reimbursement from the Contractor at rates established by the Contractor as payment in fullmil, which rates shall be no more than the level of reimbursement applicable to similar providers within the Contractor's network for such services; and B) Adhere adhere to the Contractor's quality assurance requirements and agrees to provide to the Contractor necessary medical information related to such care; and C) Otherwise otherwise adhere to the Contractor's policies and procedures including, but not limited to procedures regarding referrals and obtaining pre-authorization in a treatment plan approved by the Contractor. ii) In no event shall this requirement be construed to require the Contractor to provide coverage for benefits not otherwise covered.