Services Rendered by Other Providers. You agree that when the need arises for a State Health Plan Member to receive other professional services, hospital, or other institutional services, or supplies, outside of the scope of services that you provide, you will assist with the referral, admission and/or transfer of the State Health Plan Member locally within the North Carolina State Health Plan Network, when reasonably possible and consistent with good medical care. In the event that you refer a State Health Plan Member outside of the North Carolina State Health Plan Network to a Non-Participating Provider for any reason, you agree to first inform the State Health Plan Member that the State Health Plan may not reimburse the full amount of a provider’s charge, unless the provider’s charge is less than the allowed amount that would otherwise be paid to the Non-Participating Provider; and, as a result, the State Health Plan Member may be subject to higher out-of-pocket payments by using a Non-Participating Provider. You acknowledge that repeated referrals to Non-Participating Providers without reasonable cause may subject you to sanctions, as outlined in the Provider Manual and Section 5.2 of this agreement. You further agree that you will not limit, restrict, or prohibit a Practitioner by contract or otherwise from exercising their independent medical judgment and referring State Health Plan Members to any participating provider in the North Carolina State Health Plan Network that the Practitioner chooses and deems to be in the best interest of the Plan Member when balancing quality, affordability, and the medical needs of the State Health Plan Member. Nothing contained herein will be construed to require us to cover services provided by a given specialty or in a given setting when a lower level of care is deemed appropriate by us.
