Common use of After Normal Business Hours Clause in Contracts

After Normal Business Hours. Members who need medical services after normal business hours should contact their PCP. The PCP’s answering service may take the Member’s call. If so, the answering service will contact the Member’s physician or the physician on call, who will contact the Member as soon as possible. After normal business hours calls should be limited to medical problems requiring immediate attention. However, Members should not postpone calling their PCP’s office if they believe they need medical attention.  All continuing care as a result of Emergency Services must be provided or Referred by a Member’s Primary Care Physician or coordinated through Keystone’s Customer Service Department.  Some services must be Preauthorized by the HMO. Your Primary Care Physician or Participating Specialist works with the HMO's Care Management and Coordination team during the Preauthorization process. Services in this category include, but are not limited to: hospitalization; certain outpatient services; Skilled Nursing Facility services; and home health care. Services that require Preauthorization are noted in the attached Medical Care Preauthorization Schedule included with this Agreement. You have the right to appeal any decisions through the Member Appeal Process. Instructions for the appeal will be described in the denial notifications.  All services must be received from Participating Providers within Keystone’s Limited Network Area unless Preauthorized by Keystone, or except in cases requiring (1) Emergency Services or Urgent Care while outside Keystone’s Limited Network Area but within Keystone’s Approved Service Area; (2) Emergency Service, Urgent Care and follow-up care under the BlueCard Program while outside Keystone’s Approved Service Area; or (3) Guest Membership Benefits under the Away From Home Care Program while outside Keystone’s Approved Service Area. See Sections ER – Emergency, Urgent, Follow-up Care and GM – Away From Home Care Program Guest Membership Benefits. See also Section ACC - Access to Primary, Specialist and Hospital Care Network for procedures for obtaining Preauthorization for use of a Non-Participating Provider. Keystone Members may submit a written request for a written list of Participating Providers affiliated with participating Hospitals. Use your Provider Directory to find out more about the individual Providers and their qualifications, including Hospitals and Primary Care Physicians and Participating Specialists and their affiliated Hospitals. The directory also lists whether the Provider is accepting new patients.  To change Primary Care Physician, call Keystone’s Customer Service Department at the telephone number shown on the ID Card or go to Keystone’s website at xxxxxxxxxxxx.xxx.  Services Coordinated By The Contracted Behavioral Health Management Company. Members seeking mental health care and substance abuse services may obtain preauthorization for such services from the contracted behavioral health management company. The contracted behavioral health management company may refer members to participating providers for mental health care and substance abuse services and may also coordinate emergency care for such services. Members may contact the contracted behavioral health management company by calling 1-800- 216-9748 (TTY number: 0-000-000-0000). Any such services which are not coordinated, or which exceed the services authorized by the member’s PCP or the contracted behavioral health management company, are not covered. For outpatient non-emergency services to be covered, the services must be received from a Participating Provider and must have a prior notification by the contracted behavioral health management company. If a need for inpatient care or partial hospitalization is identified, the inpatient stay or partial hospitalization must be preauthorized by the contracted behavioral health management company. SECTION CM – CLINICAL MANAGEMENT A wide range of Clinical Management Programs are available under this coverage with Keystone. These Clinical Management Programs are intended to provide a personal touch to the administration of the benefits available under this coverage. Program goals are focused on providing members with the skills necessary to become more involved in the prevention, treatment and recovery processes related to their specific illness or injury. Clinical Management Programs include:  Utilization Management (Preauthorization, Concurrent Review, Discharge Planning, and Medical Claims Review);  Care Management (Case Management, Specialized case Management Oncology Program, Transplant Case Management, Case Management Awareness Program, Discharge Outreach call Program, Transition of Care Program, Emergency Room Utilization Program);  Disease Management;  Maternity Management; and  Quality Management

After Normal Business Hours. Members who need medical services after normal business hours should contact their PCP. The PCP’s answering service may take the Member’s call. If so, the answering service will contact the Member’s physician or the physician on call, who will contact the Member as soon as possible. After normal business hours calls should be limited to medical problems requiring immediate attention. However, Members should not postpone calling their PCP’s office if they believe they need medical attention.  All continuing care as a result of Emergency Services must be provided or Referred by a Member’s Primary Care Physician or coordinated through Keystone’s Customer Service Department.  Some services must be Preauthorized by the HMO. HMO – Your Primary Care Physician or Participating Specialist works with the HMO's Care Management and Coordination team HMO during the Preauthorization process. Services in this category include, but are not limited to: hospitalization; certain outpatient services; Skilled Nursing Facility services; and home health care. Services that require Preauthorization are noted in the attached Medical Care Preauthorization Schedule included with this Agreement. You have the right to appeal any decisions through the Member Appeal Process. Instructions for the appeal will be described in the denial notifications.  All services must be received from Participating Providers within Keystone’s Limited Network Approved Service Area unless Preauthorized by Keystone, or except in cases requiring (1) Emergency Services or Urgent Care while outside Keystone’s Limited Network Area but within Keystone’s Approved Service Area; (2) Emergency Service, Urgent Care and follow-up care under the BlueCard Program while outside Keystone’s Approved Service Area; or (32) Guest Membership Benefits under the Away From Home Care Program while outside Keystone’s Approved Service Area. See Sections ER VII – Emergency, Urgent, Follow-up Care and GM VIII – Away From Home Care Program Guest Membership Benefits. See also Section ACC VI - Access to Primary, Specialist and Hospital Care Network for procedures for obtaining Preauthorization for use of a Non-Participating Nonparticipating Provider. Keystone Members may submit a written request for a written list of Participating Providers affiliated with participating Hospitals. Use your Provider Directory to find out more about the individual Providers and their qualifications, including Hospitals and Primary Care Physicians and Participating Specialists and their affiliated Hospitals. The directory also lists whether the Provider is accepting new patients.  To change Primary Care Physician, call Keystone’s Customer Service Department at the telephone number shown on the ID Card or go to Keystone’s website at xxxxxxxxxxxx.xxx.  Services Coordinated By The Contracted Behavioral Health Management Company. Company – Members seeking mental health care Mental Health Care and substance abuse services Substance Use Disorder Services may obtain preauthorization Preauthorization for such services from the contracted behavioral health management company. The contracted behavioral health management company may refer members Members to participating providers Participating Providers for mental health care Mental Health Care and substance abuse services Substance Use Disorder Services and may also coordinate emergency care for such services. Members may contact the contracted behavioral health management company by calling 10-800- 216000-9748 000-0000 (TTY number: 0-000-000-0000). Any such services which are not coordinated, or which exceed the services authorized by the memberMember’s PCP or the contracted behavioral health management company, are not covered. For outpatient non-emergency services to be covered, the services must be received from a Participating Provider and must have a prior notification by the contracted behavioral health management company. If a need for inpatient Inpatient care or partial hospitalization Partial Hospitalization is identified, the inpatient Inpatient stay or partial hospitalization Partial Hospitalization must be preauthorized Preauthorized by the contracted behavioral health management company. SECTION CM – CLINICAL MANAGEMENT A wide range of Clinical Management Programs are available under this coverage with Keystone. These Clinical Management Programs are intended to provide a personal touch to the administration of the benefits available under this coverage. Program goals are focused on providing members with the skills necessary to become more involved in the prevention, treatment and recovery processes related to their specific illness or injury. Clinical Management Programs include:  Utilization Management (Preauthorization, Concurrent Review, Discharge Planning, and Medical Claims Review);  Care Management (Case Management, Specialized case Management Oncology Program, Transplant Case Management, Case Management Awareness Program, Discharge Outreach call Program, Transition of Care Program, Emergency Room Utilization Program);  Disease Management;  Maternity Management; and  Quality Management.

After Normal Business Hours. Members who need medical services after normal business hours should contact their PCP. The PCP’s answering service may take the Member’s call. If so, the answering service will contact the Member’s physician or the physician on call, who will contact the Member as soon as possible. After normal business hours calls should be limited to medical problems requiring immediate attention. However, Members should not postpone calling their PCP’s office if they believe they need medical attention.  All continuing care as a result of Emergency Services must be provided or Referred by a Member’s Primary Care Physician or coordinated through Keystone’s Customer Service Department.  Some services must be Preauthorized by the HMO. Your Primary Care Physician or Participating Specialist works with the HMO's Care Management and Coordination team during the Preauthorization process. Services in this category include, but are not limited to: hospitalization; certain outpatient services; Skilled Nursing Facility services; and home health care. Services that require Preauthorization are noted in the attached Medical Care Preauthorization Schedule included with this Agreement. You have the right to appeal any decisions through the Member Complaint Appeal and Grievance Appeal Process. Instructions for the appeal will be described in the denial notifications.  All services must be received from Participating Providers within Keystone’s Limited Network Approved Service Area unless Preauthorized by Keystone, or except in cases requiring (1) Emergency Services or Urgent Care while outside Keystone’s Limited Network Area but within Keystone’s Approved Service Area; (2) Emergency Service, Urgent Care and follow-up care under the BlueCard Program while outside Keystone’s Approved Service Area; or (32) Guest Membership Benefits under the Away From Home Care Program while outside Keystone’s Approved Service Area. See Sections ER – Emergency, Urgent, Follow-up Care and GM – Away From Home Care Program Guest Membership Benefits. See also Section ACC - Access to Primary, Specialist and Hospital Care Network for procedures for obtaining Preauthorization for use of a Non-Participating Provider. Keystone Members may submit a written request for a written list of Participating Providers affiliated with participating Hospitals. Use your Provider Directory to find out more about the individual Providers and their qualifications, including Hospitals and Primary Care Physicians and Participating Specialists and their affiliated Hospitals. The directory also lists whether the Provider is accepting new patients.  To change Primary Care Physician, call Keystone’s Customer Service Department at the telephone number shown on the ID Card or go to Keystone’s website at xxxxxxxxxxxx.xxx.  Services Coordinated By The Contracted Behavioral Health Management Company. Members seeking mental health care and substance abuse services may obtain preauthorization for such services from the contracted behavioral health management company. The contracted behavioral health management company may refer members to participating providers for mental health care and substance abuse services and may also coordinate emergency care for such services. Members may contact the contracted behavioral health management company by calling 1-800- 216000-9748 0000 (TTY number: 0-000-000-0000). Any such services which are not coordinated, or which exceed the services authorized by the member’s PCP or the contracted behavioral health management company, are not covered. For outpatient non-emergency services to be covered, the services must be received from a Participating Provider and must have a prior notification by the contracted behavioral health management company. If a need for inpatient care or partial hospitalization is identified, the inpatient stay or partial hospitalization must be preauthorized by the contracted behavioral health management company. SECTION CM – CLINICAL MANAGEMENT A wide range of Clinical Management Programs are available under this coverage with Keystone. These Clinical Management Programs are intended to provide a personal touch to the administration of the benefits available under this coverage. Program goals are focused on providing members with the skills necessary to become more involved in the prevention, treatment and recovery processes related to their specific illness or injury. Clinical Management Programs include:  Utilization Management (Preauthorization, Concurrent Review, Discharge Planning, and Medical Claims Review);  Care Management (Case Management, Specialized case Management Oncology Program, Transplant Case Management, Case Management Awareness Program, Discharge Outreach call Program, Transition of Care Program, Emergency Room Utilization Program);  Disease Management;  Maternity Management; and  Quality Management