Common use of Continued Care Clause in Contracts

Continued Care. Where a Member is in the midst of a course of treatment from a UPMC Provider that is an Out-of-Network Provider under this Agreement, the Member may, at his/her option, request to continue treatment with that UPMC Provider. Covered Services shall be available at the Standard Value level of benefits. The need for a continuing course of treatment with a UPMC Provider shall be determined, in the first instance, by the Member’s treating Physician acting in consultation and in accordance with the wishes of the Member or the Member’s authorized representative. A Member with a pregnancy that has been confirmed before December 31, 2015 or who has started a continuing course of treatment for a chronic or persistent medical condition with a UPMC Provider in calendar years 2013, 2014 or 2015 (or on or before June 30, 2016 for UPMC Mercy) may continue treatment with that UPMC Provider through the period of delivery and post-partum care for that pregnancy or completed treatment of the chronic or persistent medical condition. Notwithstanding the above, a Member who was treated at UPMC Mercy and by a UPMC Mercy Physician for a confirmed pregnancy on or before June 30, 2016, may continue to receive treatment at UPMC Mercy through the period of delivery and post-partum care for that pregnancy or completed treatment of the chronic or persistent medical condition. Services such as routine wellness care and routine preventive care are not considered to be continued care under this Paragraph. Furthermore, benefits will not be provided under this Paragraph when the course of treatment for a chronic or persistent medical condition started before January 1, 2013 but for which no treatment was subsequently received from a UPMC Provider, unless the UPMC Provider can demonstrate that the Member was receiving ongoing care in accordance with recognized medical protocols and/or standards. While undergoing a continuing course of treatment with such UPMC Provider, benefits will include all Covered Services reasonably related to the treatment including, but not limited to, testing and follow-up care. In the event that the Plan disputes the opinion of the treating Physician that a continuation of care is Medically Necessary and Appropriate, or disputes the scope of that care, the Pennsylvania Department of Health or its designated representative will review that matter and make a final non-appealable determination.

Continued Care. Where a Member is in the midst of a course of treatment from a UPMC Provider that is an Out-of-Network Provider under this Agreement, the Member may, at his/her option, request to continue treatment with that UPMC Provider. Covered Services shall be available at the Standard Value level of benefits. The need for a continuing course of treatment with a UPMC Provider shall be determined, in the first instance, by the Member’s treating Physician acting in consultation and in accordance with the wishes of the Member or the Member’s authorized representative. A Member with a pregnancy that has been confirmed before December 31, 2015 or who has started a continuing course of treatment for a chronic or persistent medical condition with a UPMC Provider in calendar years 2013, 2014 or 2015 (or on or before June 30, 2016 for UPMC Mercy) may continue treatment with that UPMC Provider through the period of delivery and post-partum care for that pregnancy or completed treatment of the chronic or persistent medical condition. Notwithstanding the above, a Member who was treated at UPMC Mercy and by a UPMC Mercy Physician physician for a confirmed pregnancy on or before June 30, 2016, may continue to receive treatment at UPMC Mercy through the period of delivery and post-partum care for that pregnancy or completed treatment of the chronic or persistent medical condition. Services such as routine wellness care and routine preventive care are not considered to be continued care under this Paragraph. Furthermore, benefits will not be provided under this Paragraph when the course of treatment for a chronic or persistent medical condition started before January 1, 2013 but for which no treatment was subsequently received from a UPMC Provider, unless the UPMC Provider can demonstrate that the Member was receiving ongoing care in accordance with recognized medical protocols and/or standards. While undergoing a continuing course of treatment with such UPMC Provider, benefits will include all Covered Services reasonably related to the treatment including, but not limited to, testing and follow-up care. In the event that the Plan disputes the opinion of the treating Physician that a continuation of care is Medically Necessary and Appropriate, or disputes the scope of that care, the Pennsylvania Department of Health or its designated representative will review that matter and make a final non-appealable determination.

Continued Care. Where a Member is in the midst of a course of treatment from a UPMC Provider that is an Out-of-Network Provider under this Agreement, the Member may, at his/her option, request to continue treatment with that UPMC Provider. Covered Services shall be available at the Standard Value Network Services level of benefits. The need for a continuing course of treatment with a UPMC Provider shall be determined, in the first instance, by the Member’s treating Physician acting in consultation and in accordance with the wishes of the Member or the Member’s authorized representative. A Member with a pregnancy that has been confirmed before December 31, 2015 or who has started a continuing course of treatment for a chronic or persistent medical condition with a UPMC Provider in calendar years 2013, 2014 or 2015 (or on or before June 30, 2016 for UPMC Mercy) may continue treatment with that UPMC Provider through the period of delivery and post-partum care for that pregnancy or completed treatment of the chronic or persistent medical condition. Notwithstanding the above, a Member who was treated at UPMC Mercy and by a UPMC Mercy Physician for a confirmed pregnancy on or before June 30, 2016, may continue to receive treatment at UPMC Mercy through the period of delivery and post-partum care for that pregnancy or completed treatment of the chronic or persistent medical condition. Services such as routine wellness care and routine preventive care are not considered to be continued care under this Paragraph. Furthermore, benefits will not be provided under this Paragraph when the course of treatment for a chronic or persistent medical condition started before January 1, 2013 but for which no treatment was subsequently received from a UPMC Provider, unless the UPMC Provider can demonstrate that the Member was receiving ongoing care in accordance with recognized medical protocols and/or standards. While undergoing a continuing course of treatment with such UPMC Provider, benefits will include all Covered Services reasonably related to the treatment including, but not limited to, testing and follow-up care. In the event that the Plan disputes the opinion of the treating Physician that a continuation of care is Medically Necessary and Appropriate, or disputes the scope of that care, the Pennsylvania Department of Health or its designated representative will review that matter and make a final non-appealable determination.

Continued Care. Where a Member is in the midst of a course of treatment from a UPMC Provider that is an Out-of-Network Provider under this Agreement, the Member may, at his/her option, request to continue treatment with that UPMC Provider. Covered Services shall be available at the Standard Value level of benefits. The need for a continuing course of treatment with a UPMC Provider shall be determined, in the first instance, by the Member’s treating Physician acting in consultation with and in accordance with the wishes of the Member or the Member’s authorized representative. A Member with a pregnancy that has been confirmed before December 31, 2015 or who has started a continuing course of treatment for a chronic or persistent medical condition with a UPMC Provider in calendar years 2013, 2014 or 2015 (or on or before June 30, 2016 for UPMC Mercy) may continue treatment with that UPMC Provider through the period of delivery and post-partum care for that pregnancy or completed treatment of the chronic or persistent medical condition. Notwithstanding the above, a Member who was treated at UPMC Mercy and by a UPMC Mercy Physician for a confirmed pregnancy on or before June 30, 2016, may continue to receive treatment at UPMC Mercy through the period of delivery and post-partum care for that the pregnancy or completed treatment of the chronic or persistent medical condition. Services such as routine wellness care and routine preventive care are not considered to be continued care under this Paragraph. Furthermore, benefits will not be provided under this Paragraph when the course of treatment for a chronic or persistent medical condition started before January 1, 2013 but for which no treatment was subsequently received from a UPMC Provider, unless the UPMC Provider can demonstrate that the Member was receiving ongoing care in accordance with recognized medical protocols and/or standards. While undergoing a continuing course of treatment with such UPMC Provider, benefits will include all Covered Services reasonably related to the treatment includingtreatment, including but not limited to, testing and follow-up care. In the event that the Plan disputes the opinion of the treating Physician that a continuation of care is Medically Necessary and Appropriate, or disputes the scope of that care, the Pennsylvania Department of Health or its designated representative will review that matter and make a final non-appealable determination.

Continued Care. Where a Member is in the midst of a course of treatment from a UPMC Provider that is an Out-of-Network Provider under this Agreement, the Member may, at his/her option, request to continue treatment with that UPMC Provider. Covered Services shall be available at the Standard Value level of benefits. The need for a continuing course of treatment with a UPMC Provider shall be determined, in the first instance, by the Member’s treating Physician acting in consultation and in accordance with the wishes of the Member or the Member’s authorized representative. A Member with a pregnancy that has been confirmed before December 31, 2015 or who has started a continuing course of treatment for a chronic or persistent medical condition with a UPMC Provider in calendar years 2013, 2014 or 2015 (or on or before June 30, 2016 for UPMC Mercy) may continue treatment with that UPMC Provider through the period of delivery and post-partum care for that pregnancy or completed treatment of the chronic or persistent medical condition. Notwithstanding the above, a Member who was treated at UPMC Mercy and by a UPMC Mercy Physician for a confirmed pregnancy on or before June 30, 2016, may continue to receive treatment at UPMC Mercy through the period of delivery and post-post- partum care for that the pregnancy or completed treatment of the chronic or persistent medical condition. Services such as routine wellness care and routine preventive care are not considered to be continued care under this Paragraph. Furthermore, benefits will not be provided under this Paragraph when the course of treatment for a chronic or persistent medical condition started before January 1, 2013 but for which no treatment was subsequently received from a UPMC Provider, unless the UPMC Provider can demonstrate that the Member was receiving ongoing care in accordance with recognized medical protocols and/or standards. While undergoing a continuing course of treatment with such UPMC Provider, benefits will include all Covered Services reasonably related to the treatment including, but not limited to, testing and follow-up care. In the event that the Plan disputes the opinion of the treating Physician that a continuation of care is Medically Necessary and Appropriate, or disputes the scope of that care, the Pennsylvania Department of Health or its designated representative will review that matter and make a final non-appealable determination.

Continued Care. Where a Member is in the midst of a course of treatment from a UPMC Provider that is an Out-of-Network Provider under this Agreement, the Member may, at his/her option, request to continue treatment with that UPMC Provider. Covered Services shall be available at the Standard Value level of benefits. The need for a continuing course of treatment with a UPMC Provider shall be determined, in the first instance, by the Member’s treating Physician acting in consultation and in accordance with the wishes of the Member or the Member’s authorized representative. A Member with a pregnancy that has been confirmed before December 31, 2015 or who has started a continuing course of treatment for a chronic or persistent medical condition with a UPMC Provider in calendar years 2013, 2014 or 2015 (or on or before June 30, 2016 for UPMC Mercy) may continue treatment with that UPMC Provider through the period of delivery and post-partum care for that pregnancy or completed treatment of the chronic or persistent medical condition. Notwithstanding the above, a Member who was treated at UPMC Mercy and by a UPMC Mercy Physician for a confirmed pregnancy on or before June 30, 2016, may continue to receive treatment at UPMC Mercy through the period of delivery and post-partum care for that pregnancy or completed treatment of the chronic or persistent medical condition or completed treatment of the chronic or persistent medical condition. Services such as routine wellness care and routine preventive care are not considered to be continued care under this Paragraph. Furthermore, benefits will not be provided under this Paragraph when the course of treatment for a chronic or persistent medical condition started before January 1, 2013 but for which no treatment was subsequently received from a UPMC Provider, unless the UPMC Provider can demonstrate that the Member was receiving ongoing care in accordance with recognized medical protocols and/or standards. While undergoing a continuing course of treatment with such UPMC Provider, benefits will include all Covered Services reasonably related to the treatment including, but not limited to, testing and follow-up care. In the event that the Plan disputes the opinion of the treating Physician that a continuation of care is Medically Necessary and Appropriate, or disputes the scope of that care, the Pennsylvania Department of Health or its designated representative will review that matter and make a final non-appealable determination.