Common use of Managed Care Process Clause in Contracts

Managed Care Process. This section tells you about HPN’s Managed Care Program and which Covered Services require Prior Authorization. HPN's Managed Care Program, using the services of professional medical peer review committees, utilization review committees, and/or the Medical Director, determines whether services and supplies are Medically Necessary. HPN’s Managed Care Program helps direct the patient to the most appropriate setting to provide healthcare in a cost-effective manner. HPN's Managed Care Program requires the Member, Plan Providers and HPN to work together.  All Plan Providers have agreed to participate in HPN’s Managed Care Program. Plan Providers have agreed to accept HPN’s Reimbursement Schedule amount as payment in full for Covered Services, less the Member’s payment of any applicable Copayment, Deductible or Coinsurance amount, whereas Non-Plan Providers have not. Members enrolled under HPN’s HMO Plans who use the services of Non-Plan Providers will receive no benefit payments or reimbursement for amounts for any Covered Service, except in the case of Emergency Services or Urgently Needed Services as defined in this AOC, or other Covered Services provided by a Non-Plan Provider that are Prior Authorized by HPN’s Managed Care Program including any Prior Authorized Covered Services obtained from a Non-Plan outpatient facility, such as a laboratory, radiological facility (x-ray), or any The Medical Director and/or HPN's Utilization Review Committee will review proposed services and supplies to be received by a Member to determine: