Common use of Managed Care Program Requirements Clause in Contracts

Managed Care Program Requirements. SHL's Managed Care Program requires the Insured, Plan Providers and SHL to work together. All Plan Providers have agreed to participate in SHL’s Managed Care Program. Plan Providers have agreed to accept SHL’s Reimbursement Schedule amount as payment in full for Covered Services, less the Insured’s payment of any applicable Calendar Year Deductible, Copayment or Coinsurance amount, whereas Non-Plan Providers have not. Insureds enrolled under SHL’s Exclusive Provider Organization (EPO) 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 or  other Covered Services provided by a Non-Plan Provider that are Prior Authorized by SHL’s Managed Care Program. This includes any Prior Authorized Covered Services obtained from a Non-Plan outpatient facility, such as a laboratory, radiological facility (x-ray), or any complex diagnostic or therapeutic services. In no event will SHL pay more than the maximum payment allowance established in the SHL Reimbursement Schedule. It is the Insured's responsibility to verify that the Provider selected is a Plan Provider before receiving any non-Emergency Services and to comply with all other rules of SHL’s Managed Care Program. Failure of the Insured to comply with the requirements of SHL’s Managed Care Program will result in a reduction of benefits. Benefits payable for Covered Services from Plan Providers which are not Prior Authorized by SHL’s Managed Care Program will be reduced to 50% of what the Insured would have received with Prior Authorization.

Managed Care Program Requirements. SHLHPN's Managed Care Program requires the InsuredMember, Plan Providers and SHL HPN to work together. All Plan Providers have agreed to participate in SHLHPN’s Managed Care Program. Plan Providers have agreed to accept SHLHPN’s Reimbursement Schedule amount as payment in full for Covered Services, less the InsuredMember’s payment of any applicable Calendar Year Deductible, Copayment or Coinsurance amount, whereas Non-Plan Providers have not. Insureds Members enrolled under SHLHPN’s Exclusive Provider Organization (EPO) 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 or  other Covered Services Services, as defined in this AOC, provided by a Non-Plan Provider that are Prior Authorized by SHLHPN’s Managed Care Program. This includes any Prior Authorized Covered Services obtained from a Non-Plan outpatient facility, such as a laboratory, radiological facility (x-ray), or any complex diagnostic or therapeutic services. In no event will SHL HPN pay more than the maximum payment allowance established in the SHL HPN Reimbursement Schedule. It is the InsuredMember's responsibility to verify that the a Provider selected is a Plan Provider before receiving any non-Emergency Services and to comply with all other rules of SHLHPN’s Managed Care Program. Compliance by the Member with HPN’s Managed Care Program is mandatory. Failure of by the Insured Member to comply with the requirements rules of SHLHPN’s Managed Care Program will result in a reduction of benefits. Benefits payable for Covered Services from Plan Providers which are not Prior Authorized by SHL’s Managed Care Program means the Member will be reduced to 50% responsible for costs of what the Insured would have received with Prior Authorizationservices received.

Managed Care Program Requirements. SHLHPN's Managed Care Program requires the InsuredMember, Plan Providers and SHL HPN to work together. All Plan Providers have agreed to participate in SHLHPN’s Managed Care Program. Plan Providers have agreed to accept SHLHPN’s Reimbursement Schedule amount as payment in full for Covered Services, less the InsuredMember’s payment of any applicable Calendar Year Deductible, Copayment or Coinsurance amount, whereas Non-Plan Providers have not. Insureds Members enrolled under SHLHPN’s Exclusive Provider Organization (EPO) 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 Services; or  Agreement of Coverage • for other Covered Services Services, as defined in this AOC, provided by a Non-Plan Provider that are Prior Authorized by SHLHPN’s Managed Care Program. This includes any Prior Authorized Covered Services obtained from a Non-Plan outpatient facility, such as a laboratory, radiological facility (x-ray), or any complex diagnostic or therapeutic services. In no event will SHL HPN pay more than the maximum payment allowance established in the SHL HPN Reimbursement Schedule. It is the InsuredMember's responsibility to verify that the Provider selected is a Plan Provider before receiving any non-Emergency Services and to comply with all other rules of SHLHPN’s Managed Care Program. Compliance by the Member with HPN’s Managed Care Program is mandatory. Failure of the Insured to comply with the requirements rules of SHLHPN’s Managed Care Program will result in a reduction of benefits. Benefits payable for Covered Services from Plan Providers which are not Prior Authorized by SHL’s Managed Care Program means the Member will be reduced to 50% responsible for costs of what the Insured would have received with Prior Authorizationservices received.

Managed Care Program Requirements. SHL's Managed Care Program requires the Insured, Plan Providers and SHL to work together. All Plan Providers have agreed to participate in SHL’s Managed Care Program. Plan Providers have agreed to accept SHL’s Reimbursement Schedule amount as payment in full for Covered Services, less the Insured’s payment of any applicable Calendar Year Deductible, Copayment or Coinsurance amount, whereas Non-Plan Providers have not. Insureds enrolled under SHL’s Exclusive Provider Organization (EPO) 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 or  • other Covered Services provided by a Non-Plan Provider that are Prior Authorized by SHL’s Managed Care Program. This includes any Prior Authorized Covered Services obtained from a Non-Plan outpatient facility, such as a laboratory, radiological facility (x-ray), or any complex diagnostic or therapeutic services. In no event will SHL pay more than the maximum payment allowance established in the SHL Reimbursement Schedule. It is the Insured's responsibility to verify that the Provider selected is a Plan Provider before receiving any non-Emergency Services and to comply with all other rules of SHL’s Managed Care Program. Failure of the Insured to comply with the requirements of SHL’s Managed Care Program will result in a reduction of benefits. Benefits payable for Covered Services from Plan Providers which are not Prior Authorized by SHL’s Managed Care Program will be reduced to 50% of what the Insured would have received with Prior Authorization.

Managed Care Program Requirements. SHLHPN's Managed Care Program requires the InsuredMember, Plan Providers and SHL HPN to work together. All Plan Providers have agreed to participate in SHLHPN’s Managed Care Program. Plan Providers have agreed to accept SHLHPN’s Reimbursement Schedule amount as payment in full for Covered Services, less the InsuredMember’s payment of any applicable Calendar Year Deductible, Copayment or Coinsurance amount, whereas Non-Plan Providers have not. Insureds Members enrolled under SHLHPN’s Exclusive Provider Organization (EPO) 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 Services; or Agreement of Coverage  for other Covered Services Services, as defined in this AOC, provided by a Non-Plan Provider that are Prior Authorized by SHLHPN’s Managed Care Program. This includes any Prior Authorized Covered Services obtained from a Non-Plan outpatient facility, such as a laboratory, radiological facility (x-ray), or any complex diagnostic or therapeutic services. In no event will SHL HPN pay more than the maximum payment allowance established in the SHL HPN Reimbursement Schedule. It is the InsuredMember's responsibility to verify that the Provider selected is a Plan Provider before receiving any non-Emergency Services and to comply with all other rules of SHLHPN’s Managed Care Program. Compliance by the Member with HPN’s Managed Care Program is mandatory. Failure of the Insured to comply with the requirements rules of SHLHPN’s Managed Care Program will result in a reduction of benefits. Benefits payable for Covered Services from Plan Providers which are not Prior Authorized by SHL’s Managed Care Program means the Member will be reduced to 50% responsible for costs of what the Insured would have received with Prior Authorizationservices received.

Managed Care Program Requirements. SHLHPN's Managed Care Program requires the InsuredMember, Plan Providers and SHL HPN to work together. • All Plan Providers have agreed to participate in SHLHPN’s Managed Care Program. Plan Providers have agreed to accept SHLHPN’s Reimbursement Schedule amount as payment in full for Covered Services, less the InsuredMember’s payment of any applicable Calendar Year DeductibleCopayment, Copayment Deductible or Coinsurance amount, whereas Non-Plan Providers have not. Insureds Members enrolled under SHLHPN’s Exclusive Provider Organization (EPO) 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 SHLHPN’s Managed Care Program. This includes Program including any Prior Authorized Covered Services obtained from a Non-Plan outpatient facility, such as a laboratory, radiological facility (x-ray), or any complex diagnostic or therapeutic services. In no event will SHL HPN pay more than the maximum payment allowance established in the SHL HPN Reimbursement Schedule. • It is the InsuredMember's responsibility to verify that the a Provider selected is a Plan Provider before receiving any non-non- Emergency Services and to comply with all other rules of SHLHPN’s Managed Care Program. • Compliance by the Member with HPN’s Managed Care Program is mandatory. Failure of by the Insured Member to comply with the requirements rules of SHLHPN’s Managed Care Program will result in a reduction of benefits. Benefits payable for Covered Services from Plan Providers which are not Prior Authorized by SHL’s Managed Care Program means the Member will be reduced to 50% responsible for costs of what the Insured would have received with Prior Authorizationservices received.

Managed Care Program Requirements. SHLthe most appropriate setting to provide healthcare in a cost-effective manner. HPN's Managed Care Program requires the InsuredMember, Plan Providers and SHL HPN to work together.  All Plan Providers have agreed to participate in SHLHPN’s Managed Care Program. Plan Providers have agreed to accept SHLHPN’s Reimbursement Schedule amount as payment in full for Covered Services, less the InsuredMember’s payment of any applicable Calendar Year DeductibleCopayment, Copayment Deductible or Coinsurance amount, whereas Non-Plan Providers have not. Insureds Members enrolled under SHLHPN’s Exclusive Provider Organization (EPO) 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 SHLHPN’s Managed Care Program. This includes Program including any Prior Authorized Covered Services obtained from a Non-Plan outpatient facility, such as a laboratory, radiological facility (x-ray), or any complex diagnostic or therapeutic services. In no event will SHL HPN pay more than the maximum payment allowance established in the SHL HPN Reimbursement Schedule.  It is the InsuredMember's responsibility to verify that the a Provider selected is a Plan Provider before receiving any non-Emergency Services and to comply with all other rules of SHLHPN’s Managed Care Program. Failure of the Insured to comply with the requirements of SHL’s Managed Care Program will result in a reduction of benefits. Benefits payable for Covered Services from Plan Providers which are not Prior Authorized by SHL’s Managed Care Program will be reduced to 50% of what the Insured would have received with Prior Authorization.