Common use of Out-of-Network Service Denial Clause in Contracts

Out-of-Network Service Denial. You also have the right to Appeal the denial of a Preauthorization request for an out-of-network health service when We determine that the out-of- network health service is not materially different from an available in-network health service. A denial of an out-of-network health service is a service provided by a Non-Participating Provider, but only when the service is not available from a Participating Provider. For a Utilization Review Appeal of denial of an out-of-network health service, You, or Your designee, must submit: • A written statement from Your attending Physician, who must be a licensed, board- certified or board-eligible Physician qualified to practice in the specialty area of practice appropriate to treat Your condition, that the requested out-of-network health service is materially different from the alternate health service available from a Participating Provider that We approved to treat Your condition; and • Two (2) documents from the available medical and scientific evidence that the out-of- network service: 1) is likely to be more clinically beneficial to You than the alternate in- network service; and 2) that the adverse risk of the out-of-network service would likely not be substantially increased over the in-network health service.

Out-of-Network Service Denial. You also have the right to Appeal the denial of a Preauthorization request for an out-of-network health service when We determine that the out-of- of-network health service is not materially different from an available in-network health service. A denial of an out-of-network health service is a service provided by a Non-Participating Provider, but only when the service is not available from a Participating Provider. For a Utilization Review Appeal of denial of an out-of-network health service, You, or Your designee, must submit: • A written statement from Your attending Physician, who must be a licensed, board- certified or board-eligible Physician qualified to practice in the specialty area of practice appropriate to treat Your condition, that the requested out-of-network health service is materially different from the alternate health service available from a Participating Provider that We approved to treat Your condition; and • Two (2) documents from the available medical and scientific evidence that the out-of- network service: 1) is likely to be more clinically beneficial to You than the alternate in- network service; and 2) that the adverse risk of the out-of-network service would likely not be substantially increased over the in-network health service.

Out-of-Network Service Denial. You also have the right to Appeal the denial of a Preauthorization request for an out-of-network health service when We determine that the out-of- of-network health service is not materially different from an available in-in- network health service. A denial of an out-of-network health service is a service provided by a Non-Participating Provider, but only when the service is not available from a Participating Provider. For a Utilization Review Appeal of denial of an out-of-of- network health service, You, or Your designee, must submit: •  A written statement from Your attending Physician, who must be a licensed, board- board-certified or board-eligible Physician qualified to practice in the specialty area of practice appropriate to treat Your condition, that the requested out-of-of- network health service is materially different from the alternate health service available from a Participating Provider that We approved to treat Your condition; and •  Two (2) documents from the available medical and scientific evidence that the out-of- of-network service: 1) is likely to be more clinically beneficial to You than the alternate in- in-network service; and 2) that the adverse risk of the out-of-of- network service would likely not be substantially increased over the in-network health service.

Out-of-Network Service Denial. You also have the right to Appeal the denial of a Preauthorization request for an out-of-network health service when We we determine that the out-of- of-network health service is not materially different from an available in-network health service. A denial of an out-of-network health service is a service provided by a Non-Participating Provider, but only when the service is not available from a Participating Provider. You are not eligible for a Utilization Review Appeal if the service you request is available from a Participating Provider, even if the Non-Participating Provider has more experience in diagnosing or treating your condition. (Such an Appeal will be treated as a Grievance.) For a Utilization Review Appeal of denial of an out-of-network health service, You, You or Your designee, designee must submit: • A written statement from Your attending Physician, who must be a licensed, board- board-certified or board-eligible Physician qualified to practice in the specialty area of practice appropriate to treat Your condition, that the requested out-of-network health service is materially different from the alternate health service available from a Participating Provider that We approved to treat Your condition; and • Two (2) documents from the available medical and scientific evidence that the out-of- of-network service: 1) is likely to be more clinically beneficial to You than the alternate in- in-network service; and 2) that the adverse risk of the out-of-network service would likely not be substantially increased over the in-network health service.and

Out-of-Network Service Denial. You also have the right to Appeal the denial of a Preauthorization request for an out-of-network health service when We we determine that the out-of- of-network health service is not materially different ditferent from an available in-network health service. A denial of an out-of-network health service is a service provided by a Non-Participating Provider, but only when the service is not available from a Participating Provider. You are not eligible for a Utilization Review Appeal if the service you request is available from a Participating Provider, even if the Non-Participating Provider has more experience in diagnosing or treating your condition. (Such an Appeal will be treated as a Grievance.) For a Utilization Review Appeal of denial of an out-of-network health service, You, You or Your designee, designee must submit: • A written statement from Your attending Physician, who must be a licensed, board- board-certified or board-eligible Physician qualified to practice in the specialty area of practice appropriate to treat Your condition, that the requested out-of-network health service is materially different ditferent from the alternate health service available from a Participating Provider that We approved to treat Your condition; and • Two (2) documents from the available medical and scientific evidence that the out-of- of-network service: 1) is likely to be more clinically beneficial to You than the alternate in- in-network service; and 2) that the adverse risk of the out-of-network service would likely not be substantially increased over the in-network health service.and

Out-of-Network Service Denial. You also have the right to Appeal the denial of a Preauthorization request for an out-of-network health service when We determine that the out-of- of-network health service is not materially different from an available in-network health service. A denial of an out-of-network health service is a service provided by a Non-Participating Provider, but only when the service is not available from a Participating Provider. For a Utilization Review Appeal of denial of an out-of-network health service, You, or Your designee, must submit: • A written statement from Your attending Physician, who must be a licensed, board- certified or board-eligible Physician qualified to practice in the specialty area of practice appropriate to treat Your condition, that the requested out-of-network health service is materially different from the alternate health service available from a Participating Provider that We approved to treat Your condition; and • Two (2) documents from the available medical and scientific evidence that the outout- of-of- network service: 1) is likely to be more clinically beneficial to You than the alternate in- in-network service; and 2) that the adverse risk of the out-of-network service would likely not be substantially increased over the in-network health service.

Out-of-Network Service Denial. Effective on the date of issuance or renewal of this Contract; on or after April 1, 2015, You also have the right to Appeal the denial of a Preauthorization request for an out-of-network health service when We determine that the out-of- of-network health service is not materially different from an available in-in- network health service. A denial of an out-of-network health service is a service provided by a Non-Participating Provider, but only when the service is not available from a Participating Provider. You are not eligible for a Utilization Review Appeal if the service You request is available from a Participating Provider, even if the Non- Participating Provider has more experience in diagnosing or treating Your condition. (Such an Appeal will be treated as a Grievance.) For a Utilization Review Appeal of denial of an out-of-network health service, You, You or Your designee, designee must submit: • A written statement from Your attending Physician, who must be a licensed, board- board-certified or board-eligible Physician qualified to practice in the specialty area of practice appropriate to treat Your condition, that the requested out-of-of- network health service is materially different from the alternate health service available from a Participating Provider that We approved to treat Your condition; and • Two (2) documents from the available medical and scientific evidence that the out-of- of-network service: 1) is likely to be more clinically beneficial to You than the alternate in- in-network service; and 2) that the adverse risk of the out-of-network service would likely not be substantially increased over the in-network health service.

Out-of-Network Service Denial. You also have the right to Appeal the denial of a Preauthorization request for an out-of-network health service when We determine that the out-of- of-network health service is not materially different from an available in-network health service. A denial of an out-of-network health service is a service provided by a Non-Participating Provider, but only when the service is not available from a Participating Provider. For a Utilization Review Appeal of denial of an out-of-network health service, You, or Your designee, must submit: • A written statement from Your attending Physician, who must be a licensed, board- board-certified or board-eligible Physician qualified to practice in the specialty area of practice appropriate to treat Your condition, that the requested out-of-of- network health service is materially different from the alternate health service available from a Participating Provider that We approved to treat Your condition; and • Two (2) documents from the available medical and scientific evidence that the out-of- of-network service: 1) is likely to be more clinically beneficial to You than the alternate in- in-network service; and 2) that the adverse risk of the out-of-network service would likely not be substantially increased over the in-network health service.

Out-of-Network Service Denial. You also have the right to Appeal the denial of a Preauthorization request for an out-of-network health service when We determine that the out-of- of-network health service is not materially different from an available in-network health service. A denial of an out-of-network health service is a service provided by a Non-Participating Provider, but only when the service is not available from a Participating Provider. You are not eligible for a Utilization Review Appeal if the service You request is available from a Participating Provider, even if the Non-Participating Provider has more experience in diagnosing or treating Your condition. (Such an Appeal will be treated as a Grievance.) For a Utilization Review Appeal of denial of an out-of-network health service, You, or Your designee, must submit: • A written statement from Your attending Physician, who must be a licensed, board- board-certified or board-eligible Physician qualified to practice in the specialty area of practice appropriate to treat Your condition, that the requested out-of-network health service is materially different from the alternate health service available from a Participating Provider that We approved to treat Your condition; and • Two (2) documents from the available medical and scientific evidence that the out-of- of-network service: 1) is likely to be more clinically beneficial to You than the alternate in- in-network service; and 2) that the adverse risk of the out-of-network service would likely not be substantially increased over the in-network health service.

Out-of-Network Service Denial. You also have the right to Appeal the denial of a Preauthorization request for an out-of-network health service when We determine that the out-of- network health service is not materially different from an available in-network health service. A denial of an out-of-network health service is a service provided by a Non-Participating Provider, but only when the service is not available from a Participating Provider. For a Utilization Review Appeal of denial of an out-of-network health service, You, or Your designee, must submit: •  A written statement from Your attending Physician, who must be a licensed, board- board-certified or board-eligible Physician qualified to practice in the specialty area of practice appropriate to treat Your condition, that the requested out-of-network health service is materially different from the alternate health service available from a Participating Provider that We approved to treat Your condition; and •  Two (2) documents from the available medical and scientific evidence that the out-of- of-network service: 1) is likely to be more clinically beneficial to You than the alternate in- in-network service; and 2) that the adverse risk of the out-of-network service would likely not be substantially increased over the in-network health service.