PREAUTHORIZATION FOR NONPARTICIPATING PROVIDERS Sample Clauses

PREAUTHORIZATION FOR NONPARTICIPATING PROVIDERS. Services by a Nonparticipating Provider require a Referral from the Member’s PCP and Preauthorization by the HMO. A Member’s Primary Care Physician is required to obtain Preauthorization from the HMO for services provided by a Nonparticipating Provider. The HMO may approve payment for Covered Services provided by a Nonparticipating Provider if a Member has:  First sought and received care from a Participating Provider in the same American Board of Medical Specialties (ABMS) recognized specialty as the Nonparticipating Provider that you have requested.  Been advised by the Participating Provider that there are no Participating Providers that can provide the requested Covered Services; and  Obtained authorization from the HMO prior to receiving care. The HMO reserves the right to make the final determination whether there is a Participating Provider that can provide the Covered Services. If the HMO approves the use of a Nonparticipating Provider, a Member will not be responsible for the difference between the provider's billed charges and the HMO's payment to the Provider but a Member will be responsible for applicable Copayments, Coinsurance and/or Deductibles. Applicable program terms including Medical Necessity, Referrals and Preauthorization by the HMO, when required, will apply.‌