Common use of Request for Additional Information Clause in Contracts

Request for Additional Information. The Post-Service Medical Necessity Review process may require additional documentation from the Member’s health care provider or pharmacist. In addition to the written request for Post-Service Medical Necessity Review, the health care provider or pharmacist may be required to include pertinent documentation explaining the services rendered, the functional aspects of the treatment, the projected outcome, treatment plan and any other supporting documentation, study models, prescription, itemized repair and replacement cost statements, photographs, x-rays, etc., as may be requested by The Plan to make a determination of coverage pursuant to the terms and conditions of this Contract. Care Management‌ The goal of Care Management is to help the Member receive the most appropriate care that is also cost effective. If the Member has an ongoing medical condition or a catastrophic Illness, the Member should contact The Plan. If appropriate, a care manager will be assigned to work with the Member and the Member’s providers to facilitate a treatment plan. Care Management includes Member education, referral coordination, utilization review and individual care planning. Involvement in Care Management does not guarantee payment by The Plan. To be eligible for enrollment, the applicant must and any Dependents for whom coverage is sought must: 1. Be a resident of the state of Montana; and 2. Complete an application. Eligibility for this coverage will be determined by the Exchange in accordance with applicable law. For questions regarding eligibility, refer to ▇▇▇▇▇▇▇▇▇▇.▇▇▇. Applying for Coverage‌ An applicant may apply for coverage in a Qualified Health Plan (QHP) through the Exchange for himself/herself and/or any eligible Dependents (see below) by submitting the application(s) for individual medical insurance form, along with any exhibits, appendices, addenda and/or other required information (“application(s)”) to Blue Cross and Blue Shield of Montana and the Exchange, as appropriate. The application(s) for coverage may or may not be accepted. No eligibility rules or variations in premium will be imposed based on health status, medical condition, claims experience, receipt of healthcare, medical history, genetic information, evidence of insurability, disability, or any other health status related factor. Applicants will not be discriminated against for coverage under this Plan on the basis of race, color, national origin, disability, age, sex, gender identity, or sexual orientation. Variation in the administration, processes or Benefits of this policy that are based on clinically indicated, reasonable medical management practices, or are part of permitted wellness incentives, disincentives and/or other programs do not constitute discrimination. An applicant may enroll in or change a QHP for himself/herself and/or any eligible Dependents during one of the Initial and Annual Enrollment Periods as set by the Exchange. The Effective Date will be determined by Blue Cross and Blue Shield of Montana and the Exchange, as appropriate, depending upon the date the application is received, payment of the initial premiums no later than the day before the Effective Date of coverage (unless any Advance Premium Tax Credit is greater than the initial premium), and other determining factors. Special Enrollment Events‌

Request for Additional Information. The Post-Service Medical Necessity Review process may require additional documentation from the Member’s health care provider or pharmacist. In addition to the written request for Post-Service Medical Necessity Review, the health care provider or pharmacist may be required to include pertinent documentation explaining the services rendered, the functional aspects of the treatment, the projected outcome, treatment plan and any other supporting documentation, study models, prescription, itemized repair and replacement cost statements, photographs, x-rays, etc., as may be requested by The Plan to make a determination of coverage pursuant to the terms and conditions of this Contract. Care Management‌ The goal of Care Management is to help the Member receive the most appropriate care that is also cost effective. If the Member has an ongoing medical condition or a catastrophic Illness, the Member should contact The Plan. If appropriate, a care manager will be assigned to work with the Member and the Member’s providers to facilitate a treatment plan. Care Management includes Member education, referral coordination, utilization review and individual care planning. Involvement in Care Management does not guarantee payment by The Plan. To be eligible for enrollment, the applicant must and any Dependents for whom coverage is sought must: 1. Be a resident of the state of Montana; and 2. Complete an application. Eligibility for this coverage will be determined by the Exchange in accordance with applicable law. For questions regarding eligibility, refer to ▇▇▇▇▇▇▇▇▇▇.▇▇▇. Applying for Coverage‌ An applicant may apply for coverage in a Qualified Health Plan (QHP) through the Exchange for himself/herself and/or any eligible Dependents (see below) by submitting the application(s) for individual medical insurance form, along with any exhibits, appendices, addenda and/or other required information (“application(s)”) to Blue Cross and Blue Shield of Montana and the Exchange, as appropriate. The application(s) for coverage may or may not be accepted. No eligibility rules or variations in premium will be imposed based on health status, medical condition, claims experience, receipt of healthcare, medical history, genetic information, evidence of insurability, disability, or any other health status related factor. Applicants will not be discriminated against for coverage under this Plan on the basis of race, color, national origin, disability, age, sex, gender identity, or sexual orientation. Variation in the administration, processes or Benefits of this policy that are based on clinically indicated, reasonable medical management practices, or are part of permitted wellness incentives, disincentives and/or other programs do not constitute discrimination. An applicant may enroll in or change a QHP for himself/herself and/or any eligible Dependents during one of the Initial and Annual Enrollment Periods as set by the Exchange. The Effective Date will be determined by Blue Cross and Blue Shield of Montana and the Exchange, as appropriate, depending upon the date the application is received, payment of the initial premiums no later than the day before the Effective Date of coverage (unless any Advance Premium Tax Credit is greater than the initial premium), and other determining factors. Special Enrollment Events‌