Common use of RIGHT TO RECOVER PAYMENTS MADE IN ERROR Clause in Contracts

RIGHT TO RECOVER PAYMENTS MADE IN ERROR. If the HMO should pay for any contractually excluded services through inadvertence or error, the HMO maintains the right to seek recovery of such payment from the Provider or Member to whom such payment was made. SECTION ER - EMERGENCY, URGENT CARE, FOLLOW-UP CARE WHAT ARE EMERGENCY SERVICES‌ "Emergency Services" are any health care services provided to a Member after the sudden onset of a medical condition. The condition manifests itself by acute symptoms of sufficient severity or severe pain, such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in:  placing the health of the Member or with respect to a pregnant Member, the health of the Member or her unborn child, in serious jeopardy;  serious impairment to bodily functions; or  serious dysfunction of any bodily organ or part.  Other serious medical consequences Emergency transportation and related Emergency Service provided by a licensed ambulance service shall constitute an Emergency Service. In a true emergency, the first concern is to obtain necessary medical treatment; so Members should seek care from the nearest appropriate Facility Provider. Emergency Services do not require a Referral for treatment from the Primary Care Physician. Emergency Services Inside and Outside Keystone’s Limited Network Area Emergency Services are covered whether they are provided inside or outside Keystone’s Limited Network Area. Emergency Services do not require a Referral for treatment from the Member’s Primary Care Physician. A Member must notify their Primary Care Physician to coordinate all continuing care. Medically Necessary Care by any provider other than the Member’s Primary Care Physician will be covered until the Member can, without medically harmful consequences, be transferred to the care of their Primary Care Physician, a Referred Specialist designated by their Primary Care Physician, an Obstetrician or Gynecologist, or a Dialysis Specialist. When Emergency Services are provided by Non-Participating Providers, Benefits will be provided at the in- network benefit level. Members will be responsible for any applicable Cost-Sharing Amounts such as Deductibles, Coinsurance, and Copayments. In situations where emergency services cannot reasonably be attended to by a preferred provider, the Member is not liable for a greater out-of-pocket expense than if they had been attended to by a preferred provider. Examples of conditions requiring Emergency Services are: excessive bleeding; broken bones; serious xxxxx; sudden onset of severe chest pain; sudden onset of acute abdominal pains; poisoning; unconsciousness; convulsions; and choking. In these circumstances, 911 services are appropriate and do not requires Preauthorization.

RIGHT TO RECOVER PAYMENTS MADE IN ERROR. ‌ If the HMO should pay for any contractually excluded services through inadvertence or error, the HMO maintains the right to seek recovery of such payment from the Provider or Member to whom such payment was made. SECTION ER - EMERGENCY, URGENT CARE, FOLLOW-UP CARE WHAT ARE EMERGENCY SERVICES‌ SERVICES‌‌‌ "Emergency Services" are any health care services provided to a Member after the sudden onset of a medical condition. The condition manifests itself by acute symptoms of sufficient severity or severe pain, such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in:  • placing the health of the Member or with respect to a pregnant Member, the health of the Member or her unborn child, in serious jeopardy;  • serious impairment to bodily functions; or  • serious dysfunction of any bodily organ or part.  • Other serious medical consequences Emergency transportation and related Emergency Service provided by a licensed ambulance service shall constitute an Emergency Service. In a true emergency, the first concern is to obtain necessary medical treatment; so Members should seek care from the nearest appropriate Facility Provider. Emergency Services do not require a Referral for treatment from the Primary Care Physician. Emergency Services Inside and Outside Keystone’s Limited Network Eligibility & Service Area Emergency Services are covered whether they are provided inside or outside Keystone’s Limited Network Eligibility & Service Area. Emergency Services do not require a Referral for treatment from the Member’s Primary Care Physician. A Member must notify their Primary Care Physician to coordinate all continuing care. Medically Necessary Care by any provider other than the Member’s Primary Care Physician will be covered until the Member can, without medically harmful consequences, be transferred to the care of their Primary Care Physician, a Referred Specialist designated by their Primary Care Physician, an Obstetrician or Gynecologist, or a Dialysis Specialist. When Emergency Services are provided by Non-Participating Providers, Benefits will be provided at the in- network benefit level. Members will be responsible for any applicable Cost-Sharing Amounts such as Deductibles, Coinsurance, and Copayments. In situations where emergency services cannot reasonably be attended to by a preferred provider, the Member is not liable for a greater out-of-pocket expense than if they had been attended to by a preferred provider. Examples of conditions requiring Emergency Services are: excessive bleeding; broken bones; serious xxxxx; sudden onset of severe chest pain; sudden onset of acute abdominal pains; poisoning; unconsciousness; convulsions; and choking. In these circumstances, 911 services are appropriate and do not requires Preauthorization.

RIGHT TO RECOVER PAYMENTS MADE IN ERROR. ‌ If the HMO should pay for any contractually excluded services through inadvertence or error, the HMO maintains the right to seek recovery of such payment from the Provider or Member to whom such payment was made. SECTION ER - EMERGENCY, URGENT CARE, FOLLOW-UP CARE WHAT ARE EMERGENCY SERVICES‌ SERVICES‌‌‌ "Emergency Services" are any health care services provided to a Member after the sudden onset of a medical condition. The condition manifests itself by acute symptoms of sufficient severity or severe pain, such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in:  • placing the health of the Member or with respect to a pregnant Member, the health of the Member or her unborn child, in serious jeopardy;  • serious impairment to bodily functions; or  • serious dysfunction of any bodily organ or part.  • Other serious medical consequences Emergency transportation and related Emergency Service provided by a licensed ambulance service shall constitute an Emergency Service. In a true emergency, the first concern is to obtain necessary medical treatment; so Members should seek care from the nearest appropriate Facility Provider. Emergency Services do not require a Referral for treatment from the Primary Care Physician. Emergency Services Inside and Outside Keystone’s Limited Network 13-County Eligibility Area Emergency Services are covered whether they are provided inside or outside Keystone’s Limited Network 13-County Eligibility Area. Emergency Services do not require a Referral for treatment from the Member’s Primary Care Physician. A Member must notify their Primary Care Physician to coordinate all continuing care. Medically Necessary Care by any provider other than the Member’s Primary Care Physician will be covered until the Member can, without medically harmful consequences, be transferred to the care of their Primary Care Physician, a Referred Specialist designated by their Primary Care Physician, an Obstetrician or Gynecologist, or a Dialysis Specialist. When Emergency Services are provided by Non-Participating Providers, Benefits will be provided at the in- network benefit level. Members will be responsible for any applicable Cost-Sharing Amounts such as Deductibles, Coinsurance, and Copayments. In situations where emergency services cannot reasonably be attended to by a preferred provider, the Member is not liable for a greater out-of-pocket expense than if they had been attended to by a preferred provider. Examples of conditions requiring Emergency Services are: excessive bleeding; broken bones; serious xxxxx; sudden onset of severe chest pain; sudden onset of acute abdominal pains; poisoning; unconsciousness; convulsions; and choking. In these circumstances, 911 services are appropriate and do not requires Preauthorization.

RIGHT TO RECOVER PAYMENTS MADE IN ERROR. ‌ If the HMO should pay for any contractually excluded services through inadvertence or error, the HMO maintains the right to seek recovery of such payment from the Provider or Member to whom such payment was made. SECTION ER - EMERGENCY, URGENT CARE, FOLLOW-UP CARE WHAT ARE EMERGENCY SERVICES‌ SERVICES‌‌‌ "Emergency Services" are any health care services provided to a Member after the sudden onset of a medical condition. The condition manifests itself by acute symptoms of sufficient severity or severe pain, such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in:  • placing the health of the Member or with respect to a pregnant Member, the health of the Member or her unborn child, in serious jeopardy;  • serious impairment to bodily functions; or  • serious dysfunction of any bodily organ or part.  • Other serious medical consequences Emergency transportation and related Emergency Service provided by a licensed ambulance service shall constitute an Emergency Service. In a true emergency, the first concern is to obtain necessary medical treatment; so Members should seek care from the nearest appropriate Facility Provider. Emergency Services do not require a Referral for treatment from the Primary Care Physician. Emergency Services Inside and Outside Keystone’s Limited Network Approved Service Area Emergency Services are covered whether they are provided inside or outside Keystone’s Limited Network Approved Service Area. Emergency Services do not require a Referral for treatment from the Member’s Primary Care Physician. A Member must notify their Primary Care Physician to coordinate all continuing care. Medically Necessary Care by any provider other than the Member’s Primary Care Physician will be covered until the Member can, without medically harmful consequences, be transferred to the care of their Primary Care Physician, a Referred Specialist designated by their Primary Care Physician, an Obstetrician or Gynecologist, or a Dialysis Specialist. When Emergency Services are provided by Non-Participating Providers, Benefits will be provided at the in- network benefit level. Members will be responsible for any applicable Cost-Sharing Amounts such as Deductibles, Coinsurance, and Copayments. In situations where emergency services cannot reasonably be attended to by a preferred provider, the Member is not liable for a greater out-of-pocket expense than if they had been attended to by a preferred provider. Examples of conditions requiring Emergency Services are: excessive bleeding; broken bones; serious xxxxx; sudden onset of severe chest pain; sudden onset of acute abdominal pains; poisoning; unconsciousness; convulsions; and choking. In these circumstances, 911 services are appropriate and do not requires Preauthorization.

RIGHT TO RECOVER PAYMENTS MADE IN ERROR. If the HMO should pay for any contractually excluded services through inadvertence or error, the HMO maintains the right to seek recovery of such payment from the Provider or Member to whom such payment was made. SECTION ER - EMERGENCY, URGENT CARE, FOLLOW-UP CARE WHAT ARE EMERGENCY SERVICES‌ "Emergency Services" are any health care services provided to a Member after the sudden onset of a medical condition. The condition manifests itself by acute symptoms of sufficient severity or severe pain, such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in:  placing the health of the Member or with respect to a pregnant Member, the health of the Member or her unborn child, in serious jeopardy;  serious impairment to bodily functions; or  serious dysfunction of any bodily organ or part.  Other serious medical consequences Emergency transportation and related Emergency Service provided by a licensed ambulance service shall constitute an Emergency Service. In a true emergency, the first concern is to obtain necessary medical treatment; so Members should seek care from the nearest appropriate Facility Provider. Emergency Services do not require a Referral for treatment from the Primary Care Physician. Emergency Services Inside and Outside Keystone’s Limited Network Approved Service Area Emergency Services are covered whether they are provided inside or outside Keystone’s Limited Network Approved Service Area. Emergency Services do not require a Referral for treatment from the Member’s Primary Care Physician. A Member must notify their Primary Care Physician to coordinate all continuing care. Medically Necessary Care by any provider other than the Member’s Primary Care Physician will be covered until the Member can, without medically harmful consequences, be transferred to the care of their Primary Care Physician, a Referred Specialist designated by their Primary Care Physician, an Obstetrician or Gynecologist, or a Dialysis Specialist. When Emergency Services are provided by Non-Participating Providers, Benefits will be provided at the in- network benefit level. Members will be responsible for any applicable Cost-Sharing Amounts such as Deductibles, Coinsurance, and Copayments. In situations where emergency services cannot reasonably be attended to by a preferred provider, the Member is not liable for a greater out-of-pocket expense than if they had been attended to by a preferred provider. Examples of conditions requiring Emergency Services are: excessive bleeding; broken bones; serious xxxxx; sudden onset of severe chest pain; sudden onset of acute abdominal pains; poisoning; unconsciousness; convulsions; and choking. In these circumstances, 911 services are appropriate and do not requires Preauthorization.