What if the medical care recommended by a PCP is not available through a plan specialist or plan provider?
If medically necessary covered services are not available through plan physicians or plan providers, Health Advantage, on the request of a plan physician or plan provider or the member, made within a reasonable period prior to receiving the service, may authorize covered services by a non-plan physician or provider at the allowable charge or an agreed rate. Even though services are covered at the in-network benefit level, a non-plan physician or provider may bill the member for the charges in excess of the allowable charges. The member may have information or medical records submitted from the physician with their out-of-network request.
Related Questions
- What if the medical care recommended by a primary care physician is not available through a plan specialist or plan provider?
- What if the medical care recommended by a PCP is not available through a plan specialist or plan provider?
- What if the medical care recommended by my PCP is not available through a plan specialist or provider?
