Claims|Authorizations

Part C Out-of-Network Information:

You must receive your care from a network provider.In most cases, care you receive from an out-of-network provider (a provider who is not part of our plan’s network) will not be covered.

Here are three exceptions:

• The plan covers emergency care or urgently needed care that you get from an out-of-network provider. For more information about this, and to see what emergency or urgently needed care means, see Section 3 in this chapter.
• If you need medical care that Medicare requires our plan to cover and the providers in our network cannot provide this care, you can get this care from an out-of-network provider. You must obtain prior authorization from Touchstone Health for these services. In this situation, you will pay the same as you would pay if you got the care from a network provider.
• Kidney dialysis services that you get at a Medicare-certified dialysis facility when you are temporarily outside the plan’s service area.

For POS Plans:

You may use either network providers or out of network providers for medical care, however, your out of network services will be at a higher cost sharing. When you receive covered services out of network, you are responsible for a 20% coinsurance of the Medicare fee schedule. This 20% coinsurance applies to all covered out of network services. You don’t need prior authorization before you get care from an out of network provider for routine care, however, prior to receiving theses services, you must call Member Services to confirm that the services are covered by the Plan and are medically necessary. You should also confirm that the provider accepts Medicare assignments and have not opted out of the Medicare Program.