Out-of-Network Coverage Rules

First See Your Primary Care Physician

With limited exceptions, while you are a member of our plan you must use network providers to get your medical care and services. Most of your care may likely be performed by your Primary Care Physician (PCP). When you need other services like seeing a specialist, getting tests, or getting surgical procedures, your PCP will request those services in advance and get approval so the health plan will pay for all or much of the costs.

Exceptions for Getting Out-of-Area Emergency Services

There are some exceptions when Brand New Day covers out-of-area services:

• Emergencies when you are temporarily out of the service area
• Urgently needed care when you are temporarily out of the service area
• Out-of-area dialysis services (please notify us in advance and we will help arrange for those services)

Exceptions for Getting Out-of-Area Specialty Services

If you need a specialist that is not in your local contracting network, Brand New Day will arrange for services with a non-contracting specialist to ensure there is no delay in getting you the care you need. These services need to be arranged in advance.

When Would I Be Responsible for Paying the Full Cost of Services?

• If you did not get advanced written approval or an authorization and obtained services from a non-contracted provider
• If you did not get advance written approval/authorization for specialty services
• If you did not get advanced written approval or an authorization and obtained services out of the service area

For Help in Obtaining Approval or Authorizations:

1. See your PCP first, if possible, and request for an authorization for the services you need.
2. If you're unable to schedule an appointment, call Brand New Day and request an authorization: