Out-of-Network Coverage Rules | ProCare Advantage
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Out-of-Network Coverage Rules

As a member of ProCare Advantage (HMO I-SNP), you must use network providers. If you receive unauthorized care from an out-of-network provider, we may deny coverage and you will be responsible for the entire cost.

Here are three exceptions:

1.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 learn what emergency or urgently needed care means, please contact Member Services at
1-844-206-3719 (TTY 711).

2.If you need medical care that 1) Medicare requires our plan to cover, and 2) the provider in our network cannot provide this care, you can get this care from an out- of-network provider. Prior Authorization should be obtained from the plan prior to seeking care. In this situation, if the care is approved, you would pay the same as you would pay if you got the care from a network provider. Your PCP or other network provider will contact us to obtain authorization for you to see an out-of- network provider.

3. Kidney dialysis services that you get at a Medicare-certified dialysis facility when you are temporarily outside the plan’s service area. In these special circumstances, it is best to ask an out-of-network provider to bill us first. If you have already paid for the covered services or if the out-of-network provider sends you a bill that you think we should pay, please contact Member Services at 1-844-206-3719 (TTY 711) or send us the bill.

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