Covered services received from providers are subject to the deductible and coinsurance specified in the Outline of Coverage. Members may be required to submit payment in full to Providers at the time Health Care Services are rendered. If a Member pays amounts above the applicable Deductible and Coinsurance for Covered Services, the Member may submit a claim for Reimbursement directly to New West. Please note that claims for Reimbursement Benefits must be submitted to New West Health Services within one year of the date that the Health Care Services were rendered. Reimbursement is based on the New West fee schedule.
Reimbursement is less when services are received from non-participating providers.
In addition to applicable Deductible and Coinsurance obligations, Members may be financially responsible for any amounts a Provider charges that are above the amount New West Health Services considers Usual, Customary and Reasonable for such Covered Services, or for any services rendered that are not Medically Necessary Covered Services as described in the Group Contract. In an Emergency, a Member should call 911 or go directly to the nearest Hospital emergency room or medical facility for treatment. Emergency Health Care Services are subject to the Deductible and Coinsurance as specified in the Outline of Coverage and fall under your in-network benefits. Members must notify a New West Health Services Patient Care Coordinator of an Emergency Room visit within 48 hours of treatment, or as soon as is reasonably possible thereafter. However, New West Health Services shall not deny reimbursement for Emergency services claims if the Member possesses average knowledge of health and medicine and in good faith seeks medical care for what reasonably appears to the Member to be an acute condition that requires immediate medical attention, even if the Member's condition is subsequently determined not to be an Emergency.