Out-of-Network Medical Coverage

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 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 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 You Could Become Responsible for Paying the Full Cost of Services:

  • If you obtained services from non-contracting providers without advance written approval/authorization
  • If you did not get advance approval/authorization for specialty services
  • If you were out of the service area and obtained services without advance written approval/authorization

For help in obtaining approval/authorizations:

  1. See your PCP first, if possible.
  2. Call Brand New Day and request an authorization:

Call 866-255-4795 or TTY 866-321-5955 and ask for the Authorization Dept. These departments handle this kind of request between 8 a.m. and 5 p.m. unless it is very urgent, in which case we can be reached 24 hours a day, 7 days a week.

Please refer to Chapter 3 your Evidence of Coverage for full information on out-of-network medical coverage.