Out-of-Network Providers refers to physicians and professional providers that are not in-network providers. Except for the following exceptions, services received from out-of-network providers are not covered:
- Emergency services including emergency ground ambulance transportation, and including emergency air ambulance transportation (but only with pre-certification or when ground transportation would endanger the life of the member);
- Urgent care: Approved Unavailable Service Request Form (“USRF”) services;
- Service received at an in-network facility that is prescribed by a PPO provider (in which case the service will be covered at the PPO level even if performed by an out-of-network provider);
- Any other medically necessary covered service if coverage is required by the No Surprises Act; and
- Service received in an included territory by an employee stationed in an included territory (or the employee’s eligible dependent).