41 5. Understand the Impact of Failure to Request Prior Authorization. Failure to timely submit a Prior Authorization request may result in a reduction of benefits, a denial of coverage, or assessment of penalties as reflected in in the Plan’s Schedule of Benefits and/or SBC. Any penalty charges assessed during Claim processing are not applied toward the Member’s satisfaction of the Deductible, Co-insurance amounts, or Out-of-Pocket limits under the Plan. However, you will not be penalized for failure to obtain Prior Authorization if a prudent layperson, who has an average knowledge of health and medicine, could reasonably expect that the absence of immediate medical attention would jeopardize the life or long-term health of the individual. Those who receive care on this basis should contact the Care Coordinators no later than two (2) business days after receiving care or a hospital admittance. 6. Understand that Participation in the Program Is Not a Guarantee of Benefits. Quantum Health strives to supply accurate and up-to-date information about provider network status, benefit estimates and Plan coverage through the Program. However, engagement with the Care Coordinators for any reason, including Pre-determinations, is not a guarantee of benefits. You are still responsible for educating yourself on the benefits available to you (under the Plan and as otherwise provided by the Plan Sponsor or community resources). Further, Prior Authorization approvals issued by Quantum Health mean that the medical condition, services, and care settings meet the Medical Management Standards adopted by the Plan. The approvals do not guarantee that the service will be a covered benefit at the time the Claim is submitted for processing as a Post-Service Claim, that you are eligible for such benefits, that other benefit conditions such as Co-payments, Deductibles, Co-insurance, or Out-of-Pocket limits have been satisfied or that you will not be subject to balance billing where services are provided by an out-of- network provider. Final determinations of coverage and eligibility for benefits are made by the Plan when the Claim is submitted for payment. The Plan’s Medical Management Standards Determinations involving medical judgment (i.e., experimental/investigative and medical necessity) that require interpretation of clinical information are reviewed by a clinician under the terms of the Plan and the clinical review criteria approved by the Plan Administrator. If the clinician is not able to justify coverage based on the established criteria or no applicable criteria is available, it is referred to a medical director for review using the general clinical review criteria or medical director criteria or is referred to a “Peer Reviewer.” A Peer Reviewer is a staff medical director or an independent reviewer but will be a Doctor of Medicine or a Doctor of Osteopathic Medicine or in the same licensure category as the ordering provider. If an initial adverse determination is pending or issued by Quantum Health based on medical judgment, the ordering provider may request a peer-to-peer conversation with the Peer Reviewer to discuss the determination and supply more information that may support coverage. The peer-to-peer must be requested by the ordering provider prior to the Member (or Authorized Representative) filing an appeal under the Plan’s Claim and Appeal procedures.