Issued and entered November 22, 2002 by Frank M. Fitzgerald, Commissioner

ORDER

I
PROCEDURAL BACKGROUND

On August 20, 2002, Petitioner XXXX XXXXXXX filed a request for external review with the Commissioner of Financial and Insurance Services (Commissioner) under the Patient’s Right to Independent Review Act, MCL 550.1901 et seq. The Commissioner did not accept the request because it did not provide proof Petitioner exhausted the internal grievance process of her health maintenance organization (HMO). However, on October 24, 2002, Petitioner submitted a copy of the final adverse determination issued at the conclusion of her internal grievance. Such information allowed the Commissioner to then accept Petitioner’s request for external review.

The case does not involve a medical issue; therefore, review by an Independent Review Organization (IRO) is not required. The issue is contractual in nature. The Commissioner reviews contractual issues under MCL 550.1911(7). On November 12, 2002, the Office of Financial and Insurance Services (OFIS) received from Physicians Health Plan of Mid-Michigan (PHPMM) the information used to make the final adverse determination in Petitioner’s case.

II
FACTUAL BACKGROUND

Petitioner is a PHPMM member. Her health care plan allows her to seek services from participating providers in other Physicians Health Plan networks in Michigan. She chose a Primary Physician from the Physicians Health Plan of Southwest Michigan (PHPSWM) network. This choice caused PHPSWM to become her Servicing Plan, responsible for customer service and the resolution of member complaints and grievances. PHPMM is still her benefit provider, and Petitioner’s PHPMM Certificate of Coverage still governs her coverage. PHPMM acts as her Sponsor Plan, responsible for responding to member appeals to OFIS.

Petitioner underwent orthoscopic knee surgery in XXXXXXXX after which her in-network surgeon recommended physical therapy. The surgeon referred her to an out-of-network clinic located in the same building as his office. She did not receive a referral from her Primary Physician. She went to the out-of-network clinic for 10 physical therapy sessions from XXXX, XXXXXXXXXXXXXXXXXXXXXXXX. Almost two years later, she received a bill from the out-of-network clinic. The clinic noted Petitioner had been denied coverage for the physical therapy due to non-notification of services. Petitioner initiated PHPMM’s internal grievance process on July 2, 2002. Her grievances were heard by PHPSWM, because it was her Servicing Plan. PHPSWM reached a final adverse determination in her case on July 25, 2002.

III
ISSUE

Did PHPSWM properly deny Petitioner coverage for out-of-network physical therapy services referred by an in-network specialist?

IV
ANALYSIS

PETITIONER’S ARGUMENT

Petitioner argues she should receive coverage for the services at issue in this case because she thought the clinic she went to was an in-network facility. She asserts this belief was reasonable based on the following facts:

1. Her orthoscopic surgeon is an in-network specialist, and the clinic was in the same building as his office.
2. Her in-network surgeon referred her to the clinic.
3. The clinic led her to believe that she would receive full coverage for her treatment there.

Petitioner claims that if these factors had not combined to give her the reasonable belief that she was free from financially liability for her physical therapy, she would have gone elsewhere or at least not accumulated as large a bill. Therefore, Petitioner asserts PHPSWM’s final adverse determination in her case should be reversed.

PHPMM’S ARGUMENT

In a letter dated November 11, 2002, PHPMM submitted to OFIS its argument in this case. The letter states:

Absent ambiguity in the terms of the benefit contract, the contract must be interpreted according to the provisions, as written and approved. The PHPMM benefit contract contains multiple references within the document, all of which are clear and unambiguous, and which PHPMM believes supports its denial of coverage…These specific references are included in the…Certificate of Coverage…

1. Page iii, Health Services Covered Under the Policy, paragraph 1, provides that:
   
   “[I]n order for Health Services to be covered, you must obtain all Health Services directly from or through your Primary Physician, with the exception of Medically Necessary Emergency Health Services and Health Services provided at an Urgent Care Center outside the Service Area.”

[The clinic where Petitioner received the services at issue] is a specialist provider, this does not qualify as [Petitioner’s] Primary Physician, nor was [Petitioner] referred to [the clinic] by her Primary Physician. The physical therapy services provided, similarly, do not qualify as emergent or urgent medical services. Under the express terms of this section, coverage is not available for these services.

2. Page iii, Health Services Covered Under the Policy, paragraph 1, provides an advisory statement that reads:
   
   “[s]o that you will not be required to pay bills for non-Covered services, you must always verify the participation status of a Physician, Hospital or other provider.…You can verify the participation status by calling the PLAN. …” (emphasis added)

This provision clearly imposes an affirmative obligation on an enrollee to verify the status of participation. …The language is clear, and PHPMM should not be held financially liable for [Petitioner’s] failure to take the single step of verifying participation status.

3. Section 4.1 Reimbursement of Eligible Expenses…states that:
   
   “[t]he Plan shall reimburse you for Eligible Expenses incurred with non-network providers only for emergency health services, health services at an urgent care center outside of the service area, or services authorized or approved by the plan in accordance with the terms of the Policy.” (emphasis added)
   
   …[Petitioner’s] therapy services are none of the above that are eligible for reimbursement. …
   
4. Section 9.1 Health Services Rendered by Network Providers, states in paragraphs 1 and 2, that:
   
   “[y]ou are eligible for Coverage for Health services…provided by or under the direction of your Primary Physician. …
   
   Health Services which are not provided by or under the direction of your Primary Physician are not Covered…
   (emphasis added)
   
   …The physical therapy services obtained by [Petitioner] do not satisfy any of the criteria for coverage under this section. …
   
5. Section 9.3 Verification of Participation Status…states:
   
   If you fail to verify participation status or to show your ID card, and that failure results in non-compliance with required plan procedures, Coverage may be denied. (emphasis added)

…Grievant at no time, made any effort to verify the participation status of [the clinic where she obtained the services at issue]. …

6. Section 9.5 Referral Health Services…clearly states that all services must be coordinated or provided by the Primary Physician. This section also describes the several situations where a referral from the Primary Physician is not required.
   
   The physical therapy services obtained by Grievant are not on the list of services that do not require referral [by the Primary Physician]. …
   
7. Section 9.6 Prior Plan Approval. This section provides that:
   
   [I]t is your Primary Physicians responsibility to obtain the required PLAN approval prior to issuing a referral for you to see any other provider. The PLAN has identified for your Primary Physician those Health Services which require prior approval and has designated the appropriate process for referral.”

Had [Petitioner] followed the terms of this section, her Primary Physician would have known to refer to a participating provider for physical therapy, and this dispute would not have occurred. PHPMM should not be held responsible for [Petitioner’s] failure to follow the clearly described protocols for obtaining services.

CONCLUSION

The terms of this benefit contract clearly and repeatedly refer to the requirement that service be provided by or directed by a Primary Physician. The terms of the contract clearly and repeatedly refer to the enrollee’s responsibility to verify the participation status of…providers before obtaining services, and clearly states that there is a risk that a failure to verify participation status may result in enrollee liability.

While it is unfortunate that [Petitioner] has been left in this position, PHPMM believes that the clear language of its benefit contract must be given force. …The treating provider may have acted inconsistent with expectations of a physician’s office, but PHPMM cannot intervene in that circumstance, nor should PHPMM be held responsible for payment of those services.

COMMISSIONER’S REVIEW

The Commissioner carefully reviewed the arguments and documents presented by the parties in this matter. The focus of this analysis is whether the out-of-network physical therapy services Petitioner received from XXXXXXXXX through XXXXXXXXXX, are a covered benefit under her PHPMM Certificate of Coverage. After a close examination of the terms of the Certificate, the Commissioner concurs with PHPMM’s argument in this case. The Certificate provisions entitled “Health Services Covered Under this Policy,” as well as Section 4.1 “Reimbursement of Eligible Expenses,” Section 9.1 “Health Services Rendered,” Section 9.3 “Verification of Participation Status,” Section 9.5 “Referral Health Services,” and Section 9.6 “Prior Plan Approval,” clearly and repeatedly establish that for any service to be eligible for PHPMM coverage, the service must be obtained from or directed by a member’s Primary Physician. Also, the service must be obtained within a network of participating providers.

The language of the Certificate also clearly and unambiguously establishes that it is a PHPMM member’s responsibility to make sure the referral requirements are met prior to obtaining health care. The services at issue in this case did not meet either of these two requirements. Also, Petitioner took no action to make sure the services were eligible for coverage before they were performed. Accordingly, the Commissioner finds that PHPSWM’s final adverse determination in this matter is valid.

V
ORDER

It is ORDERED that PHPSWM’s July 25, 2002, final adverse determination in this case is upheld. PHPMM is not required to cover Petitioner for the out-of-network physical therapy she received from XXXXXXXXXX through XXXXXXXXXXX.

This is a final decision of an administrative agency. Under MCL 550.1915, any person aggrieved by this Order may seek judicial review no later than sixty days from the date of this Order in the Circuit Court for the county where the covered person resides or in the Circuit Court of Ingham County. A copy of the petition for judicial review should be sent to the Commissioner of the Office of Financial and Insurance Services, Health Plans Division, Post Office Box 30220, Lansing, MI 48909-7720.