Will a Health Maintenance Organization (HMO) plan cover an out-of-network (OON) gastroenterology consultation when an in-network option is available?

HMO Out-of-Network Gastroenterology Consultation Coverage Decision

This request should be denied based on the member certificate language, as the HMO plan explicitly excludes coverage for specialty care provided by non-contracted providers when the service can be provided by an in-network specialist.

Certificate Language Analysis

The member's HMO certificate is unambiguous on this matter:

• The certificate states that "specialty medical care provided by a non-[LOCATION] Provider, whether or not under contract with [LOCATION], is not covered if the service requested may be provided by a [LOCATION] specialty Provider" 1
• The plan explicitly limits prior authorizations for specialty care to the contracted provider panel 1
• This is a fundamental limitation of HMO plan design, where members accept restricted provider networks in exchange for lower premiums 1

Clinical Context Does Not Override Contract Language

While the member has a legitimate clinical need for ongoing gastroenterology follow-up after her POEM procedure:

• The previous out-of-network approvals were specifically justified because the POEM procedure itself was not available at in-network facilities 1
• Standard gastroenterology consultation services for post-procedural follow-up are routinely available through in-network gastroenterologists 2
• Post-POEM follow-up does not require the same specialist who performed the procedure, nor does it require specialized expertise beyond standard gastroenterology practice 2

Appropriate Care Pathway

The member can receive appropriate post-procedural care through in-network options:

• Gastroenterology consultation for achalasia management, including post-POEM follow-up, represents standard specialty care that in-network gastroenterologists are qualified to provide 2
• Telemedicine options with in-network gastroenterologists could facilitate continuity discussions with the out-of-network surgical team if coordination is needed 2
• The member's established relationship with the out-of-network provider does not create an exception to the certificate's in-network requirement 1

Common Pitfalls to Avoid

• Do not conflate the medical necessity of gastroenterology follow-up with the necessity of out-of-network care - these are separate determinations 1
• Avoid setting precedent that any prior out-of-network approval creates ongoing out-of-network coverage rights for related but separately available services 1
• The fact that the member has an appointment scheduled does not obligate the plan to cover services that fall outside certificate benefits 1

Coverage Decision Rationale

The denial is appropriate because:

• In-network gastroenterology providers are available and capable of providing the requested consultation services 2
• The certificate explicitly excludes out-of-network specialty care when in-network alternatives exist 1
• The previous out-of-network approvals were procedure-specific exceptions that do not extend to routine follow-up care 1
• Approving this request would violate the fundamental HMO plan structure and create unsustainable precedent 1