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obtaining written Member consent. Neither Company nor Payor shall be Uable for any health care services or supplies wh ich are determined by Compan.v. Payor or lhelr dealgnae lo be a Non -C overed Service ; however, ,the Member may be llable ror Non-Covered Se111lces subject to the lerma set forth lo Settlons 3.9.2 through 3.9.4 herein . l.n no evenl win Company or Payor be respona!ble fur any amount owed by Member to M_edlcal . Group for Non-Covered Services In the event that Medical Group Is unable to collect such amount from Member . 3.9.2 Medical Group may btll a Member ro:r services or supplies delem, ned by Comp.any or Its designee to be not Medically Necessary only II Medical Group has obtained appropriate Member consent In writing . At a minimum. the written Member consent must Include the follow!ng information: Member name : specific service or supply : date of service , if kTiown . a stalemflnt nfoiming .the Member that lhe serv,ice or supply may; be a Non-C1>vered Service; and a statement where !he Member agrees l o pay for the Non-Covered Service . The written Member consent muat be signed by She Member, _Member's .guard l.in or Membe r's eulhorized hea llh care representative and maintained In Medical Group's reco<ds . Medical Group agrees to wrlte off and not charge Company , Payoi or Member any amount owed for not Med cally Necess_ary services or supplies if Medical Group falls to oblain suc;h written consent. 3.9.3 For services re ndered 10 Members enrolled in Med icaid that are determined by Company or Payor 10 be ln11estigetional , Medical Group must obtain the written Member consent as describ~ In the Heahhy Options Administrative Manual before re,nderlng services In order to charge lhe Men1ber for the se!Vlces . II Med fcal Group fails to obtain such written Member consent Medical Group agrees to write off end not charge Coni,:,any, Payor or Member for such lnvesfigalional services . Fo r all other Members receiving services that may be deemed lnvestiga1 onal by co.,,paoy or Payor, a written Member consent Is not required In order to cJiarge Members for such .services, However, Company still enaou,-t1ges Medical Group to Inform Member before services are rlltldered that. suet, se,vlee& may be deemed Non-Covered Secvices by· Company or Payor, and that If the services are deerned Non•Covered Services the .cost of such services will be the reaponsl blfity of the Member. 3.9.4 Services or supplies provided to Members aftl!U' they have exhausted their ar,nuaJ or Nfetlme benefit for such Hrvlces as provided In lhe S1,1bserlber Agreement shall no longer be subject to lhe terms of this Agreement , except for the clalm or ciafm line (a s epplicable) that results In the heneRt maximum to be exc_eeded , For that claim or claim line (as applfcable), M~lcal Group agre11s that any, bala~ce billed to the Member shall be the lesser of billed charges or the allowed amuunl undttr thi.s Agreement less any amount paid by Company or Payor. The "clalm llne•· language 16 appllc·abfl;! where servi~ or supplies are pa id lndlvldually . Tile "claim ~ language i& applicab le for services paJd based on an episode of care . 3 .9 .6 Medical Group shall nor bill Members for C9vered Services (except for deductibles , copaymenl,s or colnS11rance) where Company or Payor der,les paymenl because Medical Gro up ha s failed to ccmply with the terms ol this Agreement. 3. 1 0 IMEllGIBLE MEMM.B..$ -Company is nol obligated to make payment t.o Mer:flcal Group for serv ice s provided to an indivi dual who is not, al the time such services are rece ived, a duly ellglble Member . The fact l~al an htdlvid ual !)Oaaesses an ldenllncation oard wl ll not obllgate Company to pay or provide services If on the dale(s) lhal such seNice11 were rendered , the Individual Is, or la later to have found to !Jave been. lnellglbte for medical benefits; eKcept in cc1ses where ·the ·Compar,y has provided prior authorlzatJon lo the Medical Group for a requested service . Authorization by company rar a re ql.lesled service does not guarantee that the Member Is eligi ble or will conl!nue to be ellglble for Asuria MGA Agreement (Rev. 0512017) A 188 t 6854AA Page 8 ol 20