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") 9.07.03 Except as provided above, no Subscriber is entitled to an extension of benefits if the termination by AvMed of this Contract is based upon one or rnore of the following reasons: a) Fraud or intentional misrepresentation in applying for any benefits under this Contract; h) Disenrollment for cause; or c) The Subscriher has left the geographic Service Area of AvMed with the intent to relocate or establish a new residence outside AvMed's Service Area. ) X. SCHEDULE OF BASIC BENEFITS AvMed is committed to arranging for comprehensive prepaid health care services rendered to its Subscribers through AvMed's network of contracted independent physicians and Hospitals and other independent health care providers, under reasonable standards of quality health care. The professional judgrnent of a physician licensed under Chapter 458 (physician), 459 (osteopath), 460 (chiropractor) or 461 (podiatrist), Florida Statutes, concerning the proper course of treatment of a Subscriber shall not be subject to modification by AvMed or its Board of Directors, Officers, or Administrators. However, this subsection is not intended to and shall not restrict any Utilization Management Program established by AvMed. Only services and benefits in conformity with Part III (DefInitions), Part X (Schedule of Basic BenefIts), Part XI (Limitations of Basic Benefits), Part Xli (Exclusions frorn Basic Benefits) and the Schedule of Benefits, which by reference is incorporated herein, are covered by AvMed. It is the Mernber's responsibility when seeking benefits under this Contract to identifY himself as a Member of AvMed and to assure that the services received by the Mernber are being rendered by Participating Providers. Any covered service for which the rnember is seeking reirnbursernent, must be submitted to the plan within one year from the date of service to be considered. Members must understand that services will not be covered if they are not, in AvMed' opinion, Medically Necessary. Any and all decisions made by AvMed in administering the provisions of this Contract, including without limitation, the provisions of Part X (Schedule of Basic Benefits), Part XI (Limitations of Basic Benefits), and Part Xli (Exclusions frorn Basic Benefits), are rnade only to determine whether payment for any benefits will be rnade by AvMed. Any and all decisions that pertain to the medical need for, or desirability of the provision or non-provision of Medical Services or benefits, including without limitation, the most appropriate level of such Medical Services or benefits, must be rnade solely by the Member and his physician, in accordance with the normal patient/physician relationship for purposes of determining what is in the best interest of the Member. AvMed does not have the right of control over the medical decisions made by the Member's physician or health care providers. The ordering of a service by a physician, whether participating or non-participating, does not in itself make such service Medically Necessary. Subscrihing Group and Mernber acknowledge that it is possible that a Member and his physician may determine that such services or supplies are appropriate even though such services or supplies are not covered and will not be arranged or paid for by AvMed. Members should remember that services that are provided or received without advance authorization from AvMed, or when the service is beyond the scope of practice authorized for that provider under State law, are not covered unless such services otherwise have been expressly authorized under the terms of this Contract or when required to treat an Emergency Medical Condition. Except for Emergency Medical Services and Care, all services rnust be received from Participating Providers. Any Member requiring medical, Hospital, or ambulance services for ernergencies (as described in Sections 3.16 and 3.17), either while temporarily outside the Service Area, or within the Service Area but before they can reach a Participating Provider, may receive the emergency benefits as specified in Section 10.11. . ) ) 21 A V -0100-2009 MP-5319 (10/09)