EOC - Erlanger Health System

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identify each health plan to which such order applies. 66. Specialty Pharmacy Products – Injectable, infusion and select oral medications that require complex care, including special handling, patient education and continuous monitoring. Specialty Pharmacy Products are listed on the administrator’s Specialty Pharmacy Products list. Specialty Pharmacy Products are categorized as provideradministered or self-administered. 67. Subscriber – An Employee who meets all applicable eligibility requirements, has enrolled for Coverage and who has submitted the applicable Payment for Coverage. 68. Totally Disabled or Total Disability – Either: a. An Employee who is prevented from performing his or her work duties and is unable to engage in any work or other gainful activity for which he or she is qualified or could reasonably become qualified to perform by reason of education, training, or experience because of injury or disease; or b. A Covered Dependent who is prevented from engaging in substantially all of the normal activities of a person of like age and sex in good health because of nonoccupational injury or disease. 69. Transplant Maximum Allowable Charge (TMAC) – The amount that the administrator, in its sole discretion, has determined to be the maximum amount payable for covered Services for Organ Transplants. Each type of Organ Transplant has a separate TMAC. 70. Transplant Services – Medically Necessary and Appropriate Services listed as Covered under the Transplant Services section in Attachment A of this EOC. 71. Waiting Period – The time that must pass before an Employee or Dependent is eligible to be Covered for benefits under the Plan. 72. Well Child Care – A routine visit to a pediatrician or other qualified Practitioner to include Medically Necessary and Medically Appropriate Periodic Health Screenings, immunizations and injections for children up to the age of 6 years. 73. Well Woman Exam – A routine visit every Calendar Year to a Provider. The visit may include Medically Necessary and Medically Appropriate mammogram and cervical cancer screenings. 34 Erlanger Health System 2009
ATTACHMENT A: COVERED SERVICES AND LIMITATIONS ON COVERED SERVICES EVIDENCE OF COVERAGE The Plan will pay the Maximum Allowable Charge for Medically Necessary and Appropriate services and supplies described below and provided in accordance with the reimbursement schedules set forth in Attachment C, Schedule of Benefits of this EOC, which is incorporated herein by reference. Charges in excess of the reimbursement rates set forth in the Schedule of Benefits are not eligible for reimbursement or payment. To be eligible for reimbursement or payment, all services or supplies must be provided in accordance with the administrator’s medical policies and procedures. (See Medical Policy and Medical Management Section.) Covered Services and Limitations set forth in this Attachment are arranged according to: ! Eligible Providers, and ! Eligible services. An advantage of using PPO Network Providers is these Providers have agreed to accept the Maximum Allowable Charge set by the Plan for Covered Services. Network Providers have also agreed not to bill You for amounts above these amounts. However, Out-of-Network Providers do not have a contract with the Plan. This means they may be able to charge You more than the allowable amount set by the Plan in its contracts. With Outof-Network Providers, You will be responsible for any difference between what the Plan pays and what You are charged. I. ELIGIBLE PROVIDERS OF SERVICE A. Practitioners All services must be rendered by a Practitioner type listed in the administrator’s Provider Directory of Network Providers, or as otherwise required by Tennessee law. The services provided by a Practitioner must be within his or her specialty or degree. All services must be rendered by the Practitioner, or the delegate actually billing for the Practitioner, and be within the scope of his or her licensure. B. Network Provider A Provider who has contracted with the administrator to provide Covered Services. C. Non-Contracted Provider A Provider that renders Covered Services to a Member but is in a specialty category or type with which We do not contract. A Non- Contracted Provider is not eligible to hold a contract with the administrator. D. Out-of-Network Provider Any Provider who is an eligible Provider type but who does not hold a contract with the administrator to provide Covered Services. E. Other Providers of Service An individual or facility, other than a Practitioner, duly licensed to provide Covered Services. Obtaining services not listed in this Attachment or not in accordance with the administrator’s medical policies and procedures may result in the denial of payment or a reduction in reimbursement for otherwise eligible Covered Services. The administrator’s Medical Policies can help Your Provider determine if a proposed service will be Covered. Attachment A 35 Erlanger Health System 2009
Page 1 and 2: ERLANGER HEALTH SYSTEM Health Benef
Page 3 and 4: Erlanger Health System 2009
Page 5 and 6: INTRODUCTION This Evidence of Healt
Page 7 and 8: ELIGIBILITY Any Employee of the Emp
Page 9 and 10: EFFECTIVE DATE OF COVERAGE If You a
Page 11 and 12: SUBROGATION AND RIGHT OF REIMBURSEM
Page 13 and 14: BLUECARD/BLUECARD PPO PROGRAM When
Page 15 and 16: CLAIMS AND PAYMENT When You receive
Page 17 and 18: PRIOR AUTHORIZATION, CARE MANAGEMEN
Page 19 and 20: Your concern will be noted and inve
Page 21 and 22: the Termination of Coverage Section
Page 23 and 24: COORDINATION OF BENEFITS This EOC i
Page 25 and 26: (1) First, the Plan of the parent w
Page 27 and 28: of This Plan and such rule states t
Page 29 and 30: II. DESCRIPTION OF THE REVIEW PROCE
Page 31 and 32: DEFINITIONS Defined terms are capit
Page 33 and 34: 24. Employee - A person who fulfill
Page 35 and 36: Investigational Service. If the Med
Page 37: difference between Billed Charges a
Page 41 and 42: C. Office Surgery Medically Necessa
Page 43 and 44: injections; (7) fertility drugs, (8
Page 45 and 46: The following Medically Necessary a
Page 47 and 48: d. If You receive Prior Authorizati
Page 49 and 50: d. Items to replace those that were
Page 51 and 52: 3. Three intensive outpatient progr
Page 53 and 54: syringes used in conjunction with i
Page 55 and 56: k. Maintenance Drug - Prescription
Page 57 and 58: EVIDENCE OF COVERAGE ATTACHMENT B:
Page 59 and 60: EVIDENCE OF COVERAGE ATTACHMENT C:
Page 61 and 62: (Family/General Practice, Internal
Page 63 and 64: Other Wellcare Screenings, age 6 an
Page 65 and 66: Schedule of Pharmacy Prescription D
Page 67 and 68: Miscellaneous Limits: In-Network Se
Page 69 and 70: Diagnostic Services and Preventive
Page 71 and 72: Services Received at a Facility Inp
Page 73 and 74: Organ Transplant Services Organ Tra
Page 75 and 76: Benefit percentages apply to BCBST
Page 77 and 78: EVIDENCE OF COVERAGE ATTACHMENT C:
Page 79 and 80: (Family/General Practice, Internal
Page 81 and 82: Other Wellcare Screenings, age 6 an
Page 83 and 84: Schedule of Pharmacy Prescription D
Page 85 and 86: Miscellaneous Limits: In-Network Se
Page 87 and 88: the U. S. Department of Labor, or m
Page 89 and 90:
UNIFORMED SERVICES EMPLOYMENT AND R
Page 91 and 92:
MARKETING: Your medical information
Page 93:
www.bcbst.com BENEFIT QUESTIONS? Ca
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