EOC - Erlanger Health System

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TABLE OF CONTENTS INTRODUCTION ...................................................................................................................1 BENEFIT ADMINISTRATION ERROR .............................................................................1 INDEPENDENT LICENSEE OF THE BLUECROSS BLUESHIELD ASSOCIATION................................................................................1 HEALTHY FOCUS PROGRAM...........................................................................................1 LIFETIME MAXIMUM.........................................................................................................1 RELATIONSHIP WITH NETWORK PROVIDERS..........................................................2 NOTIFICATION OF CHANGE IN STATUS ......................................................................2 ELIGIBILITY..........................................................................................................................3 ENROLLMENT.......................................................................................................................4 EFFECTIVE DATE OF COVERAGE..................................................................................5 TERMINATION OF COVERAGE .......................................................................................6 SUBROGATION AND RIGHT OF REIMBURSEMENT..................................................7 BLUECARD/BLUECARD PPO PROGRAM.......................................................................9 CLAIMS AND PAYMENT...................................................................................................11 PRIOR AUTHORIZATION, CARE MANAGEMENT, MEDICAL POLICY AND PATIENT SAFETY........................................................................13 CONTINUATION OF COVERAGE...................................................................................15 COORDINATION OF BENEFITS......................................................................................18 GRIEVANCE PROCEDURE...............................................................................................23 DEFINITIONS .......................................................................................................................26 ATTACHMENT A: COVERED SERVICES AND LIMITATIONS ON COVERED SERVICES.....................................................................................34 ATTACHMENT B: EXCLUSIONS FROM COVERAGE ..............................................52 ATTACHMENT C: PPO SCHEDULE OF BENEFITS ...................................................54 ATTACHMENT C: PPO SCHEDULE OF BENEFITS ...................................................63 ATTACHMENT C: PPO SCHEDULE OF BENEFITS ...................................................72 ATTACHMENT D: STATEMENT OF ERISA RIGHTS................................................81 MATERNITY AND NEWBORN COVERAGE.................................................................83 IMPORTANT NOTICE FOR MASTECTOMY PATIENTS ...........................................83 NOTICE REGARDING CERTIFICATES OF CREDITABLE COVERAGE ...............83 UNIFORMED SERVICES EMPLOYMENT AND REEMPLOYMENT RIGHTS ACT OF 1994............................................................................................84 NOTICE OF PRIVACY PRACTICES................................................................................85 Erlanger Health System 2009
INTRODUCTION This Evidence of Health Coverage (this “EOC”) is included in the Summary Plan Description document (SPD) created by the Employer (listed on the cover of this EOC) as part of its employee welfare benefit plan (the “Plan”) , and is subject to the requirements of the Employee Retirement Income Security Act of 1974, as amended (ERISA). References in this EOC to “administrator,” “We,” “Us,” “Our,” or “BCBST” mean BlueCross BlueShield of Tennessee, Inc. The Employer has entered into an Administrative Services Agreement (ASA) with BCBST for it to administer the claims Payments under the terms of the SPD, and to provide other services. BCBST is not the Plan Sponsor, the Plan Administrator or the Plan Fiduciary, as those terms are defined in ERISA. The Employer is the Plan Fiduciary, the Plan Sponsor and the Plan Administrator. Other federal laws may also affect Your Coverage. To the extent applicable, the Plan complies with federal requirements. This EOC describes the terms and conditions of Your Coverage through the Plan. It replaces and supersedes any EOC or other description of benefits You have previously received from the Plan. PLEASE READ THIS EOC CAREFULLY. IT DESCRIBES THE RIGHTS AND DUTIES OF MEMBERS. IT IS IMPORTANT TO READ THE ENTIRE EOC. CERTAIN SERVICES ARE NOT COVERED BY THE PLAN. OTHER COVERED SERVICES ARE LIMITED. THE PLAN WILL NOT PAY FOR ANY SERVICE NOT SPECIFICALLY LISTED AS A COVERED SERVICE, EVEN IF A HEALTH CARE PROVIDER RECOMMENDS OR ORDERS THAT NON-COVERED SERVICE. (SEE ATTACHMENTS A-D.) While the Employer has delegated discretionary authority to make any benefit or eligibility determinations to the administrator, the Employer also has the authority to make any final Plan determination. The Employer, as the Plan Administrator, and BCBST also have the authority to construe the terms of Your Coverage. The Plan and BCBST shall be deemed to have properly exercised that authority unless it abuses its discretion when making such determinations, whether or not the Employer’s benefit plan is subject to ERISA. In order to make it easier to read and understand this EOC, defined words are capitalized. Those words are defined in the “DEFINITIONS” section of this EOC. Please contact one of the administrator’s consumer advisors, at the number listed on the Subscriber’s membership ID card, if You have any questions when reading this EOC. The consumer advisors are also available to discuss any other matters related to Your Coverage from the Plan. BENEFIT ADMINISTRATION ERROR If the administrator makes an error in administering the benefits under this EOC, the Plan may provide additional benefits or recover any overpayments from any person, insurance company, or plan. No such error may be used to demand more benefits than those otherwise due under this EOC. INDEPENDENT LICENSEE OF THE BLUECROSS BLUESHIELD ASSOCIATION BCBST is an independent corporation operating under a license from the BlueCross BlueShield Association (the “Association.”) That license permits BCBST to use the Association’s service marks within its assigned geographical location. BCBST is not a joint venturer, agent or representative of the Association nor any other independent licensee of the Association. HEALTHY FOCUS PROGRAM Healthy Focus is a disease management program available through the Employer and managed by LifeMasters Supported SelfCare. Through this program, You can receive extra resources and personalized attention to help manage chronic health conditions and help You take better care of Yourself. Participation in the program is voluntary. LIFETIME MAXIMUM Your Lifetime Maximum is not re-set when You become Covered under this EOC. It is governed by the Employer’s Plan. ANY GRIEVANCE RELATED TO YOUR COVERAGE UNDER THIS EOC SHALL BE RESOLVED IN ACCORDANCE WITH THE “GRIEVANCE PROCEDURE” SECTION OF THIS EOC. 1 Erlanger Health System 2009
Page 1 and 2: ERLANGER HEALTH SYSTEM Health Benef
Page 3: Erlanger Health System 2009
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 and 38: difference between Billed Charges a
Page 39 and 40: ATTACHMENT A: COVERED SERVICES AND
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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EOC - Erlanger Health System

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