EOC - Erlanger Health System

ii.
iii.
Attachment C: Schedule of
Benefits, at the Transplant
Maximum Allowable Charge. The
In-Transplant Network Provider
cannot bill You for any amount
over the Transplant Maximum
Allowable Charge for the
transplant, which limits Your
liability;
In-Network transplants. You have
the transplant performed outside the
Transplant Network, but still at a
facility that is an In-Network
Provider or a BlueCard PPO
Participating Provider. The Plan
will reimburse the In-Network or
BlueCard PPO Participating
Provider at the benefit levels listed
in Attachment C: Schedule of
Benefits, limited to the Transplant
Maximum Allowable Charge.
There is no maximum to Your
liability. The Provider also has the
right to bill You for any amount not
Covered by the Plan – this amount
may be substantial;
Out-of-Network transplants. You
have the transplant performed by an
Out-of-Network Provider (i.e.,
outside the Transplant Network, and
not at a facility that is an In-
Network Provider or a BlueCard
PPO Participating Provider). The
Plan will reimburse the Out-of-
Network Provider only at the
benefit level listed in Attachment C:
Schedule of Benefits, limited to the
Transplant Maximum Allowable
Charge. There is no maximum to
Your liability. The Out-of-
Network Provider also has the
right to bill You for any amount
not Covered by the Plan - this
amount may be substantial;
You can find out what the Transplant
Maximum Allowable Charge is for Your
transplant by contacting Transplant Case
Management. Remember, the Transplant
Maximum Allowable Charge can and does
change from time to time.
f. Kidney transplants. There are two levels
of benefits for kidney transplants: In-
Network and Out-of-Network:
ii.
i. In-Network kidney transplants.
You have a kidney transplant
performed at a facility that is an In-
Network Provider or a BlueCard
PPO Participating Provider. You
receive the highest level of
reimbursement for Covered
Services. The In-Network or
BlueCard PPO Participating
Provider cannot bill You for any
amount over the Maximum
Allowable Charge for the
transplant, which limits Your
liability;
Out-of-Network kidney transplants.
You have a kidney transplant
performed by an Out-of-Network
Provider (i.e., not at a facility that
is an In-Network Provider or a
BlueCard PPO Participating
Provider). The Plan will reimburse
the Out-of-Network Provider only
at the benefit level listed in
Attachment C: Schedule of
Benefits, at the Maximum
Allowable Charge. There is no
maximum to Your liability. The
Out-of-Network Provider also has
the right to bill You for any
amount not Covered by the Plan -
this amount may be substantial;
g. If You go through Transplant Case
Management for Your transplant, follow
its procedures, cooperate fully with them,
and have Your transplant performed at an
In-Transplant Network Institution, the
transplant expenses specified in
Attachment C: Schedule of Benefits are
Covered, up to Your Lifetime Maximum.
4. Exclusions
The following services, supplies and charges
are not Covered under this section:
a. If You do not receive Prior
Authorization, the transplant and related
services will not be Covered;
b. Any service specifically excluded under
Attachment B: Exclusions from
Coverage, except as otherwise provided
in this section;
c. Services or supplies not specified as
Covered Services under this section;
Attachment A 42
Erlanger Health System 2009