State of Illinois - HealthLink

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Uterine Embryo Lavage (UEL) – means uterus is flushed to recover a preimplantation embryo (no limit). Note: Oocyte retrievals are per lifetime of the individual. If you had completed oocyte retrieval in the past that was paid for by another carrier, or not covered by insurance, it still counts toward your lifetime maximum under the law. If an oocyte donor is used, then the completed oocyte retrieval performed on the donor shall count against the covered member as one completed oocyte retrieval. Note: See Exclusions & Limitations for additional information about infertility benefits. O. Autism – Effective January 1, 2009 – Provided for individuals younger than age 21, benefits include coverage for the diagnosis of autism spectrum disorders and for the treatment of autism spectrum disorders. This benefit will be treated the same as any other illness and is subject to the regular medical co-pay, deductible and coinsurance provisions of the plan. Upon request to the provider from the payor, a provider treating the member for autism spectrum disorders shall furnish medical records, clinical notes, or other necessary data that substantiate that initial or continued medical treatment is medically necessary and is resulting in improved clinical status. If treatment is anticipated to require continued services to achieve demonstrable progress, the payor may request a treatment plan consisting of diagnosis, proposed treatment by type, frequency, anticipated duration of treatment, and the anticipated outcomes stated as goals, and the frequency by which the treatment plan will be updated. Coverage for medically necessary early intervention services must be delivered by certified early intervention specialists. See Definitions for additional information. P. Forced Providers – Are hospital-based providers that the patient cannot choose. The charges of certain forced providers will be considered at the same benefit level as the hospital facility in which services are rendered if the provider services would fall under the Tier III level of benefits. The forced provider benefit applies only to the following inpatient or outpatient hospital facility charges: • Inpatient hospital professional fees for radiology, pathology or anesthesiology • Outpatient hospital professional fees for radiology, pathology or anesthesiology Q. Services outside the United States – The plan covers eligible charges incurred outside of the United States for services that are generally accepted as medically necessary within the United States. All benefits are subject to the plan provisions and deductibles. The benefit for facility and professional charges is paid at the out-of-network level. Notification is not required for medically necessary services rendered outside of the United States; however, medically necessity must be established prior to reimbursement unless it is emergency treatment. Payment for the services will most likely be required from the employee at the time the services are rendered. Members must file a claim with the claim administrator for reimbursement. When filing a claim, enclose the itemized bill with a description of the services translated to English and the total amount of billed charges, along with the name of the patient, date of service, diagnosis, procedure code and the provider’s name, address and telephone number. 160000 Page 11
Reimbursement in American dollars will be based on the conversion rate of the billed currency on the date services were rendered. Generally, Medicare will not pay for health care obtained outside of the United States and its territories. When Medicare does not pay, the claim administrator becomes the primary payor and standard benefit levels will apply. Remember to show your HealthLink ID card anytime you receive care. If you lose your ID card or need additional cards, please call HealthLink Customer Service toll-free at 1-800- 624-2356. (You can print a temporary ID card from the HealthLink website). Note: Because this booklet is a Summary of Benefits provided under this plan, it does not explain each and every service covered under this plan. If you have coverage questions, please call HealthLink Customer Service. 160000 Page 12
Page 1 and 2: State of Illinois Employee Health C
Page 3 and 4: INTRODUCTION You have chosen to be
Page 5 and 6: WELCOME TO THE STATE OF ILLINOIS OP
Page 7 and 8: Note: Failure to obtain pre-certifi
Page 9 and 10: Note: Preventive care benefits can
Page 11: • Donor sperm and eggs (medical c
Page 15 and 16: Section III - Covered Medical Expen
Page 17 and 18: 24. Rental fees, up to the purchase
Page 19 and 20: c. Patch: Ortho Evra d. Depo-Prover
Page 21 and 22: Section IV - Exclusions and Limitat
Page 23 and 24: 20. Infertility treatment exclusion
Page 25 and 26: debriding of a nail to expose a sub
Page 27 and 28: Section V - Continuation of Coverag
Page 29 and 30: NOTE: If the terms of a court order
Page 31 and 32: 3. Medicare Due to End-Stage Renal
Page 33 and 34: appropriateness, health care settin
Page 35 and 36: C. The plan, by payment of any proc
Page 37 and 38: E. Authorization for Release - By a
Page 39 and 40: • Autism Spectrum Disorders means
Page 41 and 42: intrauterine insemination (IUI) cyc
Page 43 and 44: conditions. Hospitals are classifie
Page 45 and 46: utilize contracted providers who ar
Page 47 and 48: Utilization review is for the purpo
Page 49 and 50: Health Care Operations - We use or
Page 51 and 52: For the QCHP Medical Plan Administr
Page 53: GENERAL PLAN INFORMATION Plan Name

State of Illinois - HealthLink

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