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General Plan Exclusions and Limitations23. Charges for the following treatments, services or supplies:A. Charges related to or connected with treatments, services or supplies that are excludedunder this Plan.B. Charges that are the result of any medical complication resulting from a treatment, serviceor supply which is, or was at the time the charge was incurred, excluded from coverageunder this Plan.24. Charges for treatment, services or supplies not actually rendered to or received and used by theCovered Person.25. Broken or missed appointments.26. Charges that are incurred outside of the United States if the Covered Person traveled to such alocation for the purpose of obtaining treatment, services, drugs, or supplies.Western Montana Providence Health & Services - SPD 40Group #2000204 - January 1, 2011
COORDINATION OF BENEFITSThe Coordination of Benefits provision prevents the payment of benefits which exceed the MaximumEligible Expenses or Procedure Based Limit. It applies when the Participant or Dependent who is coveredby this Plan is or may also be covered by any other plan(s). This Plan will always pay either its benefits infull or a reduced amount which, when added to the benefits payable by the other plan(s), will not exceed100% of Maximum Eligible Expense or Procedure Based Limit. Only the amount paid by this Plan will becharged against the Plan maximums.In the event of a motor vehicle or premises accident; or an act of violence with the intent to disruptelectronic, communications, or any other business system, this Plan will be secondary to any auto “nofault” and traditional auto “fault” type contracts, homeowners, commercial general liability insurance andany other medical benefits coverage.The Coordination of Benefits provision applies whether or not a claim is filed under the other plan or plans.If needed, authorization is hereby given this Plan to obtain information as to benefits or services availablefrom the other plan or plans, or to recover overpayments.All benefits contained in the Plan <strong>Document</strong> are subject to this provision.DEFINITIONS“Plan” as used herein means any Plan providing benefits or services for or by reason of medical, dental orvision treatment, and such benefits or services are provided by:1. Group insurance or any other arrangement for coverage for Covered Persons in a group whetheron an insured or uninsured basis, including but not limited to:A. Hospital indemnity benefits; andB. Hospital reimbursement-type plans which permit the Covered Person to elect indemnity atthe time of claims; or2. Hospital or medical service organizations on a group basis, group practice and other group prepaymentplans; or3. Hospital or medical service organizations on an individual basis having a provision similar in effectto this provision; or4. A licensed Health Maintenance Organization (H.M.O.); or5. Any coverage for students which is sponsored by, or provided through a school or othereducational institution; or6. Any coverage under a Governmental program, and any coverage required or provided by anystatute; or7. Automobile insurance; or8. Individual automobile insurance coverage on an automobile leased or owned by the Company orany responsible third-party tortfeasor; or9. Individual automobile insurance coverage based upon the principles of “No-Fault” coverage; or10. Homeowner or premise liability insurance, individual or commercial.Western Montana Providence Health & Services - SPD 41Group #2000204 - January 1, 2011
Page 2: Western Montana Providence Health &
Page 9 and 10: SCHEDULE OF MEDICAL BENEFITS - PROV
Page 11 and 12: Schedule of Medical Benefits - Prov
Page 13 and 14: SCHEDULE OF MEDICAL BENEFITS - PROV
Page 16 and 17: Schedule of Medical Benefits - Prov
Page 18 and 19: Pharmacy BenefitWhen Primary Covera
Page 20 and 21: Pharmacy BenefitPRIMARY COVERAGE UN
Page 22 and 23: MEDICAL BENEFIT DETERMINATION REQUI
Page 24 and 25: Medical Benefit Determination Requi
Page 26 and 27: Medical Benefits5. Charges made by
Page 28 and 29: Medical Benefits15. Charges for dru
Page 30 and 31: Medical BenefitsGENETIC AND INFERTI
Page 32 and 33: Medical BenefitsPREVENTIVE CARE“P
Page 34 and 35: Medical Benefits3. Services provide
Page 36 and 37: Medical BenefitsBody Mass Index (BM
Page 38 and 39: Pre-Authorization6. A letter of med
Page 40 and 41: Hospital Admission CertificationCON
Page 42 and 43: Medical Benefit Exclusions10. Charg
Page 44 and 45: GENERAL PLAN EXCLUSIONS AND LIMITAT
Page 48 and 49: Coordination of Benefits“Plan”
Page 50 and 51: Coordination of Benefits3. For Cove
Page 52 and 53: Procedures for Claiming Benefits1.
Page 54 and 55: Procedures for Claiming Benefits2.
Page 56 and 57: Eligibility ProvisionsD. The ABR is
Page 58 and 59: EFFECTIVE DATE OF COVERAGEAll cover
Page 60 and 61: Effective Date of CoverageD. Placem
Page 62 and 63: QUALIFIED MEDICAL CHILD SUPPORT ORD
Page 64 and 65: FAMILY AND MEDICAL LEAVE ACT OF 199
Page 66 and 67: Family and Medical Leave ActENFORCE
Page 68 and 69: Termination of Coverage7. The date
Page 70 and 71: CONTINUATION COVERAGE AFTER TERMINA
Page 72 and 73: Continued Coverage After Terminatio
Page 74: Continued Coverage After Terminatio
Page 77 and 78: COVERAGE FOR A MILITARY RESERVISTTo
Page 80 and 81: Recovery/Reimbursement/SubrogationT
Page 82 and 83: PLAN ADMINISTRATIONPURPOSEThe purpo
Page 84 and 85: CREDITABLE COVERAGE PROCEDURESCERTI
Page 86 and 87: General ProvisionsWORKERS' COMPENSA
Page 88 and 89: General DefinitionsBENEFIT PERCENTA
Page 90 and 91: General DefinitionsCUSTODIAL CARE
Page 92 and 93: General Definitions“Reliable Evid
Page 94 and 95: General DefinitionsLATE ENROLLMENT
Page 96 and 97:
General Definitions9. Are approved
Page 98 and 99:
General DefinitionsPREVENTIVE CARE
Page 100 and 101:
General DefinitionsTOTAL DISABILITY
Page 102 and 103:
ERISA Statement of RightsIf you hav
Page 104 and 105:
HIPAA Privacy and Security Standard
Page 106:
Plan Summary9. IDENTIFICATION NUMBE
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