PPO II - EmblemHealth

More documents

Recommendations

Info

2013 Evidence of Coverage for PPO II) II Chapter 3. 3: Using the plan’s coverage for your medical services • You can get your care from an out-of-network provider, however, that provider must be eligible to participate in Medicare. We cannot pay a provider who is not eligible to participate in Medicare. If you receive care from a provider who is not eligible to participate in Medicare, you will be responsible for the full cost of the services you receive. Check with your provider before receiving services to confi rm that they are eligible to participate in Medicare. • You don’t need to get a referral or prior authorization when you get care from out-of-network providers. However, before getting services from out-of-network providers you may want to ask for a pre-visit coverage decision to confi rm that the services you are getting are covered and are medically necessary. (See Chapter 9, Section 4 for information about asking for coverage decisions.) Th is is important because: � Without a pre-visit coverage decision, if we later determine that the services are not covered or were not medically necessary, we may deny coverage and you will be responsible for the entire cost. If we say we will not cover your services, you have the right to appeal our decision not to cover your care. See Chapter 9 (What to do if you have a problem or complaint) to learn how to make an appeal. • It is best to ask an out-of-network provider to bill the plan fi rst. But, if you have already paid for the covered services, we will reimburse you for our share of the cost for covered services. Or if an out-of-network provider sends you a bill that you think we should pay, you can send it to us for payment. See Chapter 7 (Asking us to pay our share of a bill you have received for covered medical services or drugs) for information about what to do if you receive a bill or if you need to ask for reimbursement. • If you are using an out-of-network provider for emergency care, urgently needed care, or outof-area dialysis, you may not have to pay a higher cost-sharing amount. See Section 3 for more information about these situations. SECTION 3 HOW TO GET COVERED SERVICES WHEN YOU HAVE AN EMERGENCY OR URGENT NEED FOR CARE Section 3.1 Getting care if you have a medical emergency What is a “medical emergency” and what should you do if you have one? A “medical emergency” is when you, or any other prudent layperson with an average knowledge of health and medicine, believe that you have medical symptoms that require immediate medical attention to prevent loss of life, loss of a limb, or loss of function of a limb. Th e medical symptoms may be an illness, injury, severe pain, or a medical condition that is quickly getting worse. If you have a medical emergency: • Get help as quickly as possible. Call 911 for help or go to the nearest emergency room or hospital. Call for an ambulance if you need it. You do not need to get approval or a referral fi rst from your PCP. 37
38 2013 Evidence of Coverage for PPO II Chapter 3. 3: Using the plan’s coverage for your medical services • As soon as possible, make sure that our plan has been told about your emergency. We need to follow up on your emergency care. You or someone else should call to tell us about your emergency care, usually within 48 hours. Call the number on the back of your membership card. What is covered if you have a medical emergency? You may get covered emergency medical care whenever you need it, anywhere in the United States or its territories. Our plan covers ambulance services in situations where getting to the emergency room in any other way could endanger your health. For more information, see the Medical Benefi ts Chart in Chapter 4 of this booklet. Our plan covers emergency medical care anywhere in the world. Please see the benefi t chart in Chapter 4 for details. If you have an emergency, we will talk with the doctors who are giving you emergency care to help manage and follow up on your care. Th e doctors who are giving you emergency care will decide when your condition is stable and the medical emergency is over. After the emergency is over you are entitled to follow-up care to be sure your condition continues to be stable. Your follow-up care will be covered by our plan. If you get follow-up care from out-of-network providers, you will pay the higher out-of-network cost sharing. What if it wasn’t a medical emergency? Sometimes it can be hard to know if you have a medical emergency. For example, you might go in for emergency care – thinking that your health is in serious danger – and the doctor may say that it wasn’t a medical emergency after all. If it turns out that it was not an emergency, as long as you reasonably thought your health was in serious danger, we will cover your care. However, after the doctor has said that it was not an emergency, the amount of cost sharing that you pay will depend on whether you get the care from network providers or out-of-network providers. If you get the care from network providers, your share of the costs will usually be lower than if you get the care from out-of-network providers. Section 3.2 Getting care when you have an urgent need for care What is “urgently needed care”? “Urgently needed care” is a non-emergency, unforeseen medical illness, injury, or condition, that requires immediate medical care. Urgently needed care may be furnished by in-network providers or by out-ofnetwork providers when network providers are temporarily unavailable or inaccessible. Th e unforeseen condition could, for example, be an unforeseen fl are-up of a known condition that you have. What if you are in the plan’s service area when you have an urgent need for care? In most situations, if you are in the plan’s service area and you use an out-of-network provider, you will pay a higher share of the costs for your care. However, if the circumstances are unusual or extraordinary, and network providers are temporarily unavailable or inaccessible, we will allow you to get covered services from an out-of-network provider at the lower in-network cost-sharing amount.
Page 1 and 2: H5528_123133 EVIDENCE OF COVERAGE Y
Page 3 and 4: ii 2013 Evidence of Coverage for PP
Page 5 and 6: iv 2013 Evidence of Coverage for PP
Page 7 and 8: 2 2013 Evidence Evidence of Coverag
Page 15 and 16: 10 2013 Evidence Evidence of Covera
Page 17 and 18: 12 Th ese rules apply for employer
Page 19 and 20: 14 2013 Evidence of Coverage for PP
Page 31 and 32: 26 SECTION 5 SOCIAL SECURITY 2013 E
Page 41: 36 2013 Evidence of Coverage for PP
Page 53 and 54: 48 2011 Evidence of Coverage for 20
Page 87 and 88: 82 2011 Evidence of Coverage for HM
Page 89 and 90: 84 2011 Evidence of Coverage 2013 f
Page 91 and 92: 86 2013 Evidence of Cover age for P
Page 93 and 94:
88 2013 Evidence of Cover age for P
Page 95 and 96:
Page 97 and 98:
Page 99 and 100:
Page 101 and 102:
Page 103 and 104:
Page 105 and 106:
100 2013 Evidence of Cover age for
Page 107 and 108:
102 2013 Evidence of Coverage for P
Page 109 and 110:
104 • Chapter 5 of this booklet.
Page 111 and 112:
Page 113 and 114:
108 Your share of the cost when you
Page 115 and 116:
Page 117 and 118:
112 These payments are not included
Page 119 and 120:
114 � Some vaccines are considere
Page 121 and 122:
Page 123 and 124:
Page 125 and 126:
120 2011 Evidence of Coverage for 2
Page 127 and 128:
122 2011 Evidence of Coverage for H
Page 129 and 130:
Page 131 and 132:
Page 133 and 134:
Page 135 and 136:
Page 137 and 138:
Page 139 and 140:
Page 141 and 142:
Page 143 and 144:
Page 145 and 146:
Page 147 and 148:
Page 149 and 150:
Page 151 and 152:
Page 153 and 154:
Page 155 and 156:
Page 157 and 158:
Page 159 and 160:
Page 161 and 162:
Page 163 and 164:
Page 165 and 166:
Page 167 and 168:
Page 169 and 170:
Page 171 and 172:
Page 173 and 174:
Page 175 and 176:
Page 177 and 178:
Page 179 and 180:
Page 181 and 182:
Page 183 and 184:
Page 185 and 186:
Page 187 and 188:
Page 189 and 190:
Page 191 and 192:
Page 193 and 194:
Page 195 and 196:
Page 197 and 198:
Page 199 and 200:
Page 201 and 202:
Page 203 and 204:
Page 205 and 206:
Page 207 and 208:
Page 209 and 210:
Page 211 and 212:
Page 213 and 214:
Page 215 and 216:
Page 217 and 218:
Page 219 and 220:
Page 221:
55 Water Street, New York, New York
show all

PPO II - EmblemHealth

You also want an ePaper? Increase the reach of your titles

Delete template?

Save as template?