PPO/DRP Medical Plan - Advocate Benefits - Advocate Health Care

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Upon receipt of a notice that the IRO has reversed the claim or appeal denial, the Plan will immediately provide coverage or payment for the denied claim. Expedited External Review Process The external review process described above may be conducted on an expedited basis if: The claim denial involves a medical condition for which the timeframe for completing an urgent care claim internal appeal (provided the claimant has filed an internal appeal for an urgent care claim denial) or would seriously jeopardize the life or health of the participant or would jeopardize the participant’s ability to regain maximum function, The denial of the internal appeal involves a medical condition for which the timeframe for completing a standard external appeal would seriously jeopardize the life or health of the participant or would jeopardize the participant’s ability to regain maximum function, or The denial of the internal appeal concerned an admission, availability of care, continued stay or health care item or service for which the participant received emergency services but has not been discharged from a facility. Under an expedited external review process, the PPO/DRP administrator will complete its preliminary review immediately and will immediately thereafter send a notice to the claimant of the request’s eligibility for an expedited external review. The PPO/DRP administrator will then assign an IRO to such request if it is eligible for an expedited external review and will provide or transmit all necessary documentation and information considered in denying the claim or appeal by any available expeditious method (such as electronically or by telephone or fax). The IRO will consider the information or documentation under the procedures for a standard external review, but will complete the expedited review and provide notification to the claimant as expeditiously as the participant’s medical condition or circumstances require, but in no event more than 72 hours after the IRO receives the request for an 38 expedited external review. If this notice is not in writing, the IRO will provide written confirmation of the decision to the claimant within 48 hours after providing that notice. Assistance If you need assistance with the internal claims and appeals or the external review processes that are described in this section, you may contact the Illinois ombudsman program at 1.877.527.9431, or call the number on the back of your coverage ID card for further information. In addition, for questions about your appeal rights or for assistance, you can contact the Employee Benefits Security Administration at 1.866.444.3272. Exhaustion Upon completion of the claims and appeals and external review process under this section, the claimant will have exhausted his or her administrative remedies under this Plan. If the PPO/DRP administrator fails to complete a claim determination or an appeal according to the requirements set forth above(other than a failure that is de minimis, non-prejudicial, due to good cause or matters beyond the PPO/DRP administrator’s control, in the context of an ongoing, good-faith exchange of information, and not reflective of a pattern or practice of non-compliance), the claimant may be treated as if he or she has exhausted the internal claims and appeals process and he or she may request an external review or pursue any available remedies under applicable law. No action at law or in equity may be brought with respect to Plan benefits until all rights under this Plan have been exhausted and any such action must be brought no later than two years from the date of the PPO/ DRP administrator’s final decision upon review of a second level appeal or the expiration of the applicable limitations period under applicable law (whichever is earlier). In addition, any suit or claim must be filed in the Circuit Courts for DuPage County, Illinois (unless federal jurisdiction applies, in which case the suit or claim should be brought in the Northern District of Illinois, Eastern Division).
Other Plan Information When Medical Coverage Ends Your Coverage Your (and your dependents) coverage under the PPO/DRP will end on the earliest of: The last day of the month in which your employment with the Advocate Companies ends, including your retirement; The last day of the month in which you change to an employment status that is not eligible for PPO/DRP coverage; The date you enter the armed forces of any country, except as provided under the Uniformed Services Employment and Reemployment Rights Act (USERRA) (see Coverage During a Military Leave of Absence, page 43); For your dependents, the date the dependent ceases to be a covered dependent; The last day of the pay period if you fail to pay the required contributions for coverage; The date you die (or for your dependents, the last day of the calendar month in which you die); or The date Advocate discontinues the PPO/DRP coverage option (or the Plan). Non-Duplication of Benefits If you choose the PPO/DRP coverage option, include a family member under your coverage and this family member also has coverage under another plan (or you have coverage under another plan or Medicare), your Advocate coverage may provide primary or secondary coverage for this family member under the “non-duplication” of benefits provision. 39 Important! If you have HMO coverage as either your primary or secondary coverage, you must follow that HMO’s requirements in order to receive any other medical benefits from that plan. This plan will not pay for any charges for failure to use HMO coverage. To see how this non-duplication of benefits provision works, let’s assume that: You have included your spouse under your PPO/DRP coverage. Your spouse also is covered by his or her employer-sponsored medical plan. Your spouse undergoes inpatient surgery performed by participating providers. Your spouse already has met the deductible under both plans, and both plans provide 80% of the cost of covered services. Your spouse’s coverage under his or her employer-sponsored coverage will be primary, so that plan will pay benefits first. Since both plans provide 80% of covered charges, the full benefit your spouse receives will be paid by his or her employer sponsored coverage and no benefits will be paid under the PPO/DRP. Here are some guidelines for determining whether a plan is primary or secondary: The Plan is “primary” if you are the employee and an Advocate Company is your employer. If you cover your spouse as a dependent under your Advocate coverage and your spouse also has medical coverage through his or her employer, your spouse’s plan will be his or her primary plan, and your Advocate coverage will be secondary. If you cover your eligible children as dependents under Advocate coverage and your spouse also covers them as dependents under his or her employer plan, determination of which plan is primary will be based on the “birthday rule.” Under this rule, the coverage of the parent who has the birthday month that falls earlier in the year (e.g., March vs.
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PPO/DRP Medical Plan - Advocate Benefits - Advocate Health Care

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