AETNA PPO PLAN - My Benefits Portfolio - Trinity Health
AETNA PPO PLAN - My Benefits Portfolio - Trinity Health
AETNA PPO PLAN - My Benefits Portfolio - Trinity Health
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Women’s <strong>Health</strong> and Cancer Rights Act of 1998............................................................... 30<br />
Plan Administrator Powers................................................................................................. 31<br />
Filing a Claim for <strong>Benefits</strong> and Review Procedures ........................................................... 31<br />
How to Submit a Claim for <strong>Benefits</strong> ................................................................................... 31<br />
Reporting of Claims............................................................................................................32<br />
Claims, Appeals and External Review ............................................................................... 32<br />
Filing <strong>Health</strong> Claims Under the Plan ............................................................................ 32<br />
Other Claims ................................................................................................................ 32<br />
<strong>Health</strong> Claims: Standard Appeals ................................................................................ 33<br />
Exhaustion of Internal Appeals Process ...................................................................... 33<br />
Full and Fair Review of Claim Determinations and Appeals ........................................ 33<br />
<strong>Health</strong> Claims: Voluntary Appeals...................................................................................... 34<br />
External Review ........................................................................................................... 34<br />
Request for External Review........................................................................................ 35<br />
Preliminary Review ...................................................................................................... 35<br />
Referral to ERO............................................................................................................ 36<br />
Expedited External Review .......................................................................................... 36<br />
Referral of Expedited Review to ERO.......................................................................... 37<br />
Legal Action ....................................................................................................................... 37<br />
Subrogation and Right of Reimbursement ......................................................................... 37<br />
Amendment or Termination of the Plan ............................................................................. 39<br />
State of Michigan Disclosure Requirement ........................................................................ 40<br />
Employee Retirement Income Security Act of 1974 (ERISA)<br />
Statement of Participant Rights ........................................................................................ 41<br />
Important Information About the Plan ................................................................................. 43<br />
How Services Are Paid Through the Plan ........................................................................... 44<br />
Covered Medical Expenses................................................................................................... 45<br />
How Will You Benefit From Choosing a Network Provider? .............................................. 45<br />
What Happens If You Are Not Able to Use a Network Provider?....................................... 45<br />
What Is The Plan Deductible?............................................................................................ 46<br />
What Is Your Out-of-Pocket Maximum Expense?.............................................................. 46<br />
<strong>Health</strong> Management Services............................................................................................ 46<br />
Case Management............................................................................................................. 47<br />
Pre-Certification of Services............................................................................................... 47<br />
Mental Disorders and/or Substance Abuse........................................................................ 48<br />
Explanation of Some Important Plan Provisions ................................................................ 48<br />
Genetic Testing/Screening and Counseling....................................................................... 49<br />
Hospital Expenses ............................................................................................................. 50<br />
Inpatient Hospital Expenses......................................................................................... 50<br />
Outpatient Hospital Expenses...................................................................................... 50<br />
Outpatient Surgical Expenses...................................................................................... 51<br />
Outpatient Services and Supplies ................................................................................ 51<br />
Convalescent Facility Expenses ........................................................................................ 51<br />
Home <strong>Health</strong> Care Expenses............................................................................................. 52<br />
Preventive Physical Exam Expenses................................................................................. 53