AETNA PPO PLAN - My Benefits Portfolio - Trinity Health

Coverage will be provided in a manner determined in consultation with the attending Physician and the
patient. The Plan’s Deductibles, Coinsurance, and Copayments that are in effect at the time service is
provided will apply to the coverage described above.
PLAN ADMINISTRATOR POWERS
The Plan Administrator is empowered and authorized to make rules and regulations and establish
procedures with respect to the Plan and to determine or resolve all questions that may arise as to the
eligibility, benefits, status and right of any person claiming benefits under the Plan. The Plan
Administrator has the power and discretionary authority to construe and interpret the Plan and to correct
any defect, supply any omissions, or reconcile any inconsistencies in the Plan, and generally do all other
things which need to be handled in administering this Plan.
The exercise of the Plan Administrator’s authority shall be binding upon all interested parties, including,
but not limited to Covered Individuals, their estates and their beneficiaries, and shall be subject to review
only if it is arbitrary or capricious or otherwise inconsistent with applicable law.
The Plan Administrator will determine eligibility for benefits under the Plan. The Plan Administrator has
delegated fiduciary responsibility for medical claims to Aetna and has delegated fiduciary responsibility for
Prescription Drug claims to CVS Caremark. The Plan shall be governed by and interpreted according to
ERISA and the Internal Revenue Code and, where not pre-empted by Federal law, the laws of the state
of Michigan.
FILING A CLAIM FOR BENEFITS AND REVIEW PROCEDURES
You may file claims for benefits, and appeal adverse claim decisions, either yourself or through an
Authorized Representative.
HOW TO SUBMIT A CLAIM FOR BENEFITS
A claim must be filed before a benefit payment can be made. There are three (3) types of claims:
• A “pre-service claim” means a claim for a benefit where your plan conditions receipt of the benefit, in
whole or in part, on obtaining approval in advance of receiving medical care.
• An “urgent care claim” means a pre-service claim for medical care or treatment where the time
periods for non-urgent predeterminations could seriously jeopardize your life, health, ability to regain
maximum function or, in the opinion of a Physician who knows your medical condition, would subject
you to severe pain that cannot be adequately managed without the care or treatment you are
seeking.
If a Physician with knowledge of your medical condition determines that the claim is one involving
urgent care, the Plan Administrator or its delegate will treat it as such. Absent a determination by your
Physician, the Plan Administrator or its delegate will determine whether a claim is one involving
urgent care by using the judgment of a prudent layperson with average knowledge of health and
medicine.
• A “post-service claim” means all other claims that are not “pre-service claims” or “urgent care claims”.
The Plan Administrator has delegated its authority to make claim determinations, other than claim
determinations with respect to Prescription Drug claims, to Aetna, the Medical Claims Administrator. You
or your Authorized Representative generally must file claims in writing with your Aetna customer service
office at:
Aetna Life Insurance Company
151 Farmington Avenue
Harford, CT 06156
31