Anthem Blue Cross Blue Shield PPO Plan - Teamworks at Home ...

The plan administrator may delegate any or all
functions or decisions it may have under this section to
Anthem BCBS�
What may happen to your future benefts
If you or your dependent(s) obtain a settlement,
judgment, or other recovery from any person or entity,
including your own automobile or liability carrier,
without frst reimbursing the Plan, the Plan, in the
exercise of its sole and complete discretion, may
determine that you, your dependents, your attorneys,
or other representatives have failed to cooperate with
the Plan’s subrogation and reimbursement eforts� If
the Plan determines that you have failed to cooperate,
the Plan may decline to pay for any additional care or
treatment for you or your dependent(s) until the Plan is
reimbursed in accordance with the Plan terms or until
the additional care or treatment exceeds the amounts
that you or your dependent(s) recover� This right to
ofset will not be limited to benefts for the insured
person or to treatment related to the injury but will
apply to all benefts otherwise payable under the Plan
for you and your dependent(s)�
Fraudulent practices
Coverage for you or your dependent(s) is subject
to termination if you or your dependent(s) submit
fraudulent, altered, or duplicate billings for personal
gain or allow another party not covered under the Plan
to use your or your dependent’s coverage�
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Excessive and harmful use of health
care services
Anthem BCBS monitors claims data for many reasons�
If Anthem BCBS determines that you are receiving
an excessive number of health care services, Anthem
BCBS evaluates the medical necessity of such services�
If Anthem BCBS determines that an excessive number
of services are not medically necessary, the following
will occur:
• Anthem BCBS will send you a letter giving you
30 days to select one participating physician and
one participating hospital to coordinate all of your
health care needs� You have the right to designate
any participating physician who is in the Anthem
BCBS network and who is available to accept you
or your family� For children, you may designate a
participating pediatrician� If you do not make a
selection, Anthem BCBS will make one for you�
After the selection is made, all services must
be coordinated by the selected providers� Care
received from other providers will not be covered,
and the charges incurred for that care will be your
responsibility� To identify providers who participate
in the BlueCard PPO network, access the Provider
Directory Service through Teamworks or at
geoaccess�com/directoriesonline/wf�
• Anthem BCBS will notify you how to obtain care
not available through the coordinating health care
providers, how to access emergency care, and how
long these restrictions will be in place�
The Plan does not pay claims to providers or to team
members for services received in countries that are
sanctioned by the U�S� Department of Treasury’s Ofce
of Foreign Assets Control (OFAC)� Countries currently
sanctioned by OFAC include Cuba, Iran, and Syria�
OFAC may add or remove countries from time to time�
Anthem Blue Cross Blue Shield PPO Plan