Benefits, Exclusions and Limitations. Urgent Care Services outside of our Service Area, as described in Section 3:
Benefits, Exclusions and Limitations is Medically Necessary and our decision is final and conclusive subject to your right to appeal as set forth in Section 5:
Benefits, Exclusions and Limitations. Unless exemptions are specifically made elsewhere in this Evidence of Coverage and Health Service Agreement, these pediatric vision benefits exclude the following:
Benefits, Exclusions and Limitations. Approved Referrals, as described in this section under the Getting a Referral, including referrals for Clinical Trials as described in Section 3:
Benefits, Exclusions and Limitations. Emergency Services are available from Plan Hospital emergency departments, which are open 24/7. Emergency Services, with respect to an Emergency Medical Condition, means:
Benefits, Exclusions and Limitations. Your Benefits
1. A Plan Physician determines that the Services are Medically Necessary;
2. The Services are provided, prescribed, authorized or directed by a Plan Physician; and
a. You receive the Services at a Plan Facility, Plan Provider or contracted Skilled Nursing Facility inside our Service Area (except when specifically noted otherwise within this Agreement); or
b. You agree to have Services delivered through a patient centered medical homes program for individuals with chronic conditions, serious illnesses or complex health care needs. This includes associated costs for coordination of care, such as:
i. Liaison services between the individual and the Health Care Provider, nurse coordinator and the care coordination team;
ii. Creation and supervision of a care plan;
iii. Education of the Member and their family regarding the Member’s disease, treatment compliance and self-care techniques; and
iv. Assistance with coordination of care, including arranging consultations with Specialists and obtaining Medically Necessary supplies and services, including community resources. You must receive all covered Services from Plan Providers inside our Service Area except for:
1. Emergency Services, as described in this section;
2. Urgent Care Services outside of our Service Area, as described in this section;
3. Approved referrals, as described under Getting a Referral in Section 2: How to Get the Care You Need, including referrals for clinical trials as described in this section. Note: Some benefits may require payment of a Copayment, Coinsurance or Deductible. Refer to the Summary of Services and Cost Shares for the Cost Sharing requirements that apply to the covered Services contained within the List of Benefits in this section. This Agreement does not pay for all health care services, even if they are Medically Necessary. Your right to benefits is limited to the covered Services contained within this contract. To view your benefits, see the List of Benefits in this section. The following benefits are covered by the Health Plan. Benefits are listed alphabetically for your convenience. Some benefits are subject to benefit-specific limitations and/or exclusions, which are listed, when applicable, directly below each benefit. A broader list of exclusions that apply to all benefits, regardless of whether they are Medically Necessary, is provided under Exclusions in this section. We cover restorative Services necessary to promptly repair, but not replace, sound nat...
Benefits, Exclusions and Limitations. Appeal: A protest filed by a Member or his or her Authorized representative with the Health Plan under its internal appeal process regarding a Coverage Decision concerning a Member. An Appeal does not include a verbal request for reconsideration of a benefit and/or eligibility determination. Appeal Decision: A final determination by the Health Plan that arises from an Appeal filed with the Health Plan under its Appeal process regarding a Coverage Decision concerning a Member.
Benefits, Exclusions and Limitations. Continuity of Care for New Members, as described in Section 2: How to Get the Care You Need;
Benefits, Exclusions and Limitations. Emergency and Urgent Care Services, in addition to Services associated with pre-authorized referrals are the only Services a Member may seek outside of the Service Area.
Benefits, Exclusions and Limitations in the new region after residing there for more than ninety (90) days, unless you:
