Common use of Complaints, Grievances and Appeals Clause in Contracts

Complaints, Grievances and Appeals. 90 This Section explains how to file a Complaint, Grievance and Appeal. Overview 90 Computation of Time 90 General Requirements and Information Regarding Grievance Procedures 90 Information About Grievance Procedures 91 Confidentiality of Your Records and Medical Information 92 Preliminary Determination 92 Timeframes for Initial Determinations 93 Initial Determinations 93 Notice of Initial Determinations 94 Rights Regarding Internal Review of Adverse Determinations 95 Timeframes for Internal Review of Adverse Determinations 96 Internal Panel Review of Adverse Determinations 97 Additional Requirements for Expedited Internal Review of Adverse Determinations 98 Notice of Internal Panel Decision 99 External Review of Adverse Determinations 99 Filing Requirements for External Review of Adverse Determinations 101 Acknowledgement of Request for External Review of Adverse Determination and Copy to Health Care Insurer 102 Timeframes for External Review and Adverse Determinations 102 Criteria for Initial External Review of Adverse Determination by the Office of Superintendent of Insurance Staff 103 Additional Criteria for Initial External Review of Experimental or Investigational Treatment Adverse Determinations by the Office of Superintendent of Insurance 103 Initial External Review of Adverse Determination by the Office of Superintendent of Insurance Staff 104 Hearing Procedures for External Review of Adverse Determinations 105 Independent Co-Health Officers (ICOs) 106 Superintendent’s Decision on External Review of Adverse Determination 107 Internal Review of Administrative Grievances 107 Initial Internal Review Decision on Administrative Grievance 108 Reconsideration of Internal Review 108 Decision of Reconsideration Committee 109 External Review of Administrative Grievances 110 Filing Requirements for External Review of Administrative Grievance 111 Acknowledgement of Request for External Review of Administrative Grievance and Copy to Health Care Insurer 111 Review of Administrative Grievance by Superintendent 112 Records 113 Your medical records are important documents needed in order to administer your Health Benefits Plan. This Section explains how we ensure the confidentiality of these records and how these records are used to administer your plan. Creation of Non-Medical Records 113 Accuracy of Information 113 Consent for Use and Disclosure of Medical Records 113 Professional Review. 113 Confidentiality of Protected Health Information/Medical Records 113 Eligibility, Enrollment, Effective Dates, Termination and Continuation 120 This Section explains eligibility requirements for Subscribers and/or their Dependents, important effective dates, conditions for Termination of Coverage and continuing Coverage for Members who become ineligible for this Plan. How You Can Enroll as a Member 120 Residence of a Dependent Child 122 Enrollment and Effective Dates 123 Full, Accurate and Complete Information 125 Change in Address, Family Status and Employment 125 Termination of Coverage 126 Continuation of Coverage of your Plan 129 Premium Payment 131 This Section explains how Premium Payments are to be made to Presbyterian Health Plan Prepayments 131 Changes in Prepayments 131 General Provisions 132 This Section explains important information and provisions not covered in other Sections of this Agreement. Amendments 132 Assignment 132 Availability of Provider Services 132 Entire Contract 132 Execution of Contract - Application for Coverage 132 Federal and State Health Care Reform 132 Fraud 133 Practitioner/Provider Activity 133 Member Activity 133 Governing Law 134 HSA Note: Health Savings Account Information 134 Identification Cards 134 Legal Actions 134 Misrepresentation of Information 134 Misstatements 135 Notice 135 Policies and Procedures 135 Reinstatements 135 Right to Examine 135 Waiver by Agents 135 Workers’ Compensation Insurance 136 Glossary of Terms 137 This Section defines some of the important terms used in this Agreement. Terms defined in this Section will be capitalized throughout the Agreement. Exhibit A – Vision 156 Exhibit B – Healthways Gym Membership 158 WELCOME TO PRESBYTERIAN HEALTH PLAN! Welcome and thank you for joining Presbyterian Health Plan. We are a Health Care Insurer operated as a division of Presbyterian Healthcare Services, a locally owned New Mexico health care system. When we use the words "Presbyterian Health Plan", "PHP", "we", "us", and "our" in this document, we are referring to Presbyterian Health Plan. When we use the words “you” and “your” we are referring to each Member. As part of Presbyterian Healthcare Services, the health plan represents an organization with over 100 years of community service to New Mexicans. Our priority has been and will continue to be improving the health of individuals, families and communities. We are working to make sure that you receive quality care and service. We are pleased to provide you with access to a comprehensive network of Physicians, Hospitals, and outpatient medical Providers, who provide services for your Covered Benefits. We provide utilization management and quality improvement oversight programs with our commitment to Member service. We work closely with you, your Covered Dependents and your health care Practitioners and Providers to provide a quality, affordable health care plan. Our Agreement With You This is your Subscriber Agreement (Agreement) and it is a legal document. This Agreement, along with the Summary of Benefits and Coverage, describes the Covered Health Care Benefits and plan features that you and your eligible Dependents may receive when you enroll. Information you will find in this Agreement includes:  Your rights and responsibilities as a Member  Covered Benefits available through this Plan  How to access services from physicians, Practitioners, Providers and Pharmacies  Services that require Prior Authorization  Limitations and Exclusions for certain Covered Benefits  Coverage for your Dependents who are outside of New Mexico  A Glossary Of Terms used in this Agreement  What to do when you need assistance Throughout this Agreement, we ask you to refer to your Summary of Benefits and Coverage. The Summary of Benefits and Coverage is a chart that shows some specific Covered Benefits this Plan provides, the amount you may have to pay (Cost Sharing) and the Coverage Limitations and Exclusions. Please take time to read this Agreement and Summary of Benefits and Coverage, including Benefits, Limitations, and Exclusions. This Agreement describes your benefits and your rights and responsibilities as our Member. It also gives details on how to choose or change your Primary Care Physician, what limits are placed on certain benefits, and what services are not Covered at all. Understanding how this Plan works can help you make the best use of your Covered Benefits. You should keep this Agreement, your Summary of Benefits and Coverage, and any other attachments or Endorsements you may receive for future reference. Understanding This Agreement We use visual symbols throughout this Agreement to alert you to important requirements, restrictions and information. When one or more of the symbols is used, we will use bold print in the paragraph or section to point out the exact requirement, restriction, and information. These symbols are listed below: Refer To – This “Refer To” symbol will direct you to read related information in other sections of the Agreement or Summary of Benefits and Coverage when Refer to necessary. The Section being referenced will be bolded. Exclusion Exclusion – This “Exclusion” symbol will appear next to the description of certain Covered Benefits. The Exclusion symbol will alert you that there are some services that are excluded from the Covered Benefits and will not be paid. You should refer to the Exclusion Section when you see this symbol. Prior Auth Required Prior Authorization Required – This “Prior Authorization” symbol will appear next to those Covered Benefits that require our Authorization (approval) in advance of those services. To receive full benefits, your In-network Practitioner/Provider must call us and obtain Authorization before you receive treatment. You must call us if you are seeking services Out-of-network. In the case of a Hospital in-patient admission following an Emergency Room visit, you should call as soon as possible. Timeframe Requirement – This “Timeframe” symbol appears to remind you when you must ake action within a certain timeframe to comply with your Plan. An Timeframe associated with this item Important 

Complaints, Grievances and Appeals. 90 This Section explains how to file a Complaint, Grievance and Appeal. Overview 90 Computation of Time 90 General Requirements and Information Regarding Grievance Procedures 90 Information About Grievance Procedures 91 Confidentiality of Your Records and Medical Information 92 Preliminary Determination 92 Timeframes for Initial Determinations 93 Initial Determinations 93 Notice of Initial Determinations 94 Rights Regarding Internal Review of Adverse Determinations 95 Timeframes for Internal Review of Adverse Determinations 96 Internal Panel Review of Adverse Determinations 97 Additional Requirements for Expedited Internal Review of Adverse Determinations 98 Notice of Internal Panel Decision 99 External Review of Adverse Determinations 99 Filing Requirements for External Review of Adverse Determinations 101 Acknowledgement of Request for External Review of Adverse Determination and Copy to Health Care Insurer 102 Timeframes for External Review and Adverse Determinations 102 Criteria for Initial External Review of Adverse Determination by the Office of Superintendent of Insurance Staff 103 Additional Criteria for Initial External Review of Experimental or Investigational Treatment Adverse Determinations by the Office of Superintendent of Insurance 103 Initial External Review of Adverse Determination by the Office of Superintendent of Insurance Staff 104 Hearing Procedures for External Review of Adverse Determinations 105 Independent Co-Health Officers (ICOs) 106 Superintendent’s Decision on External Review of Adverse Determination 107 Internal Review of Administrative Grievances 107 Initial Internal Review Decision on Administrative Grievance 108 Reconsideration of Internal Review 108 Decision of Reconsideration Committee 109 External Review of Administrative Grievances 110 Filing Requirements for External Review of Administrative Grievance 111 Acknowledgement of Request for External Review of Administrative Grievance and Copy to Health Care Insurer 111 Review of Administrative Grievance by Superintendent 112 Records 113 Your medical records are important documents needed in order to administer your Health Benefits Plan. This Section explains how we ensure the confidentiality of these records and how these records are used to administer your plan. Creation of Non-Medical Records 113 Accuracy of Information 113 Consent for Use and Disclosure of Medical Records 113 Professional Review. 113 Confidentiality of Protected Health Information/Medical Records 113 Eligibility, Enrollment, Effective Dates, Termination and Continuation 120 This Section explains eligibility requirements for Subscribers and/or their Dependents, important effective dates, conditions for Termination of Coverage and continuing Coverage for Members who become ineligible for this Plan. How You Can Enroll as a Member 120 Residence of a Dependent Child 122 Enrollment and Effective Dates 123 Full, Accurate and Complete Information 125 Change in Address, Family Status and Employment 125 Termination of Coverage 126 Continuation of Coverage of your Plan 129 Premium Payment 131 This Section explains how Premium Payments are to be made to Presbyterian Health Plan Prepayments 131 Changes in Prepayments 131 General Provisions 132 This Section explains important information and provisions not covered in other Sections of this Agreement. Amendments 132 Assignment 132 Availability of Provider Services 132 Entire Contract 132 Execution of Contract - Application for Coverage 132 Federal and State Health Care Reform 132 Fraud 133 Practitioner/Provider Activity 133 Member Activity 133 Governing Law 134 HSA Note: Health Savings Account Information 134 Identification Cards 134 Legal Actions 134 Misrepresentation of Information 134 Misstatements 135 Notice 135 Policies and Procedures 135 Reinstatements 135 Right to Examine 135 Waiver by Agents 135 Workers’ Compensation Insurance 136 Glossary of Terms 137 This Section defines some of the important terms used in this Agreement. Terms defined in this Section will be capitalized throughout the Agreement. Exhibit A – Vision 156 Exhibit B – Healthways Gym Membership 158 WELCOME TO PRESBYTERIAN HEALTH PLAN! Welcome and thank you for joining Presbyterian Health Plan. We are a Health Care Insurer operated as a division of Presbyterian Healthcare Services, a locally owned New Mexico health care system. When we use the words "Presbyterian Health Plan", "PHP", "we", "us", and "our" in this document, we are referring to Presbyterian Health Plan. When we use the words “you” and “your” we are referring to each Member. As part of Presbyterian Healthcare Services, the health plan represents an organization with over 100 years of community service to New Mexicans. Our priority has been and will continue to be improving the health of individuals, families and communities. We are working to make sure that you receive quality care and service. We are pleased to provide you with access to a comprehensive network of Physicians, Hospitals, and outpatient medical Providers, who provide services for your Covered Benefits. We provide utilization management and quality improvement oversight programs with our commitment to Member service. We work closely with you, your Covered Dependents and your health care Practitioners and Providers to provide a quality, affordable health care plan. Our Agreement With You This is your Subscriber Agreement (Agreement) and it is a legal document. This Agreement, along with the Summary of Benefits and Coverage, describes the Covered Health Care Benefits and plan features that you and your eligible Dependents may receive when you enroll. Information you will find in this Agreement includes:  Your rights and responsibilities as a Member  Covered Benefits available through this Plan  How to access services from physicians, Practitioners, Providers and Pharmacies  Services that require Prior Authorization  Limitations and Exclusions for certain Covered Benefits  Coverage for your Dependents who are outside of New Mexico  A Glossary Of Terms used in this Agreement  What to do when you need assistance Throughout this Agreement, we ask you to refer to your Summary of Benefits and Coverage. The Summary of Benefits and Coverage is a chart that shows some specific Covered Benefits this Plan provides, the amount you may have to pay (Cost Sharing) and the Coverage Limitations and Exclusions. Please take time to read this Agreement and Summary of Benefits and Coverage, including Benefits, Limitations, and Exclusions. This Agreement describes your benefits and your rights and responsibilities as our Member. It also gives details on how to choose or change your Primary Care Physician, what limits are placed on certain benefits, and what services are not Covered at all. Understanding how this Plan works can help you make the best use of your Covered Benefits. You should keep this Agreement, your Summary of Benefits and Coverage, and any other attachments or Endorsements you may receive for future reference. Understanding This Agreement We use visual symbols throughout this Agreement to alert you to important requirements, restrictions and information. When one or more of the symbols is used, we will use bold print in the paragraph or section to point out the exact requirement, restriction, and information. These symbols are listed below: Refer To – This “Refer To” symbol will direct you to read related information in other sections of the Agreement or Summary of Benefits and Coverage when Refer to necessary. The Section being referenced will be bolded. Exclusion Exclusion – This “Exclusion” symbol will appear next to the description of certain Covered Benefits. The Exclusion symbol will alert you that there are some services that are excluded from the Covered Benefits and will not be paid. You should refer to the Exclusion Section when you see this symbol. Prior Auth Required Prior Authorization Required – This “Prior Authorization” symbol will appear next to those Covered Benefits that require our Authorization (approval) in advance of those services. To receive full benefits, your In-network Practitioner/Provider must call us and obtain Authorization before you receive treatment. You must call us if you are seeking services Out-of-network. In the case of a Hospital in-patient admission following an Emergency Room visit, you should call as soon as possible. Timeframe Requirement – This “Timeframe” symbol appears to remind you when you must ake action within a certain timeframe to comply with your Plan. An Timeframe associated with this item Important 158

Complaints, Grievances and Appeals. 90 This Section explains how to file a Complaint, Grievance and Appeal. Overview 90 Computation of Time 90 General Requirements and Information Regarding Grievance Procedures 90 Information About Grievance Procedures 91 Confidentiality of Your Records and Medical Information 92 Preliminary Determination 92 Timeframes for Initial Determinations 93 Initial Determinations 93 Notice of Initial Determinations 94 Rights Regarding Internal Review of Adverse Determinations 95 Timeframes for Internal Review of Adverse Determinations 96 Internal Panel Review of Adverse Determinations 97 Additional Requirements for Expedited Internal Review of Adverse Determinations 98 Notice of Internal Panel Decision 99 External Review of Adverse Determinations 99 Filing Requirements for External Review of Adverse Determinations 101 Acknowledgement of Request for External Review of Adverse Determination and Copy to Health Care Insurer 102 Timeframes for External Review and Adverse Determinations 102 Criteria for Initial External Review of Adverse Determination by the Office of Superintendent of Insurance Staff 103 Additional Criteria for Initial External Review of Experimental or Investigational Treatment Adverse Determinations by the Office of Superintendent of Insurance 103 Initial External Review of Adverse Determination by the Office of Superintendent of Insurance Staff 104 Hearing Procedures for External Review of Adverse Determinations 105 Independent Co-Health Officers (ICOs) 106 Superintendent’s Decision on External Review of Adverse Determination 107 Internal Review of Administrative Grievances 107 Initial Internal Review Decision on Administrative Grievance 108 Reconsideration of Internal Review 108 Decision of Reconsideration Committee 109 External Review of Administrative Grievances 110 Filing Requirements for External Review of Administrative Grievance 111 Acknowledgement of Request for External Review of Administrative Grievance and Copy to Health Care Insurer 111 Review of Administrative Grievance by Superintendent 112 Records 113 Your medical records are important documents needed in order to administer your Health Benefits Plan. This Section explains how we ensure the confidentiality of these records and how these records are used to administer your plan. Creation of Non-Medical Records 113 Accuracy of Information 113 Consent for Use and Disclosure of Medical Records 113 Professional Review. 113 Confidentiality of Protected Health Information/Medical Records 113 Eligibility, Enrollment, Effective Dates, Termination and Continuation 120 This Section explains eligibility requirements for Subscribers and/or their Dependents, important effective dates, conditions for Termination of Coverage and continuing Coverage for Members who become ineligible for this Plan. How You Can Enroll as a Member 120 Residence of a Dependent Child 122 121 Enrollment and Effective Dates 123 122 Full, Accurate and Complete Information 125 Change in Address, Family Status and Employment 125 Termination of Coverage 126 125 Continuation of Coverage of your Plan 129 Premium Payment 131 130 This Section explains how Premium Payments are to be made to Presbyterian Health Plan Prepayments 131 130 Changes in Prepayments 131 130 General Provisions 132 131 This Section explains important information and provisions not covered in other Sections of this Agreement. Amendments 132 131 Assignment 132 131 Availability of Provider Services 132 131 Entire Contract 132 131 Execution of Contract - Application for Coverage 132 131 Federal and State Health Care Reform 131 Fraud 132 Fraud 133 Practitioner/Provider Activity 133 132 Member Activity 133 132 Governing Law 134 HSA Note: Health Savings Account Information 134 133 Identification Cards 134 133 Legal Actions 134 133 Misrepresentation of Information 133 Misstatements 133 Notice 134 Misstatements 135 Notice 135 Policies and Procedures 135 134 Reinstatements 135 134 Right to Examine 135 134 Waiver by Agents 135 134 Workers’ Compensation Insurance 136 134 Glossary of Terms 137 136 This Section defines some of the important terms used in this Agreement. Terms defined in this Section will be capitalized throughout the Agreement. Exhibit A – Vision 156 154 Exhibit B – Healthways Gym Membership 158 156 WELCOME TO PRESBYTERIAN HEALTH PLAN! Welcome and thank you for joining Presbyterian Health Plan. We are a Health Care Insurer operated as a division of Presbyterian Healthcare Services, a locally owned New Mexico health care system. When we use the words "Presbyterian Health Plan", "PHP", "we", "us", and "our" in this document, we are referring to Presbyterian Health Plan. When we use the words “you” and “your” we are referring to each Member. As part of Presbyterian Healthcare Services, the health plan represents an organization with over 100 years of community service to New Mexicans. Our priority has been and will continue to be improving the health of individuals, families and communities. We are working to make sure that you receive quality care and service. We are pleased to provide you with access to a comprehensive network of Physicians, Hospitals, and outpatient medical Providers, who provide services for your Covered Benefits. We provide utilization management and quality improvement oversight programs with our commitment to Member service. We work closely with you, your Covered Dependents and your health care Practitioners and Providers to provide a quality, affordable health care plan. Our Agreement With You This is your Subscriber Agreement (Agreement) and it is a legal document. This Agreement, along with the Summary of Benefits and Coverage, describes the Covered Health Care Benefits and plan features that you and your eligible Dependents may receive when you enroll. Information you will find in this Agreement includes:  Your rights and responsibilities as a Member  Covered Benefits available through this Plan  How to access services from physicians, Practitioners, Providers and Pharmacies  Services that require Prior Authorization  Limitations and Exclusions for certain Covered Benefits  Coverage for your Dependents who are outside of New Mexico  A Glossary Of Terms used in this Agreement  What to do when you need assistance Throughout this Agreement, we ask you to refer to your Summary of Benefits and Coverage. The Summary of Benefits and Coverage is a chart that shows some specific Covered Benefits this Plan provides, the amount you may have to pay (Cost Sharing) and the Coverage Limitations and Exclusions. Please take time to read this Agreement and Summary of Benefits and Coverage, including Benefits, Limitations, and Exclusions. This Agreement describes your benefits and your rights and responsibilities as our Member. It also gives details on how to choose or change your Primary Care Physician, what limits are placed on certain benefits, and what services are not Covered at all. Understanding how this Plan works can help you make the best use of your Covered Benefits. You should keep this Agreement, your Summary of Benefits and Coverage, and any other attachments or Endorsements you may receive for future reference. Understanding This Agreement We use visual symbols throughout this Agreement to alert you to important requirements, restrictions and information. When one or more of the symbols is used, we will use bold print in the paragraph or section to point out the exact requirement, restriction, and information. These symbols are listed below: Refer To – This “Refer To” symbol will direct you to read related information in other sections of the Agreement or Summary of Benefits and Coverage when Refer to necessary. The Section being referenced will be bolded. Exclusion Exclusion – This “Exclusion” symbol will appear next to the description of certain Covered Benefits. The Exclusion symbol will alert you that there are some services that are excluded from the Covered Benefits and will not be paid. You should refer to the Exclusion Section when you see this symbol. Prior Auth Required Prior Authorization Required – This “Prior Authorization” symbol will appear next to those Covered Benefits that require our Authorization (approval) in advance of those services. To receive full benefits, your In-network Practitioner/Provider must call us and obtain Authorization before you receive treatment. You must call us if you are seeking services Out-of-network. In the case of a Hospital in-patient admission following an Emergency Room visit, you should call as soon as possible. Timeframe Requirement – This “Timeframe” symbol appears to remind you when you must ake action within a certain timeframe to comply with your Plan. An Timeframe associated with this item Important 

Complaints, Grievances and Appeals. 90 This Section explains how to file a Complaint, Grievance and Appeal. Overview 90 Computation of Time 90 General Requirements and Information Regarding Grievance Procedures 90 Information About Grievance Procedures 91 Confidentiality of Your Records and Medical Information 92 Preliminary Determination 92 Timeframes for Initial Determinations 93 Initial Determinations 93 Notice of Initial Determinations 94 Rights Regarding Internal Review of Adverse Determinations 95 Timeframes for Internal Review of Adverse Determinations 96 Internal Panel Review of Adverse Determinations 97 Additional Requirements for Expedited Internal Review of Adverse Determinations 98 Notice of Internal Panel Decision 99 External Review of Adverse Determinations 99 Filing Requirements for External Review of Adverse Determinations 101 Acknowledgement of Request for External Review of Adverse Determination and Copy to Health Care Insurer 102 Timeframes for External Review and Adverse Determinations 102 Criteria for Initial External Review of Adverse Determination by the Office of Superintendent of Insurance Staff 103 Additional Criteria for Initial External Review of Experimental or Investigational Treatment Adverse Determinations by the Office of Superintendent of Insurance 103 Initial External Review of Adverse Determination by the Office of Superintendent of Insurance Staff 104 Hearing Procedures for External Review of Adverse Determinations 105 Independent Co-Health Officers (ICOs) 106 Superintendent’s Decision on External Review of Adverse Determination 107 Internal Review of Administrative Grievances 107 Initial Internal Review Decision on Administrative Grievance 108 Reconsideration of Internal Review 108 Decision of Reconsideration Committee 109 External Review of Administrative Grievances 110 Filing Requirements for External Review of Administrative Grievance 111 Acknowledgement of Request for External Review of Administrative Grievance and Copy to Health Care Insurer 111 Review of Administrative Grievance by Superintendent 112 Records 113 Your medical records are important documents needed in order to administer your Health Benefits Plan. This Section explains how we ensure the confidentiality of these records and how these records are used to administer your plan. Creation of Non-Medical Records 113 Accuracy of Information 113 Consent for Use and Disclosure of Medical Records 113 Professional Review. 113 Confidentiality of Protected Health Information/Medical Records 113 Eligibility, Enrollment, Effective Dates, Termination and Continuation 120 This Section explains eligibility requirements for Subscribers and/or their Dependents, important effective dates, conditions for Termination of Coverage and continuing Coverage for Members who become ineligible for this Plan. How You Can Enroll as a Member 120 Residence of a Dependent Child 122 121 Enrollment and Effective Dates 123 122 Full, Accurate and Complete Information 125 Change in Address, Family Status and Employment 125 Termination of Coverage 126 125 Continuation of Coverage of your Plan 129 Premium Payment 131 130 This Section explains how Premium Payments are to be made to Presbyterian Health Plan Prepayments 131 130 Changes in Prepayments 131 130 General Provisions 132 131 This Section explains important information and provisions not covered in other Sections of this Agreement. Amendments 132 131 Assignment 132 131 Availability of Provider Services 132 131 Entire Contract 132 131 Execution of Contract - Application for Coverage 132 131 Federal and State Health Care Reform 131 Fraud 132 Fraud 133 Practitioner/Provider Activity 133 132 Member Activity 133 132 Governing Law 134 HSA Note: Health Savings Account Information 134 133 Identification Cards 134 133 Legal Actions 134 133 Misrepresentation of Information 133 Misstatements 133 Notice 134 Misstatements 135 Notice 135 Policies and Procedures 135 134 Reinstatements 135 134 Right to Examine 135 134 Waiver by Agents 135 134 Workers’ Compensation Insurance 136 134 Glossary of Terms 137 136 This Section defines some of the important terms used in this Agreement. Terms defined in this Section will be capitalized throughout the Agreement. Exhibit A – Vision 156 154 Exhibit B – Healthways Gym Membership 158 156 WELCOME TO PRESBYTERIAN HEALTH PLAN! Welcome and thank you for joining Presbyterian Health Plan. We are a Health Care Insurer operated as a division of Presbyterian Healthcare Services, a locally owned New Mexico health care system. When we use the words "Presbyterian Health Plan", "PHP", "we", "us", and "our" in this document, we are referring to Presbyterian Health Plan. When we use the words “you” and “your” we are referring to each Member. As part of Presbyterian Healthcare Services, the health plan represents an organization with over 100 years of community service to New Mexicans. Our priority has been and will continue to be improving the health of individuals, families and communities. We are working to make sure that you receive quality care and service. We are pleased to provide you with access to a comprehensive network of Physicians, Hospitals, and outpatient medical Providers, who provide services for your Covered Benefits. We provide utilization management and quality improvement oversight programs with our commitment to Member service. We work closely with you, your Covered Dependents and your health care Practitioners and Providers to provide a quality, affordable health care plan. Our Agreement With You This is your Subscriber Agreement (Agreement) and it is a legal document. This Agreement, along with the Summary of Benefits and Coverage, describes the Covered Health Care Benefits and plan features that you and your eligible Dependents may receive when you enroll. Information you will find in this Agreement includes:  ⮚ Your rights and responsibilities as a Member  ⮚ Covered Benefits available through this Plan  ⮚ How to access services from physicians, Practitioners, Providers and Pharmacies  ⮚ Services that require Prior Authorization  ⮚ Limitations and Exclusions for certain Covered Benefits  ⮚ Coverage for your Dependents who are outside of New Mexico  ⮚ A Glossary Of Terms used in this Agreement  ⮚ What to do when you need assistance Throughout this Agreement, we ask you to refer to your Summary of Benefits and Coverage. The Summary of Benefits and Coverage is a chart that shows some specific Covered Benefits this Plan provides, the amount you may have to pay (Cost Sharing) and the Coverage Limitations and Exclusions. Please take time to read this Agreement and Summary of Benefits and Coverage, including Benefits, Limitations, and Exclusions. This Agreement describes your benefits and your rights and responsibilities as our Member. It also gives details on how to choose or change your Primary Care Physician, what limits are placed on certain benefits, and what services are not Covered at all. Understanding how this Plan works can help you make the best use of your Covered Benefits. You should keep this Agreement, your Summary of Benefits and Coverage, and any other attachments or Endorsements you may receive for future reference. Understanding This Agreement We use visual symbols throughout this Agreement to alert you to important requirements, restrictions and information. When one or more of the symbols is used, we will use bold print in the paragraph or section to point out the exact requirement, restriction, and information. These symbols are listed below: Refer To – This “Refer To” symbol will direct you to read related information in other sections of the Agreement or Summary of Benefits and Coverage when Refer to necessary. The Section being referenced will be bolded. Exclusion Exclusion – This “Exclusion” symbol will appear next to the description of certain Covered Benefits. The Exclusion symbol will alert you that there are some services that are excluded from the Covered Benefits and will not be paid. You should refer to the Exclusion Section when you see this symbol. Prior Auth Required Prior Authorization Required – This “Prior Authorization” symbol will appear next to those Covered Benefits that require our Authorization (approval) in advance of those services. To receive full benefits, your In-network Practitioner/Provider must call us and obtain Authorization before you receive treatment. You must call us if you are seeking services Out-of-network. In the case of a Hospital in-patient admission following an Emergency Room visit, you should call as soon as possible. Timeframe Requirement – This “Timeframe” symbol appears to remind you when you must ake action within a certain timeframe to comply with your Plan. An Timeframe associated with this item Important assistance

Complaints, Grievances and Appeals. 90 This Section explains how to file a Complaint, Grievance and Appeal. Overview 90 Computation of Time 90 General Requirements and Information Regarding Grievance Procedures 90 Information About Grievance Procedures 91 Confidentiality of Your Records and Medical Information 92 Preliminary Determination 92 Timeframes for Initial Determinations 93 Initial Determinations 93 Notice of Initial Determinations 94 Rights Regarding Internal Review of Adverse Determinations 95 Timeframes for Internal Review of Adverse Determinations 96 Internal Panel Review of Adverse Determinations 97 Additional Requirements for Expedited Internal Review of Adverse Determinations 98 Notice of Internal Panel Decision 99 External Review of Adverse Determinations 99 Filing Requirements for External Review of Adverse Determinations 101 Acknowledgement of Request for External Review of Adverse Determination and Copy to Health Care Insurer 102 Timeframes for External Review and Adverse Determinations 102 Criteria for Initial External Review of Adverse Determination by the Office of Superintendent of Insurance Staff 103 Additional Criteria for Initial External Review of Experimental or Investigational Treatment Adverse Determinations by the Office of Superintendent of Insurance 103 Initial External Review of Adverse Determination by the Office of Superintendent of Insurance Staff 104 Hearing Procedures for External Review of Adverse Determinations 105 Independent Co-Health Officers (ICOs) 106 Superintendent’s Decision on External Review of Adverse Determination 107 Internal Review of Administrative Grievances 107 Initial Internal Review Decision on Administrative Grievance 108 Reconsideration of Internal Review 108 Decision of Reconsideration Committee 109 External Review of Administrative Grievances 110 Filing Requirements for External Review of Administrative Grievance 111 Acknowledgement of Request for External Review of Administrative Grievance and Copy to Health Care Insurer 111 Review of Administrative Grievance by Superintendent 112 Records 113 Your medical records are important documents needed in order to administer your Health Benefits Plan. This Section explains how we ensure the confidentiality of these records and how these records are used to administer your plan. Creation of Non-Medical Records 113 Accuracy of Information 113 Consent for Use and Disclosure of Medical Records 113 Professional Review. 113 Confidentiality of Protected Health Information/Medical Records 113 Eligibility, Enrollment, Effective Dates, Termination and Continuation 120 This Section explains eligibility requirements for Subscribers and/or their Dependents, important effective dates, conditions for Termination of Coverage and continuing Coverage for Members who become ineligible for this Plan. How You Can Enroll as a Member 120 Residence of a Dependent Child 122 Enrollment and Effective Dates 123 Full, Accurate and Complete Information 125 Change in Address, Family Status and Employment 125 Termination of Coverage 126 Continuation of Coverage of your Plan 129 Premium Payment 131 This Section explains how Premium Payments are to be made to Presbyterian Health Plan Prepayments 131 Changes in Prepayments 131 General Provisions 132 This Section explains important information and provisions not covered in other Sections of this Agreement. Amendments 132 Assignment 132 Availability of Provider Services 132 Entire Contract 132 Execution of Contract - Application for Coverage 132 Federal and State Health Care Reform 132 Fraud 133 Practitioner/Provider Activity Liability 133 Member Activity 133 Governing Law 134 HSA Note: Health Savings Account Information 134 Identification Cards 134 Legal Actions 134 Misrepresentation of Information 134 Misstatements 135 134 Notice 135 Policies and Procedures 135 Reinstatements 135 Right to Examine 135 Waiver by Agents 135 Workers’ Compensation Insurance 136 135 Glossary of Terms 137 This Section defines some of the important terms used in this Agreement. Terms defined in this Section will be capitalized throughout the Agreement. Exhibit A – Pediatric Vision 156 Exhibit B – Healthways Gym Membership 158 WELCOME TO PRESBYTERIAN HEALTH PLAN! Welcome and thank you for joining Presbyterian Health Plan. We are a Health Care Insurer operated as a division of Presbyterian Healthcare Services, a locally owned New Mexico health care system. When we use the words "Presbyterian Health Plan", "PHP", "we", "us", and "our" in this document, we are referring to Presbyterian Health Plan. When we use the words “you” and “your” we are referring to each Member. As part of Presbyterian Healthcare Services, the health plan represents an organization with over 100 years of community service to New Mexicans. Our priority has been and will continue to be improving the health of individuals, families and communities. We are working to make sure that you receive quality care and service. We are pleased to provide you with access to a comprehensive network of Physicians, Hospitals, and outpatient medical Providers, who provide services for your Covered Benefits. We provide utilization management and quality improvement oversight programs with our commitment to Member service. We work closely with you, your Covered Dependents and your health care Practitioners and Providers to provide a quality, affordable health care plan. Our Agreement With You This is your Subscriber Agreement (Agreement) and it is a legal document. This Agreement, along with the Summary of Benefits and Coverage, describes the Covered Health Care Benefits and plan features that you and your eligible Dependents may receive when you enroll. Information you will find in this Agreement includes:  Your rights and responsibilities as a Member  Covered Benefits available through this Plan  How to access services from physicians, Practitioners, Providers and Pharmacies  Services that require Prior Authorization  Limitations and Exclusions for certain Covered Benefits  Coverage for your Dependents who are outside of New Mexico  A Glossary Of Terms used in this Agreement  What to do when you need assistance Throughout this Agreement, we ask you to refer to your Summary of Benefits and Coverage. The Summary of Benefits and Coverage is a chart that shows some specific Covered Benefits this Plan provides, the amount you may have to pay (Cost Sharing) and the Coverage Limitations and Exclusions. Please take time to read this Agreement and Summary of Benefits and Coverage, including Benefits, Limitations, and Exclusions. This Agreement describes your benefits and your rights and responsibilities as our Member. It also gives details on how to choose or change your Primary Care Physician, what limits are placed on certain benefits, and what services are not Covered at all. Understanding how this Plan works can help you make the best use of your Covered Benefits. You should keep this Agreement, your Summary of Benefits and Coverage, and any other attachments or Endorsements you may receive for future reference. Understanding This Agreement We use visual symbols throughout this Agreement to alert you to important requirements, restrictions and information. When one or more of the symbols is used, we will use bold print in the paragraph or section to point out the exact requirement, restriction, and information. These symbols are listed below: Refer To – This “Refer To” symbol will direct you to read related information in other sections of the Agreement or Summary of Benefits and Coverage when Refer to necessary. The Section being referenced will be bolded. Exclusion Exclusion – This “Exclusion” symbol will appear next to the description of certain Covered Benefits. The Exclusion symbol will alert you that there are some services that are excluded from the Covered Benefits and will not be paid. You should refer to the Exclusion Section when you see this symbol. Prior Auth Required Prior Authorization Required – This “Prior Authorization” symbol will appear next to those Covered Benefits that require our Authorization (approval) in advance of those services. To receive full benefits, your In-network Practitioner/Provider must call us and obtain Authorization before you receive treatment. You must call us if you are seeking services Out-of-network. In the case of a Hospital in-patient admission following an Emergency Room visit, you should call as soon as possible. Timeframe Requirement – This “Timeframe” symbol appears to remind you when you must ake action within a certain timeframe to comply with your Plan. An Timeframe associated with this item Important 157