HCSC Sample Clauses

HCSC. Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association.

HCSC. UWS, United Wisconsin and United Heartland have formed or will form [Managing General Agent], an Illinois corporation (the "MGA"), pursuant to the terms of that certain Joint Venture and Shareholders Agreement (the "JOINT VENTURE AGREEMENT") dated as of May 3, 1999, by and among HCSC, UWS, United Wisconsin and United Heartland.

HCSC. 16 in a timely fashion, you and your entire family may be entitled to receive up to an additional 11 months of COBRA continuation coverage, for a total maximum of 29 months. The disability would have to have started at some time before the 60th day of COBRA continuation coverage and must last at least until the end of the 18‐month period of continuation coverage. Contact your employer and/or the COBRA Administrator for procedures for this notice, including a description of any required information or documentation. Second Qualifying Event Extension of 18‐Month Period of Continuation Coverage If your family experiences another qualifying event while receiving 18 months of COBRA continuation coverage, the spouse and dependent children in your family can get up to 18 additional months of COBRA continuation coverage, for a maxi­ mum of 36 months, if notice of the second qualifying event is properly given to the Plan. This extension may be available to the spouse and dependent children receiving continuation coverage if the employee or former employee dies, be­ comes entitled to Medicare benefits (under Part A, Part B, or both), or gets divorced or legally separated or if the dependent child stops being eligible under the Plan as a dependent child, but only if the event would have caused the spouse or dependent child to lose coverage under the Plan had the first qualifying event not occurred. If You Have Questions Questions concerning your Plan or your COBRA continuation coverage rights, should be addressed to your Plan Administrator. For more information about your rights under ERISA, including COBRA, the Health Insurance Portability and Ac­ countability Act (HIPAA), and other laws affecting group health plans, contact the nearest Regional or District Office of the U. S. Department of Labor's Em­ ployee Benefits Security Administration (EBSA) in your area or visit the EBSA website at xxx.xxx.xxx/xxxx. (Addresses and phone numbers of Regional and District EBSA Offices are available through EBSA's website.)

HCSC. 85 The Plan will render a decision of a post‐service appeal as soon as practical, but in no event more than 15 business days after receipt of all required information (if the appeal is related to health care services and not related to administrative mat- ters or Complaints) or 60 days after the appeal has been received by the Plan, whichever is sooner.

HCSC. 93 As expeditiously as your medical condition or circumstances requires (but in no event more than 72 hours after the date of receipt of the request for an expedited external review), the assigned IRO will render a decision whether or not to uphold or reverse the Adverse Determination or Final Adverse De- termination and will notify the Director, the Plan, you and, if applicable, your authorized representative. If the initial notice regarding its determina- tion was not in writing, within 48 hours after the date of providing such notice, the assigned IRO shall provide written confirmation of the decision to you, the Director, the Plan and, if applicable, your authorized representat- ive, including all the information outlined under the standard process above. If the external review was a review of experimental or investigational treat- ments, each clinical reviewer shall provide an opinion orally or in writing to the assigned IRO as expeditiously as your medical condition or circum- stances requires, but in no event less than five calendar days after being selected. Within 48 hours after the date it receives the opinion of each clinic- al reviewer, the IRO will make a decision and provide notice of the decision either orally or in writing to the Director, the Plan, you and your authorized representative, if applicable. If the IRO's initial notice regarding its determination was not in writing, within 48 hours after the date of providing such notice, the assigned IRO shall provide written confirmation of the decision to you, the Director, the Plan and, if applicable, your authorized representative. The assigned IRO is not bound by any decisions or conclusions reached dur- ing the Plan's utilization review process or the Plan's internal appeal process. Upon receipt of a notice of a decision reversing the Adverse Deter- mination or Final Adverse Determination, the Plan shall immediately approve the coverage that was the subject of the determination. Benefits will not be provided for services or supplies not covered under the benefit program if the IRO determines that the health care services being appealed were medically appropriate. An external review decision is binding on the Plan. An external review decision is binding on you, except to the extent you have other remedies available under applicable federal or state law. You and your authorized representative may not file a subsequent request for external review involving the same Adverse Deter- mination or...

HCSC. 14 If you are the spouse of an employee, you will become a qualified beneficiary if you lose your coverage under the Plan because any of the following qualifying events happens: • Your spouse dies; • Your spouse's hours of employment are reduced; • Your spouse's employment ends for any reason other than his or her gross misconduct; • Your spouse becomes enrolled in Medicare benefits (under Part A, Part B, or both); or • You become divorced or legally separated from your spouse. Your dependent children will become qualified beneficiaries if they lose coverage under the Plan because any of the following qualifying events happen: • The parent‐employee dies; • The parent‐employee's hours of employment are reduced; • The parent‐employee's employment ends for any reason other than his or her gross misconduct; • The parent‐employee becomes enrolled in Medicare benefits (under Part A, Part B, or both); • The parents become divorced or legally separated; or • The child stops being eligible for coverage under the Plan as a “dependent child.” If the Plan provides health care coverage to retired employees, the following ap­ plies: Sometimes, filing a proceeding in bankruptcy under title 11 of the United States Code can be a qualifying event. If a proceeding in bankruptcy is filed with respect to your employer, and that bankruptcy results in the loss of coverage of any retired employee covered under the Plan, the retired employee will become a qualified beneficiary with respect to the bankruptcy. The retired employee's spouse, surviving spouse, and dependent children will also become qualified beneficiaries if bankruptcy results in the loss of their coverage under the Plan. When Is COBRA Coverage Available? The Plan will offer COBRA continuation coverage to qualified beneficiaries only after the Plan Administrator has been notified that a qualifying event has oc­ curred. When the qualifying event is the end of employment or reduction of hours of employment, death of the employee, in the event of retired employee health coverage, commencement of a proceeding in bankruptcy with respect to the em­ ployer, or the employee's becoming entitled to Medicare benefits (under Part A, Part B, or both), the employer must notify the Plan Administrator of the qualify­ ing event.

HCSC. 85 If the Plan's decision is to continue to deny or partially deny your Claim or you do not receive timely decision, you may be able to request an external review of your Claim by an independent third party, who will review the denial and issue a final decision. Your external review rights are described in the INDEPENDENT EX­ TERNAL REVIEW section below. If an appeal is not resolved to your satisfaction, you may appeal the Plan's deci­ sion to the Illinois Department of Insurance. The Illinois Department of Insurance will notify the Plan of the appeal. The Plan will have 21 days to respond to the Illinois Department of Insurance. The operations of the Plan are regulated by the Illinois Department of Insurance. Filing an appeal does not prevent you from filing a Complaint with the Illinois Department of Insurance or keep the Illinois Department of Insurance from inves­ tigating a Complaint. The Illinois Department of Insurance can be contacted at: Illinois Department of Insurance Consumer Division 000 Xxxx Xxxxxxxxxx Xxxxxx Xxxxxxxxxxx, Xxxxxxxx 00000 or Illinois Department of Insurance Consumer Division 000 Xxxxx Xxxxxxxx Xxxxxx, 00xx Xxxxx Xxxxxxx, Xxxxxxxx 00000 You must exercise the right to internal appeal as a precondition to taking any ac­ tion against the Plan, either at law or in equity. If you have an adverse appeal determination, you may file civil action in a state or federal court. If You Need Assistance If you have any questions about the Claims procedures or the review procedure, write or call the the Plan Headquarters at 1‐800‐538‐8833. The Plan's offices are open from 8:45 a.m. To 4:45 p.m., Monday through Friday. Blue Cross and Blue Shield of Illinois P. O. Box 805107 Chicago, IL 60680‐4112 If you need assistance with the internal Claims and appeals or the external review processes that are described below, you may contact the health insurance consum­ er assistance office or ombudsman. You may contact the Illinois ombudsman program at 1‐877‐527‐9432, or call the number on the back of your identification card for contact information. In addition, for questions about your appeal rights or for assistance, you can contact the Employee Benefits Security Administration at 1‐866‐444‐EBSA (3272). GB‐16 HCSC 86