INTRODUCTION TO YOUR SUBSCRIBER AGREEMENT. Thank you for choosing Blue Cross & Blue Shield of Rhode Island (BCBSRI) for your healthcare coverage. We appreciate the trust you’ve placed in us and want to help you make the most of your health plan. In this Subscriber Agreement (agreement), you’ll find valuable information about your • how your health coverage works; • how BCBSRI processes claims for the health services you receive; • your rights and responsibilities as a BCBSRI member; • BCBSRI’s rights and responsibilities; and • tools and programs to help you stay healthy and save money. We encourage you to read this agreement to learn about all the advantages of being a BCBSRI member. Below are some helpful tips on how to find what you need in this agreement. • As a member, you are responsible for understanding the benefits to which you are entitled under this agreement and the rules you must follow to receive those benefits. • The Table of Contents will help you find the order of the sections as they appear in the agreement. • The Summary of Benefits, included in this agreement, shows the amount you pay out of your own pocket. • Important contact information, such as, telephone numbers, addresses, and websites are located at the end of this document. • Some words and phrases used in this agreement are in italics. This means that the words or phrases have a special meaning as they relate to your healthcare coverage. Please see Section 8 for definitions of these words. • When we use the words “we,” “us,” and “our,” we are referring to BCBSRI. When we use the words “you” and “your” we are referring to the enrolled subscriber and/or member. These words are also defined in the Glossary. • Many sections of this document are related to other sections. You may need to reference more than one section to find the information you need.
INTRODUCTION TO YOUR SUBSCRIBER AGREEMENT. 11 SECTION 2: ELIGIBILITY 15 SECTION 3: COVERED HEALTHCARE SERVICES 21 SECTION 4: EXCLUSIONS 49 SECTION 5: REQUESTS FOR AUTHORIZATION, DENIALS, COMPLAINTS, AND APPEALS 59 SECTION 6: CLAIM FILING AND PROVIDER PAYMENTS 67 SECTION 7: COORDINATION OF BENEFITS AND SUBROGATION 74 SECTION 8: GLOSSARY 80 SECTION 9: CONTACT INFORMATION 88 SECTION 10: NOTICES AND DISCLOSURES 90 SUMMARY OF MEDICAL BENEFITS
INTRODUCTION TO YOUR SUBSCRIBER AGREEMENT. Thank you for choosing Blue Cross & Blue Shield of Rhode Island (BCBSRI) for your dental coverage. We appreciate the trust you’ve placed in us and want to help you make the most of your dental plan. In this Subscriber Agreement (agreement), you’ll find valuable information about your • how your dental coverage works; • how BCBSRI processes claims for the dental services you receive; • your rights and responsibilities as a BCBSRI member; • BCBSRI’s rights and responsibilities. We encourage you to read this agreement to learn about all the advantages of being a BCBSRI member. Below are some helpful tips on how to find what you need in this agreement. • As a member, you are responsible for understanding the benefits to which you are entitled under this agreement and the rules you must follow to receive those benefits. • The Table of Contents will help you find the order of the sections as they appear in the agreement. • The Summary of Benefits, included in this agreement, shows the amount you pay out of your own pocket.
INTRODUCTION TO YOUR SUBSCRIBER AGREEMENT. 10 SECTION 2: ELIGIBILITY 14 SECTION 3: COVERED HEALTHCARE SERVICES 20 SECTION 4: EXCLUSIONS 43 SECTION 5: REQUESTS FOR AUTHORIZATION, DENIALS, COMPLAINTS, AND APPEALS 52 SECTION 6: CLAIM FILING AND PROVIDER PAYMENTS 60 SECTION 7: COORDINATION OF BENEFITS AND SUBROGATION 65 SECTION 8: GLOSSARY 71 SECTION 9: CONTACT INFORMATION 79 SECTION 10: NOTICES AND DISCLOSURES 81
