Not enrolled in Medicare.........................................................................................................................................................66
Medicare Private Contract Options .....................................................................................................................................66
Medicare HMO or Participating Provider Programs.....................................................................................................66
Allowable Fees .................................................................................................................................................................................66
SECTION VII - COORDINATION OF BENEFITS (COB)..............................................................................................67
COB Terms and Definitions ........................................................................................................................................................67
Order of Benefit Determination..................................................................................................................................................68
Medicare Effect on the Order of Benefit Determination.....................................................................................................70
COB Effect on Plan Benefits........................................................................................................................................................70
Right to Receive and Release Needed Information ...............................................................................................................70
Facility of Payment.........................................................................................................................................................................71
Right of Recovery...........................................................................................................................................................................71
Examples of COB Order of Benefits .........................................................................................................................................71
SECTION VIII - CLAIM SUBMISSION AND REVIEW PROCEDURES ..................................................................73
How to Submit a Claim.................................................................................................................................................................73
Network Provider Claims .......................................................................................................................................................73
Hospital Inpatient or Outpatient Claims ............................................................................................................................73
Prescription Drug Claims .......................................................................................................................................................73
Other Claim Submissions........................................................................................................................................................73
Time Limit on Claim Submission...............................................................................................................................................74
Payment of Benefits/Authorization to Pay Provider/Other Entity...................................................................................74
Your Right to Benefits ...................................................................................................................................................................74
Health Claim Inquiries..................................................................................................................................................................75
Plan Determination Notices and Claimant Appeals..............................................................................................................75
Definitions Used in This Provision........................................................................................................................................75
Plan Notifications ......................................................................................................................................................................76
Concurrent Claims ....................................................................................................................................................77
Claimant Appeals of Adverse Benefit Determinations ...................................................................................................79
Legal Proceedings...........................................................................................................................................................................81
SECTION IX - OTHER PROCEDURES AND PROVISIONS.........................................................................................82
Not an Employment Contract .....................................................................................................................................................82
Verification of Claim Information.............................................................................................................................................82
Right of Examination.....................................................................................................................................................................82
Indemnity Benefits .........................................................................................................................................................................82
Misrepresentation/Fraud..............................................................................................................................................................82
Refund Due to Overpayment of Benefits .................................................................................................................................82
Right of Subrogation/Reimbursement......................................................................................................................................83
Conditional Benefit Payment ............................................................................................................................................83
Reimbursement Agreement ....................................................................................................................................................83
Amendments or Cancellation of the Plan ................................................................................................................................84
Construction of Plan and Determination by Plan Administrator .....................................................................................84
Named Fiduciary and Plan Administrator ..............................................................................................................................84
Severability .......................................................................................................................................................................................85
Waiver and Estoppel......................................................................................................................................................................85
Headings............................................................................................................................................................................................85
Federal and State Laws .................................................................................................................................................................85
Statement of ERISA Rights .........................................................................................................................................................85
SECTION X - DEFINITIONS ....................................................................................................................................................87
