SSMC Employee Health Benefit Plan
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58. Other Plan/Benefit Penalties. Services or Supplies to the extent such expenses were disallowed by a
primary health plan due to failure by their enrollee or participant to follow the requirements of its Managed
Care Program, pre-admission reviews, second surgical opinion or any other reason, including failure to
abide by the primary care Physician network established by a health maintenance organization (HMO) or
similar plan (including Medicare-sponsored HMO plan) that is considered primary plan coverage.
59. This Plan Penalties/Deductibles/Copayments/Benefit Limits. Services or Supplies to the extent they are
not reimbursed due to Plan benefit penalties, Deductibles, Copayments or other benefit limits under any
portion of this Plan unless otherwise included when Plan is secondary payer according to the coordination
of benefits provision.
60. Late Claim Filing. Services or Supplies for which an adequate claim is not filed with the Claims
Administrator within the Plan time limit for claim submissions. Claims must be submitted within 12
months after the date the Covered Expenses were Incurred unless exception made at the discretion of the
Claims Administrator or the Plan Administrator for late filing due to extenuating circumstances beyond the
control of the Enrollee. In no event, will the Plan cover expenses submitted more than two years after the
date Incurred.
61. Provider Adjustments. Provider adjustments requested for previously submitted claims that are requested
or billed more than two years after the date Services or Supplies were Incurred will not be considered for
benefits, whatever the reason for delay. Note: The Late Claim Filing rule applies to initial claims.
62. Not Included. Services or Supplies that are not included as Covered Expenses under the Plan even if
ordered by a Physician. Covered Services or Supplies given, provided and/or billed by a Provider that is
not included for coverage under the Plan even if Medically Necessary. Services or Supplies billed by
qualified Providers that were not given by or under the direct supervision of that Provider. This applies
even if such Services or Supplies or Providers are not specifically excluded according to Plan provisions.
