SSMC Employee Health Benefit Plan
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Provider of service. Any assignment of your right to benefits or assignment of your right to take legal action
under the Plan will be void. No benefit payment under the Plan shall be subject in any way to alienation, sale,
transfer, pledge, attachment, garnishment, execution, or encumbrance of any kind, any attempt to accomplish
this shall be void. If the Plan administrator finds that such attempts have been made, the Plan Administrator,
in its sole discretion, may terminate the interest of such Covered Person or former Covered Person in such
payment. If such payments are made, the Plan Administrator may consider such payments as complete
discharge of all liability with respect to the Covered Expenses resulting in such payments.
E. Health Claim Inquiries
When you have any questions concerning your coverage, you may call the SSMC Human Resources
Department at (914) 632-5000 or phone the POMCO Toll-free number: 1-800-501-9536.
F. Plan Determination Notices and Claimant Appeals
(Effective for Claim submitted on or after January 1, 2003)
1. Definitions Used in This Provision.
ADVERSE BENEFIT DETERMINATION. Any of the following:
·
A denial, reduction, or termination of, or a failure to provide or make payment (in whole or in part) that
is based on a determination of a Participant's or beneficiary's eligibility to participate in the Plan;
·
A denial, reduction, or termination of, or a failure to provide or make payment (in whole or in part) for,
a benefit resulting from the application of any utilization review; or
·
A failure to cover an item or service for which benefits are otherwise provided because it is determined
to be Experimental or Investigative or not Medically Necessary or appropriate.
CLAIM FOR BENEFITS/CLAIM. A written communication (written or oral for an Urgent Claim)
received by the person or persons responsible for handling benefit matters that names a specific Claimant; a
specific medical condition or symptom; and a specific treatment, service, or product for which approval is
requested either on a pre-service or post service basis and is submitted in accordance with the Plan's
procedures for filing claims.
CLAIMANT. When term is used in this provision, it means the Covered Person (Plan Participant,
beneficiary, Enrollee or by whatever name called) who files a Claim for Benefits. It also means the
authorized representative acting on behalf of the Claimant.
NOTICE OR NOTIFICATION. The delivery or furnishing of information to an individual in a manner
that satisfies the standards of federal regulations under 29 CFR 2520.104b-1(b) as appropriate with respect
to material required to be furnished or made available to an individual.
POST-SERVICE CLAIM. Any Claim for Benefits under the Plan that is not a Pre-Service Claim within
the meaning of "Pre-Service Claim" described below.
PRE-SERVICE CLAIM. Any Claim for Benefits under the Plan with respect to which the terms of the
Plan condition receipt of the benefit, in whole or in part, on approval of the benefit in advance of obtaining
medical care.
RELEVANT. A document, record, or other information shall be considered ``Relevant'' to a Claimant's
Claim for Benefits if such document, record, or other information:
·
Was relied upon in making the benefit determination;
