17-321 R1/24 Platinum
COMPREHENSIVE MAJOR MEDICAL
PREFERRED PROVIDER ORGANIZATION
GROUP BENEFIT CERTIFICATE
Platinum Plan
IMPORTANT NOTICE. Except in certain circumstances (see Section 5.0), additional costs,
including balance billing, may be incurred for covered benefits received from a non-preferred
provider. (See your schedule of benefits.) Do not assume that a preferred provider’s
agreement includes all covered benefits or that all services provided a PPO Hospital are
provided by preferred providers.
Attached is the Schedule of Benefits and Identification Card indicating
name, benefits, Annual Limitation on Cost Sharing amount, group
number, identification number and effective date.
THIS BENEFIT CERTIFICATE CONTAINS SEVERAL SPECIFIC EXCLUSIONS. SEE
SECTION 4.0
ARKANSAS BLUE CROSS AND BLUE SHIELD
601 S. GAINES STREET
LITTLE ROCK, ARKANSAS 72201
2
NON-DISCRIMINATION AND LANGUAGE ASSISTANCE NOTICE
NOTICE: Our Company complies with applicable federal and state civil rights laws and does not
discriminate, exclude, or treat people differently on the basis of race, color, national origin, sex to
include discrimination on the basis of sexual orientation and gender identity, age or disability.
We provide free aids and services to people with disabilities to communicate effectively with us,
such as qualified sign language interpreters, written information in various formats (large print,
audio, accessible electronic formats, other formats), and language services to people whose
primary language is not English, such as qualified interpreters and information written in other
languages. If you need these services, contact our Civil Rights Coordinator.
If you believe that we have failed to provide these services or discriminated in another way on the
basis of race, color, national origin, age, disability, or sex, you can file a grievance with:
Civil Rights Coordinator
601 Gaines Street, Little Rock, AR 72201
Phone: 1-844-662-2276; TDD: 1-844-662-2275
You can file a grievance in person, by mail, or by email. If you need help filing a grievance our
Civil Rights Coordinator is available to help you.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services,
Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available
at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
U.S. Department of Health and Human Services
200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201
Phone: 1-800-368-1019; TDD: 1-800-537-7697
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
3
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1-844-662-2276.
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Chiamare il numero 1-844-662-2276.
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連絡ください。
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:ﺔظﺣﻼﻣ لﺎﺻﺗﻻا ﻰﺟرﯾ .كﻟ ﺔﺑﺳﻧﻟﺎﺑ ﺎﻧﺎﺟﻣ ﺔﻣدﻘﻣﻟا ﺔﯾوﻐﻠﻟا تﺎﻣدﺧﻟاو ،ﺔﯾﺳرﺎﻔﻟا ﺔﻐﻠﻟﺎﺑ ثدﺣﺗﺗ تﻧﻛ اذإ2276 -662-844-1 .
:
, :
. 1-844-662-2276.
यान द�:
1-844-662-2276
LUS CEEV: Yog tias koj hais lus Hmoob, cov kev pab txog lus, muaj kev pab dawb rau koj. Hu rau 1-844-662-
2276.
:هﺎﺑﺗﻧا ںﯾرﮐ لﺎﮐ .ںﯾﮨ تﻔﻣ بﺎﯾﺗﺳد ہﺿوﺎﻌﻣ ﻼﺑ تﺎﻣدﺧ ﯽﮐ ددﻣ ﯽﮐ نﺎﺑز ،وﺗ ںﯾﮨ ﮯﺗﻟوﺑ ودرا پآ2276-662 -844-1
ໂປດຊາບ: ຖ
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LALE: Ñe kwōj kōnono Kajin Ṃajōḷ, kwomaroñ bōk jerbal in jipañ ilo kajin ṇe aṃ ejjeḷọk wōṇāān. Kaalọk 1-844-662-
2276
4
TABLE OF CONTENTS
NON-DISCRIMINATION AND LANGUAGE ASSISTANCE NOTICE ........................................................................ 2
NOTICE OF PRIVACY PRACTICES ........................................................................................................................... 6
SCHEDULE OF BENEFITS ....................................................................................................................................... 10
1.0 HOW THE COVERAGE UNDER YOUR INSURANCE PLAN WORKS ...................................................... 11
2.0 PRIMARY COVERAGE CRITERIA .............................................................................................................. 13
2.1 Purpose and Effect of Primary Coverage Criteria. ..................................................................... 13
2.2 Elements of the Primary Coverage Criteria. ................................................................................ 13
2.3 Primary Coverage Criteria Definitions. ........................................................................................ 14
2.4 Application and Appeal of Primary Coverage Criteria. .............................................................. 15
3.0 BENEFITS AND SPECIFIC LIMITATIONS IN YOUR PLAN ....................................................................... 16
3.1 Professional Services. ................................................................................................................... 17
3.2 Preventive Health Services. .......................................................................................................... 18
3.3 Hospital Services. .......................................................................................................................... 18
3.4 Ambulatory Surgery Center. ......................................................................................................... 19
3.5 Outpatient Diagnostic Services. ................................................................................................... 19
3.6 Advanced Diagnostic Imaging Services. ..................................................................................... 19
3.7 Maternity. ........................................................................................................................................ 19
3.8 Complications of Pregnancy......................................................................................................... 21
3.9 Rehabilitation and Habilitation Services. .................................................................................... 21
3.10 Mental Illness and Substance Use Disorder. .............................................................................. 22
3.11 Autism Spectrum Disorder Benefits. ........................................................................................... 23
3.12 Emergency Care Services. ............................................................................................................ 24
3.13 Durable Medical Equipment. ......................................................................................................... 24
3.14 Medical Supplies. ........................................................................................................................... 25
3.15 Prosthetic and Orthotic Devices and Services. .......................................................................... 25
3.16 Diabetes Management Services. .................................................................................................. 26
3.17 Ambulance Services. ..................................................................................................................... 26
3.18 Skilled Nursing Facility Services. ................................................................................................. 27
3.19 Home Health Services. .................................................................................................................. 27
3.20 Hospice Care. ................................................................................................................................. 27
3.21 Dental Care Services ..................................................................................................................... 27
3.22 Reconstructive Surgery. ................................................................................................................ 29
3.23 Craniofacial Anomaly Services .................................................................................................... 29
3.24 Medications..................................................................................................................................... 30
3.25 Organ Transplant Services. .......................................................................................................... 34
3.26 Medical Disorder Requiring Specialized Nutrients or Formulas. .............................................. 35
3.27 Prenatal Tests and Testing of Newborn Children. ...................................................................... 35
3.28 Testing and Evaluation. ................................................................................................................. 35
3.29 Complications of Smallpox Vaccine. ........................................................................................... 36
3.30 Neurologic Rehabilitation Facility Services. ............................................................................... 36
3.31 Pediatric Vision Services. ............................................................................................................. 36
3.32 Adult Routine Eye Exams. ............................................................................................................. 37
3.33 Hearing Aid Benefits. ..................................................................................................................... 37
5
3.34 Temporomandibular Joint Benefits. ............................................................................................ 37
3.35 Miscellaneous Health Interventions. ............................................................................................ 37
4.0 SPECIFIC PLAN EXCLUSIONS .................................................................................................................. 39
4.1 Health Care Providers. ................................................................................................................... 39
4.2 Health Interventions. ...................................................................................................................... 40
4.3 Miscellaneous Fees and Services. ............................................................................................... 48
5.0 PROVIDER NETWORK AND COST SHARING PROCEDURES ................................................................ 50
5.1 Network Procedures ...................................................................................................................... 50
5.2. Covered Person’s Financial Obligations for Allowance or Allowable Charges under the Plan
55
5.3 Other Plans and Benefit Programs............................................................................................... 55
6.0 ELIGIBILITY STANDARDS .......................................................................................................................... 58
6.1 Eligibility for Coverage. ................................................................................................................. 59
6.2 Effective Date of Coverage............................................................................................................ 60
6.3 Termination of Coverage. .............................................................................................................. 62
6.4 Continuation Privileges ................................................................................................................. 63
6.5 Conversion Privileges ................................................................................................................... 65
7.0 CLAIM PROCESSING AND APPEALS ....................................................................................................... 66
7.1 Claim Processing. .......................................................................................................................... 66
7.2 Claim Appeals to the Plan (Internal Review). .............................................................................. 72
7.3 Independent Medical Review of Claims (External Review) ........................................................ 75
7.4 Authorized Representative ............................................................................................................ 78
8.0 OTHER PROVISIONS .................................................................................................................................. 79
8.1 Assignment of Benefits. ................................................................................................................ 79
8.2 Right of Rescission. ....................................................................................................................... 79
8.3 Claim Recoveries. .......................................................................................................................... 79
8.4 Amendment..................................................................................................................................... 79
8.5 Notice of Provider/Physician Incentives That Could Affect Your Access to Healthcare ....... 80
8.6 Pediatric Dental Plan. .................................................................................................................... 81
8.7 Value Adds. ............................................................................................................................................ 81
9.0 GLOSSARY OF TERMS .............................................................................................................................. 81
10.0 YOUR RIGHTS UNDER ERISA ................................................................................................................... 95
A
RKANSAS CONSUMERS INFORMATION NOTICE ............................................................................................................. 98
LIMITATIONS AND EXCLUSIONS UNDER THE ARKANSAS LIFE AND HEALTH INSURANCE GUARANTY
ASSOCIATION ACT .................................................................................................................................................. 99
6
NOTICE OF PRIVACY PRACTICES
ARKANSAS BLUE CROSS AND BLUE SHIELD
THIS NOTICE DESCRIBES HOW CLAIMS OR MEDICAL INFORMATION ABOUT YOU MAY BE USED AND
DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
By law, Arkansas Blue Cross and Blue Shield is required to protect the privacy of your protected health information.
We also must give you this notice to tell you how we may use and release (“disclose”) your protected health
information held by Us. Arkansas Blue Cross and Blue Shield is a business name of USAble Mutual Insurance
Company.
Throughout this notice, we will use the name “Arkansas Blue Cross” as a shorthand reference for Arkansas Blue
Cross and Blue Shield.
Arkansas Blue Cross must use and release your protected health information to provide information:
• To you or someone who has the legal right to act for you (your personal representative)
• To the Secretary of the Department of Health and Human Services, if necessary, to make sure your privacy
is protected, and
• Where required by law.
Arkansas Blue Cross has the right to use and release your protected health information to evaluate and process your
health plan or health insurance claims, enroll and disenroll you and your dependents, and perform related business
operations.
For example:
• We can use and disclose your protected health information to pay or deny your claims, to collect your
premiums, or to share your benefit payment or status with other insurer(s).
•
We can use and disclose your protected health information for regular healthcare operations. Members
of our staff may use information in your personal health record to assess our efficiency and outcomes in
your case and others like it. This information will then be used in an effort to continually improve the
quality and effectiveness of benefits and services we provide.
•
We may disclose protected health information to your employer for health plan administration
purposes, including healthcare operations of the health plan, if your employer arranges for your
insurance or funds the
health plan coverage and serves as plan administrator. If your employer meets the
requirements outlined by the privacy law to ensure adequate separation between the employer and the health
plan itself, we can disclose protected health information to the appropriate health plan administrative
department of your employer to assist in obtaining coverage or processing a claim or to modify benefits, work
to control overall plan costs, and improve service levels. This information may be provided to the appropriate
health plan administrative department of your employer in the form of routine reporting or special requests.
• We may disclose to others who are contracted to provide services as business associates on our behalf.
Some services are provided in our organization through contracts with others. Examples include pharmacy
management programs, dental benefits, and a copy service we use when making copies of your health
record. Our contracts require these business associates to appropriately protect your information in
compliance with applicable privacy and security laws.
• Our health professionals and customer service staff, using their best judgment, may disclose to a family
member, other relative, close personal friend or any other person you identify, health information relevant to
that person’s involvement in your care or payment related to your care. Examples of such releases of your
protected health information could include your spouse calling to verify a claim was paid, or the amount paid
on a claim, or an adult child inquiring about explanation of benefit forms received by an elderly parent who is
ill or impaired and unable to address their own health insurance or health plan business.
Arkansas Blue Cross may use or give out your protected health information for the following purposes, under limited
circumstances:
7
• To state and federal agencies that have the legal right to receive Arkansas Blue Cross data (such as to make
sure we are making proper claims payments)
• For public health activities (such as reporting disease outbreaks)
• For government healthcare oversight activities (such as fraud and abuse investigations)
• For judicial and administrative proceedings (such as in response to a subpoena, law enforcement agency
administrative request or other court order)
• For law enforcement purposes (such as providing limited information to locate a missing person or in response
to any federal or state agency administrative request that is authorized by law)
• For research studies that meet all privacy law requirements (such as research related to the prevention of
disease or disability)
• To avoid a serious and imminent threat to health or safety
• To contact you, either directly or through a business associate, using your postal or email addresses,
telephone numbers or other personal information, regarding new or changed health plan benefits or new
health benefits product offerings of Arkansas Blue Cross.
• To contact you, either directly or through a business associate, using your postal or email addresses,
telephone numbers or other personal information, regarding health care providers participating in our
networks, disease management, health education and health promotion, preventive care options, wellness
programs, treatment or care coordination or case management activities of Arkansas Blue Cross.
By law, Arkansas Blue Cross must have your written permission (an “authorization”) to use or release your
protected health information for any purpose other than treatment, payment or healthcare operations or
other limited exceptions outlined here or in the Privacy regulation or other applicable law. Once you have
given your permission for Us to release your protected health information you may take it back (“revoke”)
at any time by giving written notice to Us, except if we have already acted based on your original
permission. To the extent (if any) that we maintain or receive psychotherapy notes about you, most
disclosures of these notes require your authorization. Also, to the extent (if any) that we use or disclose
your information for our fundraising practices, we will provide you with the ability to opt out of future
fundraising communications. In addition, most (but not all) uses and disclosures of medical information for
marketing purposes, and disclosures that constitute a sale of protected health information require your
authorization.
Personal Health Record (PHR)
If you have a health benefit plan issued by Arkansas Blue Cross on or after October 1, 2007, you have a Personal
Health Record (PHR). Your PHR contains a summary of claims submitted for services you received while you are or
were covered by your health benefit plan, as well as non-claims data you choose to enter yourself. Your PHR will
continue to exist, even if you discontinue coverage under your health benefit plan. You have access to your PHR
through the Arkansas Blue Cross website. In addition, unless you limit access, your physician and other healthcare
providers who provide you treatment have access to your PHR. Certain information that may exist in the claims
records will not be made available to your physician and other healthcare providers automatically.
To protect your privacy, information about treatment for certain sensitive medical conditions, such as
HIV/AIDS, sexually transmitted diseases, mental health, drug or alcohol abuse or family planning, will be
viewable by you alone unless you choose to make this information available to the medical personnel who
treat you. Similarly, non-claims data, such as your medical, family and social history, will only appear in
your PHR if you choose to enter it yourself. It is important to note that you have the option to prohibit access
to your PHR completely, either by electronically selecting to prohibit access or by sending a written request
to prohibit access to the Privacy Office at the address below.
Special Note on Genetic Information
We are prohibited by law from collecting or using genetic information for purposes of underwriting, setting
premium, determining eligibility for benefits or applying any pre-existing condition exclusion under an
insurance policy or health plan. Genetic information means not only genetic tests that you have received,
but also any genetic tests of your family members, or any manifestations of a disease or disorder among
your family members. Except for pre- existing condition exclusions, we may obtain and use genetic
8
information in making a payment or denial decision, or otherwise processing a claim for benefits under
your health plan or insurance policy, to the extent that genetic information is relevant to the payment or
denial decision or proper processing of your claim.
Your Rights Regarding Information About You
You have the right to:
•
See and obtain a copy of your protected health information that is contained in a designated record
set that was used to make decisions about you. This may include an electronic copy, in certain
circumstances, if you make this request in writing.
•
Have your protected health information amended if you believe that it is wrong, or if information is
missing, and Arkansas Blue Cross agrees. If Arkansas Blue Cross disagrees, you may have a
statement of your disagreement added to your protected health information.
•
Receive a listing of those receiving your protected health information from Arkansas Blue Cross. The
listing will not cover your protected health information that was released to you or your personal
representative, or that was released for payment or healthcare operations, or that was released for
law enforcement purposes.
•
Ask Arkansas Blue Cross to communicate with you in a different manner or at a different place (for
example, by sending your correspondence to a P.O. Box instead of your home address) if you are in
danger of personal harm if the information is not kept confidential.
•
Ask Arkansas Blue Cross to limit how your protected health information is used and released to pay
your claims and perform healthcare operations. Please note that Arkansas Blue Cross may not be
able to agree to your request.
•
Get a separate paper copy of this notice.
•
For purposes of obtaining our company’s assistance with your application for coverage or associated
subsidies through ARHOME (the federal Affordable Care Act Exchange), you have the right in so doing to
request that we limit further collection, creation, disclosure, access, maintenance, storage and use of your
personally identifiable information.
Breach Notification
In the event of a breach of your health information, we will provide you notification of such a breach as required by
law or where we otherwise deem such notification appropriate.
To Exercise Your Rights
If you would like to contact Arkansas Blue Cross for further information regarding this notice, or exercise any of the
rights described in this notice, you may do so by contacting Customer Service at the following toll-free telephone
numbers:
Arkansas Blue Cross 800-238-8379
You also may access complete instructions and request forms from our companies’ websites:
arkansasbluecross.com
Changes to this Notice
We are required by law to abide by the terms of this notice. We reserve the right to change this notice and make the
revised or changed notice effective for claims or medical information we already have about you as well as any future
information we receive. When we make changes, we will notify you by sending a revised notice to the last known
address we have for you or by alternative means allowed by law or regulation. We also will post a copy of the current
notice on Arkansas Blue Cross website.
Complaints
9
If you believe your privacy rights have been violated, you may file a complaint with Arkansas Blue Cross by writing to
the following address:
Privacy Office
ATTN: Privacy Officer
P.O. Box 3216
Little Rock, AR 72201 Telephone: 866-254-4001
Email:
privacyofficeinquir[email protected]
You also may file a complaint with the Secretary of the U.S. Department of Health and Human Services.
Complaints filed directly with the Secretary must:
1. be in writing;
2. contain the name of the entity against which the complaint is lodged;
3. describe the relevant problems; and
4. be filed within 180 days of the time you became or should have become aware of the problem.
We will not penalize or in any other way retaliate against you for filing a complaint with the Secretary or
with Us.
Last material revision 05/2013 Last general revision 01/2023
10
SCHEDULE OF BENEFITS
11
1.0 HOW THE COVERAGE UNDER YOUR INSURANCE PLAN WORKS
1.1 Your employer has established and maintains an employee health benefit plan (“Plan”) for employees and
their eligible dependents. The Employer administers that Plan and actively promotes the Plan to its
employees. The Employer and you, through your premium contributions, have purchased a Plan of insurance
benefits provided by the Group Policy and Benefit Certificate issued by Arkansas Blue Cross and Blue Shield
that provides a range of coverage for medical services you may need. This is a very valuable benefit for you,
but you should understand clearly that your Plan does NOT cover all medical services, drugs, supplies, tests
or equipment (“health interventions” or “interventions”). A Plan covering all health interventions would be
prohibitively expensive. For that reason, we have offered, and you have purchased a more limited Plan. This
document is your guide to what you have and have not purchased; in other words, what is and is not eligible
for benefits under your Plan. Accordingly, you should read this entire document carefully both now
and BEFORE you obtain medical services to be sure you understand what is covered and the
limitations on your coverage.
1.2 The philosophy and purpose behind your Plan is that we want you to have coverage for the vast majority of
medical needs or emergencies you may face, including most Hospital and Physician Services, prescription
drugs, supplies and equipment. However, in order to keep costs of your Plan within reasonable limits, we
have deliberately excluded coverage of a number of specific Health Interventions, we have placed coverage
limits on some other interventions, and we have established an overall standard we call the “Primary
Coverage Criteria” that each and every claim for benefits must meet in order to be covered under your Plan.
1.3 Here is an important thing for you to clearly understand. For any Health Intervention, there are six general
coverage criteria that must be met in order for that intervention to qualify for coverage under your Plan.
1. The Primary Coverage Criteria must be met.
2. The Health Intervention must conform to specific limitations stated in your Plan.
3. The Health Intervention must not be specifically excluded under the terms of your Plan.
4. At the time of the intervention, you must meet the Plan's eligibility standards.
5. You must comply with the Plan’s Provider network and cost sharing arrangements; and
6. You must follow the Plan’s procedures for filing claims.
The following discussion will give you a brief description of each of these qualifications.
1.4 The Primary Coverage Criteria. The Primary Coverage Criteria apply to ALL benefits you may claim under
your Plan. It does not matter what types of Health Intervention may be involved or when or where you obtain
the intervention. The Primary Coverage Criteria are designed to allow Plan benefits for only those Health
Interventions that are proven as safe and effective treatment. The Primary Coverage Criteria also provide
benefits only for the less invasive or less risky intervention when such intervention would safely and effectively
treat the medical condition; or they provide benefits for treatment in an outpatient, doctor’s office or home
care setting when such treatment would be a safe and effective alternative to Hospitalization. Examples of
the types of Health Interventions that the Primary Coverage Criteria exclude from coverage include such
things as the cost of a hospitalization for a minor cold or some other condition that could be treated outside
the Hospital, or the cost of some investigational drug or treatment such as herbal therapy or some forms of
high dose Chemotherapy not shown to have any beneficial or curative effect on a particular cancerous
condition Finally, the Primary Coverage Criteria require that if there are two or more effective
alternative Health Interventions, the Company shall limit its payment to the Allowance or Allowable
Charge for the most cost-effective intervention. The specific coverage standards that must be met under
the Primary Coverage Criteria are outlined in detail in Section 2.0 of this document.
1.5 Specific Limitations in Your Plan. Because of the high cost of some Health Interventions, as well as the
difficulty in some cases of determining whether an intervention is really needed, we include coverage for such
Health Interventions but place limits on the extent of coverage by limiting the number of Provider visits or
treatments, or treatment received during a calendar year or other specified time period. Examples of such
limitations include a limit on the number of covered visits for home health services, physical, occupational
and speech therapy. Other types of limitations include requirements that an intervention be provided in a
particular location or by a Provider holding a particular type of license, or in accordance with a written
12
treatment plan or other documentation. Common benefits and limitations are outlined in detail in Section 3.0
of this document. You will note that this document refers to Coverage Policies we have developed that may
address limitations of coverage for a particular service, treatment or drug. You may request a copy of our
Coverage Policy with respect to a particular service, treatment or drug, or, if you have Internet access, you
may review all our established Coverage Policies on our web site at WWW.ARKANSASBLUECROSS.COM
1.6 Specific Exclusions in Your Plan. There are many possible reasons why we have selected a particular
condition, health care Provider, Health Intervention, or service to be excluded from your Plan. Some
exclusions are based on the availability of other coverage or financing for certain types of injuries. For
example, injuries you receive on the job are generally covered by workers’ compensation. Other exclusions
are based on the need to try to keep your coverage affordable, covering basic health care service needs, but
not covering every possible desired intervention. The exclusion for Cosmetic Services is an example of this
type of exclusion. The plan excludes coverage of some health care Providers because we believe the
Provider is not qualified or because the Provider lacks experience. For example, the plan does not cover
services rendered by unlicensed Providers or by Hospital residents, interns, students or fellows. Other
exclusions are based on our judgment that the need for such Health Intervention is questionable in many
cases, or that the services are of unknown or unproven beneficial effect. Examples of these types of
exclusions include biofeedback and cranial electrotherapy stimulation devices, as well as some forms of high
dose Chemotherapy and bone marrow transplantation. Before you undergo treatment or tests, you
should review the specific exclusions listed in Section 4.0 of this document. If you have any question
about whether a specific exclusion applies, discuss it with your doctor(s). Call our Customer Service
representatives if you need assistance. You may also request a copy of our Coverage Policy with respect
to a particular service, treatment or drug, or, if you have Internet access, you may review all our established
Coverage Policies on our web site at WWW.ARKANSASBLUECROSS.COM
.
1.7 Provider Network and Cost Sharing Procedures. Your plan does not provide coverage for a Health
Intervention unless it is provided by a Provider as defined in this Plan. See Subsection 9.97.
Your plan does not provide coverage for one hundred percent of the costs associated with covered Health
Interventions. You are expected to pay an initial amount of covered Allowable Charges you incur each
calendar year. This amount is called a “Deductible.” After you have paid the Deductible, you may pay a
percentage of Allowable Charges called “Coinsurance;” In addition, for certain Health Interventions you will
have to pay a fixed dollar amount called a “Copayment.” Once your Deductible, Coinsurance and
Copayments reach a specified amount, called an “Annual Limitation on Cost Sharing,” the Company will pay
one hundred percent of covered Allowable Charges you incur until the end of the calendar year.
Provider networks are designed to try to hold down the costs of your Plan through discounted medical fees
that the Company has negotiated with these Providers. Your Plan includes incentives in the form of lower
Deductible, lower Coinsurance and a lower Copayment to encourage you to consult and seek treatment from
physicians, Hospitals and other health care Providers who participate in our Provider network, called
“Preferred Providers.” A full explanation of the Deductible, Coinsurance and Copayments applicable to your
Plan are set out in Section 5.0 and the Schedule of Benefits.
You and your physician are always free to make any decision you believe is best for you concerning whether
to receive any particular service or treatment, or whether to see any practitioner or Provider (in or out of the
network). However, if you go “out-of-network” for services or treatment, your coverage will be reduced or
limited to the out-of-network rate. There are exceptions to the network procedures; for example, Emergency
Care or if, prior to your effective date of coverage, you were engaged with a Non-Preferred Provider for a
scheduled procedure and you receive PRIOR approval from the Company to continue at the Preferred
Provider benefit level for the scheduled procedure. Unless one of these exceptions applies, if you want to
receive the full benefit of your Plan, you should check in advance to see if the Provider is a Preferred Provider.
Preferred Providers are identified in our published Provider directory, or you may call Customer Service to
ask about a specific Provider, or visit our web site at WWW.ARKANSASBLUECROSS.COM
1.8 Eligibility Standards. You must be eligible for benefits under your Plan at the time you receive a Health
Intervention. Eligibility standards are set forth in Section 6.0 of this document. Since your coverage is through
a group policy, this means you must be an eligible member of the Group, either as an Employee, or an eligible
Dependent of an Employee. In order to be an eligible member of the Group, you must meet the Group
eligibility standards, which may include a Waiting Period, before your Group coverage takes effect. In all
13
cases, in order to be considered “eligible” for coverage, your Plan must be valid and in force at the time the
services or treatment are provided. All premiums must be timely paid. It is important to understand the
provisions of Section 6.0 that outline the circumstances under which your coverage may terminate under the
Plan. This section also describes the special situations provided by state and federal law that allow continued
coverage under the Plan for a limited time after you are no longer an Employee or Dependent.
1.9 Claim Filing Procedures. Your Plan provides procedures that you, your Provider or your Authorized
Representative must follow in filing claims with the Company. Your failure to follow these procedures could
result in significant delays in the processing of your claim, as well as potential denial of benefits. These
procedures are set out in Section 7.0. In addition, Section 7.0 explains how you can appeal a benefit
determination in the event you believe that such benefit determination does not comply with the terms of the
Plan. Through the appeals process, you may participate in decisions regarding your health plan coverage
and communicate your preferences and point of view.
1.10 Plan Administration. Certain important matters, including financial incentives for Providers not otherwise
described in this Benefit Certificate, are set out in Section 8.0. Section 9.0 is a glossary of defined terms
used in the Benefit Certificate. Finally, Section 10.0 provides information the Plan is required to provide in
accordance with the Employee Retirement Income Security Act of 1974 (ERISA).
2.0 PRIMARY COVERAGE CRITERIA
2.1 Purpose and Effect of Primary Coverage Criteria. The Primary Coverage Criteria are set out in this
Section 2.0 of this document. The Primary Coverage Criteria are designed to allow Plan benefits for only
those Interventions that are proven as safe and effective treatment. Another goal of the Primary Coverage
Criteria is to provide benefits only for the less invasive or least risky Intervention when such Intervention
would safely and effectively treat the medical condition, or to provide benefits for treatment in an outpatient,
doctor’s office or home care setting when such treatment would be a safe and effective alternative to
hospitalization. Finally, if there is more than one effective Health Intervention available, the Primary Coverage
Criteria allow the Plan to limit its payment to the Allowance or Allowable Charge for the most cost-effective
Intervention. Regardless of anything else in this Plan, and regardless of any other communications or
materials you may receive in connection with your Plan, you will not have coverage for any service, any
medication, any treatment, any procedure or any equipment, supplies or associated costs UNLESS the
Primary Coverage Criteria set forth in this Section are met. At the same time, bear in mind that just because
the Primary Coverage Criteria are met does not necessarily mean the treatment or services will be covered
under your Plan. For example, a Health Intervention that meets the Primary Coverage Criteria will be
excluded if the condition being treated is a non-covered treatment excluded by the Plan. (See Subsection
4.2.) As explained in the preceding Section 1.0, the Primary Coverage Criteria represent one category of six
general coverage criteria that must be met for coverage in all cases. The Primary Coverage Criteria are as
follows:
2.2 Elements of the Primary Coverage Criteria. In order to be covered, medical services, drugs, treatments,
procedures, tests, equipment or supplies (“Interventions”) must be recommended by your treating physician
and meet all of the following requirements:
1. The Intervention must be an item or service delivered or undertaken primarily to prevent, diagnose,
detect, treat, palliate, or alleviate a medical condition or to maintain or restore functional ability of the
mind or body. A “medical condition” means a disease, illness, injury, pregnancy or a biological or
psychological condition that, if untreated, impairs or threatens to impair ability of the body or mind to
function in a normal, healthy manner.
2. The Intervention must be proven to be effective (as defined in Subsections 2.3.1.a. or 2.3.1.b, below)
in preventing, treating, diagnosing, detecting, or palliating a medical condition.
3. The Intervention must be the most appropriate supply or level of service, considering potential
benefits and harm to the patient. The following three examples illustrate application of this standard
(but are not intended to limit the scope of the standard): (i) An Intervention is not appropriate, for
purposes of the Primary Coverage Criteria, if it would expose the patient to more invasive procedures
14
or greater risks when less invasive procedures or less risky Interventions would be safe and effective
to prevent diagnose, detect, treat or palliate a medical condition. (ii) An Intervention is not
appropriate, under the Primary Coverage Criteria, if it involves hospitalization or other intensive
treatment settings when the Intervention could be administered safely and effectively in an outpatient
or other less intensive setting, such as the home.
4. The Primary Coverage Criteria allow the Plan to limit its coverage to payment of the Allowance or
Allowable Charge for the most cost-effective Intervention.
“Cost-effective” means a Health Intervention where the benefits and harms relative to the costs
represent an economically efficient use of resources for patients with the medical condition being
treated through the Health Intervention. For example, if the benefits and risks to the patient of two
alternative Interventions are comparable, a Health Intervention costing $1,000 will be more cost
effective than a Health Intervention costing $10,000. “Cost-effective” shall not necessarily mean the
lowest price.
2.3 Primary Coverage Criteria Definitions. The following definitions are used in describing the elements of the
Primary Coverage Criteria:
1. Effective defined
a. An existing Intervention (one that is commonly recognized as accepted or standard treatment
or which has gained widespread, substantially unchallenged use and acceptance throughout
the United States) will be deemed “effective” for purposes of the Primary Coverage Criteria
if the Intervention is found to achieve its intended purpose and to prevent, cure, alleviate, or
enable diagnosis or detection of a medical condition without exposing the patient to risks that
outweigh the potential benefits. This determination will be based on consideration of the
following factors, in descending order of priority and weight:
i. scientific evidence, as defined in Subsection 2.3.2, below (where available); or
ii. if scientific evidence is not available, expert opinion(s) (whether published or
furnished by private letter or report) of an Independent Medical Reviewer(s) with
education, training and experience in the relevant medical field or subject area; or
iii. if scientific evidence is not available, and if expert opinion is either unavailable for
some reason or is substantially equally divided, professional standards, as defined
and qualified in Subsection 2.3.3, below, may be consulted.
iv. If neither scientific evidence, expert opinion nor professional standards show that an
existing Intervention will achieve its intended purpose to prevent, cure, alleviate, or
enable diagnosis or detection of a medical condition, then the Company in its
discretion may find that such existing Intervention is not effective and, on that basis,
fails to meet the Primary Coverage Criteria.
b. A new Intervention (one that is not commonly recognized as accepted or standard treatment
or which has not gained widespread, substantially unchallenged use and acceptance
throughout the United States) will be deemed “effective” for purposes of the Primary
Coverage Criteria if there is scientific evidence (as defined in Subsection 2.3.2, below)
showing that the Intervention will achieve its intended purpose and will prevent, cure,
alleviate or enable diagnosis or detection of a medical condition without exposing the patient
to risks that outweigh the potential benefits. Scientific evidence is deemed to exist to show
that a new Intervention is not effective if the procedure is the subject of an ongoing phase I,
II, or III trial or is otherwise under study to determine its maximum tolerated dose, its toxicity,
its safety, its efficacy, or its efficacy as compared with a standard means of treatment or
diagnosis. If there is a lack of scientific evidence regarding a new Intervention, or if the
available scientific evidence is in conflict or the subject of continuing debate, the new
Intervention shall be deemed “not effective,” and therefore not covered in accordance with
the Primary Coverage Criteria, with one exception -- if there is a new Intervention for which
clinical trials have not been conducted because the disease at issue is rare or new or affects
only a remote population, then the Intervention may be deemed “effective” if, but only if, it
15
meets the definition of “effective” as defined for existing Interventions in Subsection 2.3.1.a.,
above.
2. Scientific Evidence defined. “Scientific Evidence,” for purposes of the Primary Coverage Criteria,
shall mean only one or more of the following listed sources of relevant clinical information and
evaluation:
a. Results of randomized controlled clinical trials, as published in the authoritative medical and
scientific literature that directly demonstrate a statistically significant positive effect of an
Intervention on a medical condition. For purposes of this Subsection a., “authoritative
medical and scientific literature” shall be such publications as are recognized by the
Company, listed in its Coverage Policy or otherwise listed as authoritative medical and
scientific literature on the Company’s web site at WWW.ARKANSASBLUECROSS.COM
; or
b. Published reports of independent technology or pharmaceutical assessment organizations
recognized as authoritative by the Company. For purposes of this Subsection b. an
independent technology or pharmaceutical assessment organization shall be considered
“authoritative” if it is recognized as such by the Company, listed in its Coverage Policy or
otherwise listed as authoritative on the Company’s web site at
WWW.ARKANSASBLUECROSS.COM
.
3. Professional Standards defined. “Professional standards,” for purposes of applying the
“effectiveness” standard of the Primary Coverage Criteria to an existing Intervention, shall mean only
the published clinical standards, published guidelines or published assessments of professional
accreditation or certification organizations or of such accredited national professional associations
as are recognized by the Company’s Medical Director as speaking authoritatively on behalf of the
licensed medical professionals participating in or represented by the associations. The Company
shall have full discretion whether to accept or reject the statements of any professional association
or professional accreditation or certification organization as “professional standards” for purposes of
this Primary Coverage Criteria. No such statements shall be regarded as eligible to be classified as
“professional standards” under the Primary Coverage Criteria unless such statements specifically
address effectiveness of the Intervention, and conclude with substantial supporting evidence that the
Intervention is safe, that its benefits outweigh potential risks to the patient, and that it is more likely
than not to achieve its intended purpose and to prevent, cure, alleviate, or enable diagnosis or
detection of a medical condition.
2.4 Application and Appeal of Primary Coverage Criteria.
1. The following rules apply to any application of the Primary Coverage Criteria. The Company shall
have full discretion in applying the Primary Coverage Criteria, and in interpreting any of its terms or
phrases, or the manner in which it shall apply to a given Intervention. No Intervention shall be
deemed to meet the Primary Coverage Criteria unless the Intervention qualifies under ALL of the
following rules:
a. Illegality – An Intervention does not meet the Primary Coverage Criteria if it is illegal to
administer or receive it under federal laws or regulations or the law or regulations of the state
where administered.
b. FDA Position – An Intervention does not meet the Primary Coverage Criteria if it involves
any device or drug that requires approval of the U.S. Food and Drug Administration (“FDA”),
and FDA approval for marketing of the drug or device for a particular medical condition has
not been issued prior to your date of service. In addition, an Intervention does not meet the
Primary Coverage Criteria if the FDA or the U.S. Department of Health and Human Services
or any agency or division thereof, through published reports or statements, or through official
announcements or press releases issued by authorized spokespersons, have concluded that
the Intervention or a means or method of administering it is unsafe, unethical or contrary to
federal laws or regulations. Neither FDA Pre-Market Approval nor FDA finding of substantial
equivalency under 510(k) automatically guarantees coverage of a drug or device.
c. Proper License – An Intervention does not meet the Primary Coverage Criteria if the health
care professional or facility administering it does not hold the proper license, permit,
16
accreditation or other regulatory approval required under applicable laws or regulations in
order to administer the Intervention.
d. Plan Exclusions, Limitations or Eligibility Standards – Even if an Intervention otherwise meets
the Primary Coverage Criteria, it is not covered under this Plan if the Intervention is subject
to a Plan exclusion or limitation, or if you fail to meet Plan eligibility requirements.
e. Position Statements of Professional Organizations – Regardless of whether an Intervention
meets some of the other requirements of the Primary Coverage Criteria, the Intervention
shall not be covered under the Plan if any national professional association, any accrediting
or certification organization, any widely-used medical compendium, or published guidelines
of any national or international workgroup of scientific or medical experts have classified such
Intervention or its means or method of administration as “experimental” or “investigational”
or as questionable or of unknown benefit. However, an Intervention that fails to meet other
requirements of the Primary Coverage Criteria shall not be covered under the Plan, even if
any of the foregoing organizations or groups classify the Intervention as not “experimental”
or not “investigational,” or conclude that it is beneficial or no longer subject to question. For
purposes of this Subsection e., “national professional association” or “accrediting or certifying
organization,” or “national or international workgroup of scientific or medical experts” shall
be such organizations or groups recognized by the Company, listed in its Coverage Policy
or otherwise listed as authoritative on the Company’s web site at
WWW.ARKANSASBLUECROSS.COM.
f. Coverage Policy – With respect to certain drugs, treatments, services, tests, equipment or
supplies, the Company has developed specific Coverage Policies, which have been put into
writing, and are published on the Company’s web site at
WWW.ARKANSASBLUECROSS.COM. If the Company has developed a specific Coverage
Policy that applies to the drug, treatment, service, test, equipment or supply that you received
or seek to have covered under your Plan, the Coverage Policy shall be deemed to be
determinative in evaluating whether such drug, treatment, service, test, equipment or supply
meets the Primary Coverage Criteria; however, the absence of a specific Coverage
Policy with respect to any particular drug, treatment, service, test, equipment or
supply shall not be construed to mean that such drug, treatment, service, test,
equipment or supply meets the Primary Coverage Criteria.
2. You may appeal a determination by the Company that an Intervention does not meet the Primary
Coverage Criteria to the Appeals Coordinator. Use the procedures for appeals outlined in Sections
7.2 and 7.3.
3. Any appeal available with respect to a Primary Coverage Criteria determination shall be subject to
the terms, conditions and definitions set forth in the Primary Coverage Criteria. An appeal shall also
be subject to the terms, conditions and definitions set forth elsewhere in this Plan. The Appeals
Coordinator or an External Review organization shall render its independent evaluation so as to
comply with and achieve the intended purpose of the Primary Coverage Criteria and other provisions
of this Plan.
3.0 BENEFITS AND SPECIFIC LIMITATIONS IN YOUR PLAN
Because of the high cost of some services or treatments, as well as the difficulty in some cases of determining whether
services are really needed, we include coverage for such services or treatments but place limits on the extent of
coverage, by limiting the number of Provider visits or treatments during a calendar year or other specified period of
time. This Section 3.0 describes medical services, drugs, supplies, tests and equipment for which coverage is
provided under the Plan, provided all terms, conditions, exclusions and limitations of the Plan, including the six
coverage criteria, are satisfied. This Section 3.0 sets out specific limitations applicable to each covered medical
service, drug, supply, test or equipment.
You will note references to Deductible, Coinsurance and Copayment obligations. For a description of the amount of
these obligations and how they may vary depending upon whether you select an In-Network Provider or an Out-of-
17
Network Provider, refer to Section 5.0, the definition of Allowance or Allowable Charge as set out in the Glossary of
Terms and the Schedule of Benefits.
3.1 Professional Services. Subject to all terms, conditions, exclusions and limitations of the Plan set forth in
this Benefit Certificate, coverage is provided for the following professional services when performed by a
Physician. All Covered Services are subject to the applicable Deductible, Copayment and Coinsurance
specified in the Schedule of Benefits.
1. Primary Care Physician Office Visits. Coverage is provided for the diagnosis and treatment of
illness or Injury when provided in the medical office of your Primary Care Physician. The Covered
Person is responsible for the Copayment, Deductible and Coinsurance specified in the Schedule of
Benefits.
You are encouraged to select and maintain a patient-physician relationship with a PCP. A PCP can
be helpful to you in managing your health care. The PCP selected must be an In-network Physician
listed in the Preferred Provider Directory as a PCP and must be accepting new patients. You may
contact Customer Service to select a PCP or change your PCP
2. Specialty Care Physician Office Visits. Coverage is provided for the diagnosis and treatment of
illness or Injury when provided in the medical office of the Specialty Care Physician. The Covered
Person is responsible for the Copayment, Deductible and Coinsurance specified in the Schedule of
Benefits.
3. Physician Hospital Visits.
Coverage is provided for services of Physicians for diagnosis, treatment
and consultation while the Covered Person is admitted as an inpatient in a Hospital for Covered
Services.
4. Surgical Services. Coverage is provided for services of Physicians for surgery, either as an
inpatient or outpatient. If coverage is provided for two (2) or more surgical operations performed
during the same surgical encounter or for bilateral procedures, payment for the secondary or
subsequent procedure will be made at a reduced rate. In general, overall payment for one or more
procedures during the same operative setting will be no more than if the procedures had been done
by one Physician. Details as to how such payments are calculated are provided to In-Network
Physicians through Provider News and Coverage Policy.
5. Telephone and Other Electronic Consultation. Subject to all other terms, conditions, exclusions,
and limitations of this Plan set forth in this Benefit Certificate.
i. Coverage is provided for Telemedicine services performed by a Provider licensed, certified,
or otherwise authorized by the laws of Arkansas to administer health care in the ordinary
course of the practice of his or her profession at the same rate as if it had been performed
in-person provided the Telemedicine service is comparable to the same service provided in
person.
ii. However, electronic consultations such as, but not limited to, telephonic, interactive audio,
fax, text messaging, email, or for services, which are, by their nature, hands-on (e.g.,
surgery, interventional radiology, coronary, angiography, anesthesia, and endoscopy) are
not covered. Audio-only communication is covered if it is real-time, interactive and
substantially meets the requirements for a Covered Service that would otherwise be covered
by the Plan.
iii. Communications made by a Physician responsible for the direct care of a Covered Person
in Case Management with involved health care Providers, or consultative electronic
communication between a Primary Care Physician and other health care Providers
regarding a Covered Person’s care, however, are covered.
6. Assistant Surgeon Services. Not all surgeries merit coverage for an assistant surgeon. Further,
the Company's payment for a covered assistant surgeon shall be limited to one Physician qualified
to act as an assistant for the surgical procedure. Surgical first assistants are not covered (See
Section 4.1.10).
18
7. Standby Physicians. Services of standby physicians are only covered in the event such physician
is required to assist with certain high-risk services specified by the Company, and only for such time
as such physician is in immediate proximity to the patient.
8. Abortions. Abortions are not covered, see Subsection 4.2.1. Pregnancy terminations under the
direction of a Physician are covered, but only when performed in an In-Network Hospital or Outpatient
Hospital setting.
3.2 Preventive Health Services. Subject to all terms, conditions, exclusions and limitations of the Plan as set
forth in this Benefit Certificate, the Company will pay one hundred percent (100%) of the Allowance or
Allowable Charges for the routine preventive health services listed below when provided by a an In-Network
Primary Care Physician or an advanced practice nurse or physician’s assistant who provides primary medical
care in the areas of general practice, pediatrics, family practice, internal medicine or obstetrics/gynecology,
which are performed in the Primary Care Physician’s office. When the service cannot be performed in an
office by a Primary Care Physician, coverage is also provided for certain preventive health services listed
below when performed in an In-Network Outpatient Hospital or Ambulatory Surgery Center setting when the
service cannot be performed in an office by a Primary Care Physician, unless otherwise provided below.
1. evidence-based items or services that have in effect a rating of “A” or “B” in the current
recommendations of the United States Preventive Services Task Force but not for the related
treatment of disease; and
2. routine immunizations that have in effect a recommendation from the Advisory Committee on
Immunization Practices of the Centers for Disease Control and Prevention with respect to the
individual involved; and
3. with respect to infants, children, and adolescents, evidence-informed preventive care and screenings
provided for in the comprehensive guidelines supported by the Health Resources and Services
Administration; and
4. with respect to women, such additional preventive care and screenings not described in paragraph
(1) as provided for in comprehensive guidelines supported by the Health Resources and Services
Administration for purposes of this subsection; and
5. the current recommendations of the United States Preventive Service Task Force regarding breast
cancer screening, mammography, and prevention, unless state law provides a greater benefit; and
6. with respect to prostate cancer screenings for men, one screening per year for a man forty (40)
years of age or older in accordance with the National Comprehensive Cancer Network guidelines
as in effect on January 1, 2023
1
;
and
7. an in-home health evaluation once per year.
3.3 Hospital Services. Subject to all terms, conditions, exclusions and limitations of the Plan set forth in this
Benefit Certificate, including applicable Deductible, Copayment and Coinsurance specified in the Schedule
of Benefits, coverage is provided for the following Hospital services. All Hospital services must be performed
or prescribed by a Physician and provided by a Hospital.
1. Inpatient Hospital Services. This benefit is subject to the following specific limitations:
.a. All Hospital admissions, including admissions to a Long-Term Acute Care facility, are subject
to all terms, conditions, exclusions and limitations of the Plan set forth in this Benefit
Certificate, including Coverage Policy terms as applicable.
b.. Payment for Hospital charges for inpatient admissions shall be limited to the lesser of the
billed charge or the Allowance or Allowable Charge established by the Company.
c.. If you have a condition requiring that you be isolated from other patients, the Company will
pay for an isolation unit equipped and staffed as such.
19
d.. In the event services are rendered for a covered benefit during an inpatient admission to a
Hospital where the admitting diagnosis was for a non-covered benefit, the Company will pay
that portion of the Hospital charge which is attributable to services rendered for the covered
benefit.
e. The services of social workers shall be included in the basic daily room and board allowance.
f.. Services rendered in a Hospital in a country outside of the United States of America shall not
be paid except at the sole discretion of the Company.
2. Outpatient Hospital Services. Subject to all terms, conditions, exclusions and limitations of the
Plan set forth in this Benefit Certificate, including Coverage Policy terms as applicable, coverage is
provided for services, including but not limited to chemotherapy and renal dialysis, in an Outpatient
Hospital, Outpatient Surgery Center or Outpatient Radiation Therapy Center.
a. If you use an out of state Outpatient Surgery Center that does not contract with the local Blue
Cross and Blue Shield Plan, payment for all such services, including Professional Services,
will be limited to the Allowance or Allowable Charge for all the services or $500 whichever is
less. See Subsection 3.4.
3. Hospital Services in Connection with Dental Treatment. Coverage is provided for Hospital
services, including anesthesia, services in connection with treatment for a complex dental condition
provided to: (i) a Covered Person who is determined by two (2) dentists (in separate practices) to
require the dental treatment without delay; (ii) a Covered Person with a diagnosis of serious mental
or physical condition; or (iii) a Covered Person, certified by his or her Primary Care Physician to have
a significant behavioral problem.
3.4 Ambulatory Surgery Center. Subject to all terms, conditions, exclusions and limitations of the Plan as set
forth in this Benefit Certificate and subject to the Deductible, Copayment and Coinsurance specified in the
Schedule of Benefits, and subject to all terms, conditions, exclusions and limitations of the Plan set forth in
this Benefit Certificate, as well as Coverage Policy terms as applicable, coverage is provided for specific
surgical services received at an Ambulatory Surgery Center that are performed or prescribed by a Physician.
1. Covered services include diagnostic imaging and laboratory services required to augment a surgical
service and performed on the same day as such surgical service.
2. Ambulatory Surgery Center services in connection with treatment for a complex dental condition are
provided in accordance with Subsection 3.3.3.
3. If you use an out of state Ambulatory Surgery Center that does not contract with the local
Blue Cross and Blue Shield Plan, payment for all such services, including Professional
Services, will be limited to the Allowance or Allowable Charge incurred for all the services or
$500, whichever is less.
3.5 Outpatient Diagnostic Services. Subject to all terms, conditions, exclusions and limitations of the Plan as
set forth in this Benefit Certificate, coverage is provided for diagnostic services and materials, including but
not limitedto, diagnostic imaging (e.g. x-rays, fluoroscopy, ultrasounds, radionuclide studies)
electrocardiograms, electroencephalograms and laboratory tests when performed or prescribed by a
Physician and subject to the Deductible, Copayment and Coinsurance specified in the Schedule of Benefits.
3.6 Advanced Diagnostic Imaging Services. Subject to all terms, conditions, exclusions and limitations of the
Plan set forth in this Benefit Certificate, as well as Coverage Policy terms as applicable, coverage is provided
for and subject to the Deductible and Coinsurance specified in the Schedule of Benefits, computed
tomography scanning (“CT SCAN”), Magnetic Resonance Angiography or Imaging (“MRI/MRA”), Nuclear
Cardiology and positron emission tomography scans (“PET SCAN”) (collectively referred to as “Advanced
Diagnostic Imaging”). PET Scans are covered to diagnose or screen for cancer in Covered Persons who
have been previously diagnosed with cancer, subject to the terms, conditions, exclusions and limitations set
forth in Coverage Policy.
3.7 Maternity. Subject to all terms, conditions, exclusions and limitations of the Plan as set forth in this Benefit
Certificate, coverage is provided for Maternity Care when performed or prescribed by a Physician subject to
the Deductible, Copayment and Coinsurance amounts specified in the Schedule of Benefits.
20
1. Maternity and Obstetrical Care.
a. Coverage is provided for Maternity and Obstetrical Care, including Routine Prenatal Care
and postnatal care; and use of Hospital delivery rooms and related facilities; special
procedures as may be necessary. Coverage includes screening the birth mother for
depression within the first six (6) weeks of birth, not subject to the Deductible or Copayment.
b. Routine Prenatal Care includes the coverage of one routine ultrasound only. See Subsection
4.2.97 concerning exclusion of additional routine ultrasounds.
c. Notification. Coverage for Maternity and Obstetrical Care requires the Covered Person or
the Covered Person’s treating Provider to notify the Company of a pregnancy. You are
encouraged to notify the Company within the first trimester.
2. Midwives. Services provided by any lay midwife are not covered. See Subsection 4.1.4. However,
subject to all terms, conditions, exclusions and limitations of the Plan as set forth in this Benefit
Certificate, coverage is provided for services provided by a certified nurse midwife who has a
collaborative agreement with a Physician who is within immediate proximity to the Hospital utilized
by the certified nurse midwife in case there is need for assistance during the delivery.
3. Newborn Care in the Hospital. Provided the Child’s coverage becomes effective on his or her date
of birth in accordance with the provisions of Section 6.0, coverage is provided for a Hospital stay for
the mother and newborn child of at least forty-eight (48) hours following a vaginal delivery or at least
ninety-six (96) hours following a cesarean section, unless the treating provider, after consulting with
the mother, discharges the mother or newborn child earlier. An Employee’s or Spouse’s newborn
Child will be covered from the date of birth, including use of newborn nursery (for up to five (5) days
or until the mother is discharged, whichever is the lesser period of time) and related services.
However, if such Child is born in an Out-of-Network Hospital, the Child’s coverage for Out-of-Network
services in the first 90 days is limited to the Allowance or Allowable Charges incurred or $2,000,
whichever is less
If a Child is born in an Out-of-Network Hospital because the Employee’s Spouse has other coverage,
or if such Child is an adopted child born in an Out-of-Network Hospital, nursery charges are covered
up to the Allowance or Allowable Charge incurred or $2,000, whichever is less.
4. Family Planning Services. Subject to all terms, conditions, exclusions and limitations of the Plan
as set forth in this Benefit Certificate, coverage is provided for the following family planning services
when authorized and provided by In-Network Physicians:
a. Counseling and planning services for Infertility;
b. Pregnancy terminations under the direction of a Physician are covered, but only when
performed in an In-Network Hospital or In-Network Outpatient Hospital setting. Abortion is
not covered. See Subsection 4.2.1.;
c. Contraceptives are covered under Subsections 3.2 – Preventive Health Services and 3.24 -
Medications;
d. Voluntary sterilizations (vasectomies and tubal ligations). Reversal of a voluntary sterilization
is not covered.
5. Allowable Charges for Infertility Testing, Artificial Insemination and In Vitro Fertilization.
Subject to all terms, conditions, exclusions, and limitations of the Plan as set forth in this Benefit
Certificate, coverage is provided for Allowable Charges for the above-referenced services when the
criteria, as defined in the applicable Coverage Policy, is established and the services are provided
by an In-Network Provider.
a. Infertility Diagnostic Testing. Coverage is provided for certain diagnostic testing of a
Covered Person, as set out in the Coverage Policy, to establish or confirm a diagnosis of
infertility.
21
b. Artificial Insemination. Coverage is provided for artificial insemination when the Covered
Person has a medically documented inability to conceive due to a diagnosis of infertility listed
in the Coverage Policy.
Coverage is provided for no more than six cycles.
c. In-vitro Fertilization. Coverage is provided for in-vitro fertilization when the criteria, as
defined in the applicable Coverage Policy, is established. The Covered Person’s oocytes
must be fertilized with the sperm of the Covered Person’s Spouse unless the reason for
infertility is related to the absence of sperm in the Spouse or the absence of oocytes in the
Covered Person, or the presence of unviable sperm in the Spouse or unviable oocytes in the
Covered Person.
The in-vitro fertilization procedure must be performed by a Board-Certified Reproductive
Endocrinology and Infertility Physician Specialist in order to be eligible for benefits. The in-
vitro fertilization benefit is limited to four complete oocyte retrievals per lifetime of the member
or two live births from separate pregnancies as a result of the in vitro fertilization procedures.
After a first live birth is achieved as a result of a successful in vitro fertilization cycle, up to
two additional complete oocyte retrievals may be covered. All viable embryos, fresh or
frozen, must be used before undergoing additional oocyte retrieval.
d. Exclusions of Infertility and In-Vitro Fertilization Coverage. Benefits for infertility
diagnostic testing, artificial insemination and in-vitro fertilization are not available if:
i. the Covered Person or his or her Spouse has previously had a voluntary sterilization;
or
ii. the infertility is related to natural age-related hormone reduction (i.e.,
postmenopausal or 45 years of age or older); or
iii. a surrogate is used; or
iv. one of the Covered Persons has previously had three live births by any means.
e. No benefits are available for post-coital testing of cervical mucus, screening for anti-sperm
antibodies, hamster testing, sperm penetration assay, assisted hatching, co-culture of
embryos, cryopreservation of ovarian tissue or oocytes, cryopreservation of testicular tissues
in prepubertal boys, or for storage or thawing of ovarian tissue, oocytes or testicular tissue.
3.8 Complications of Pregnancy. Subject to all terms, conditions, exclusions and limitations of the Plan as set
forth in this Benefit Certificate, coverage is provided for treatment of Complications of Pregnancy when
performed or prescribed by a Physician, subject to the Deductible and Coinsurance amounts specified in the
Schedule of Benefits. See Subsection 9.16 for the definition of Complications of Pregnancy.
3.9 Rehabilitation and Habilitation Services. Subject to all terms, conditions, exclusions and limitations of the
Plan as set forth in this Benefit Certificate and any applicable Coverage Policy, coverage is provided for
Rehabilitation and Habilitation when performed or prescribed by an In-Network Physician and performed in
an In-Network facility. Such therapy and developmental services include physical and occupational therapy
as well as services provided for developmental delay, developmental speech or language disorder,
developmental coordination disorder and mixed developmental disorder. Therapy must be performed by an
appropriate registered physical, occupational or speech-language therapist licensed by the appropriate State
Licensing Board and must be furnished in accordance with a written treatment Plan established and certified
by the treating Physician. Developmental Services must be provided by a provider licensed by the state or
certified by an organization approved by the Company and must be furnished in accordance with a written
treatment plan established and certified by the treating Physician. This benefit is subject to the Copayment
and/or Deductible and Coinsurance specified in the Schedule of Benefits.
1. Rehabilitation Services
a. Inpatient Therapy. Coverage is provided for inpatient therapy services, including
professional services, when performed or prescribed by a Physician and rendered in a
Hospital. Inpatient stays for therapy are limited to sixty (60) days per Covered Person per
calendar year .
22
b. Outpatient Therapy. Coverage is provided for outpatient therapy services when performed
or prescribed by a Physician. Coverage for outpatient visits for physical therapy, occupational
therapy, speech therapy and chiropractic services is limited to an aggregate maximum of
thirty (30) visits per Covered Person per calendar year. Coverage for physical, occupational
and speech therapy is subject to the Primary Care Physician copayment as listed in the
Schedule of Benefits. Coverage for chiropractic services is subject to the Specialty Care
Physician benefit listed in the Schedule of Benefits. See Subsection 9.77 - Outpatient
Therapy Visit.
c. Cardiac and Pulmonary Rehabilitation Therapy. Coverage for cardiac and pulmonary
rehabilitation therapy is provided in accordance with Coverage Policy. Coverage for cardiac
rehabilitation therapy limited to a maximum of 36 visits per Covered Person per calendar
year. However, coverage is not provided for cardiac or pulmonary rehabilitation therapy from
Freestanding Facilities. Peripheral vascular disease rehabilitation therapy is not covered.
See Subsection 4.2.78.
d. Cognitive Rehabilitation. Cognitive Rehabilitation is generally not covered. See
Subsections 4.2.15 and 9.13.
e. Radio-Frequency Thermal Therapy. The use of radio-frequency thermal therapy for
treatment of orthopedic conditions is not covered. See Subsection 4.2.80. However, subject
to all terms, conditions, exclusions and limitations of the Plan as set forth in this Benefit
Certificate, coverage for radio-frequency thermal therapy is provided and included in the
payment for the primary procedure of the orthopedic condition.
2. Habilitation Services
a. Outpatient Therapy. Coverage is provided for outpatient therapy services when performed
or prescribed by a Physician. Coverage for outpatient visits for physical therapy,
occupational therapy, speech therapy and chiropractic services is limited to an aggregate
maximum of thirty (30) visits per Covered Person per calendar year. Coverage for physical,
occupational and speech therapy is subject to the Primary Care Physician copayment as
listed in the Schedule of Benefits. Coverage for chiropractic services is subject to the
Specialty Care Physician benefit listed in the Schedule of Benefits. See Subsection 9.77 -
Outpatient Therapy Visit.
b. Developmental Services. Coverage is provided for Developmental Services when
performed or prescribed by a Physician and is limited to a maximum of 180 Developmental
Services Visit per Covered Person per calendar year. See Subsection 9.29 - Developmental
Service Visit.
c. Durable Medical Equipment. Durable Medical Equipment required for Habilitation is
covered in accordance with Subsection 3.13.
3.10 Mental Illness and Substance Use Disorder. Subject to all terms, conditions, exclusions and limitations of
the Plan as set forth in this Benefit Certificate as well as the Deductible, Copayment and Coinsurance set out
in the Schedule of Benefits, coverage is provided for Health Interventions to treat Mental Illness and
Substance Use Disorder.
1. Inpatient, Partial Hospitalization Program and Intensive Outpatient Program Health
Interventions. Coverage for Inpatient Hospitalization, Partial Hospitalization Programs or Intensive
Outpatient Programs for Mental Illness or Substance Use Disorder Health Interventions is subject to
the following requirements.
a. Inpatient Hospitalization requires a patient to receive Covered Services 24 hours a day as an
inpatient in a Hospital.
b. Partial Hospitalization Programs generally require the patient to receive Covered Services six
to eight hours a day, five to seven days per week in a Hospital outpatient setting.
c. Intensive Outpatient Programs generally require the patient to receive Covered Services
lasting two to four hours a day, three to five days per week in a Hospital outpatient setting.
23
2. Non-Hospital Health Interventions.
a. Office Visits. Coverage is provided for a Health Intervention provided during an office visit
with a Psychiatrist, Psychologist or other Provider licensed to provide treatment for Mental
Illness or Substance Use Disorder.
b. Residential Treatment Facilities. Coverage is provided for a maximum of 60 days per
Covered Person per calendar year for Health Interventions at a Residential Treatment Facility
for Mental Illness or Substance Use Disorder.
i. The facility is licensed by the State of Arkansas or the appropriate agency in the state
where the facility is located.
ii. The facility is accredited by The Joint Commission (TJC) or the Commission on
Accreditation of Rehabilitation Facilities (CARF International).
iii. Coverage is provided for a maximum of 60 days per Covered Person per calendar
year. The 60-day maximum limitation for Residential Treatment Facilities applies to
all three services listed below whether it is one service or a combination of services.
(1.) Residential Treatment Programs - Covered Person sleeps in the facility
engaging in 6 to 8 hours of a multidisciplinary treatment program.
(2.) Partial Day Rehabilitation- Covered Person sleeps elsewhere- 6 hours of
multidisciplinary treatment program minimum of 5 days a week.
(3.) Intensive Outpatient Rehabilitation- Covered Person sleeps elsewhere - 3
hours of multidisciplinary treatment program 5 days a week.
iv. The services must be of a temporary nature and required to increase ability to
function.
v. Custodial care is not covered.
3. Coverage for counseling or treatment of marriage, family or child relationship dysfunction is only
covered if the dysfunction is due to a condition defined in the most recent edition of the Diagnostic
and Statistical Manual of Mental Disorders of the American Psychiatric Association.
4. Hypnotherapy is not covered for any diagnosis or medical condition. See Subsection 4.2.50.
5. Repetitive Transcranial Magnetic Stimulation Treatment (rTMS). Coverage is provided for repetitive
transcranial magnetic stimulation treatment (rTMS) to treat refractory depression subject to Coverage
Policy.
3.11 Autism Spectrum Disorder Benefits. Subject to all other terms, conditions, exclusions, and limitations of
the Plan as set forth in this Benefit Certificate as well as the Deductible, Copayment, and Coinsurance set
out in the Schedule of Benefits, coverage is provided for:
1. Covered Persons with autism spectrum disorder.
2. Applied behavioral analysis as specified in Coverage Policy, when ordered by a medical doctor or a
psychologist for a Covered Person provided under the direction of a Board-Certified Behavioral
Analyst (BCBA):
Category Limits
Applied Behavioral Analysis Assessment: up to six (6) hours up to twice yearly;
Applied Behavioral Analysis BCBA services: up to eight (8) hours per week for fifty (50) weeks;
Applied Behavioral Analysis Treatment by
Behavioral Technician, a Board Certified
Associate Behavioral Analyst or a Board-Certified
Behavioral Analyst (direct or line):
up to forty (40) hours per week for fifty (50) weeks
24
3.12 Emergency Care Services. Subject to all terms, conditions, exclusions and limitations of the Plan as set
forth in this Benefit Certificate, coverage is provided for Emergency Care. When Emergency Care is needed
the Covered Person should seek care at the nearest facility. Emergency Care received within forty-eight (48)
hours of the emergency is subject to the Deductible, Copayment and Coinsurance specified in the Schedule
of Benefits. If the Covered Person is admitted as an inpatient to the same Hospital where Emergency Care
was rendered, the Emergency Care Copayment is waived, and all services are subject to the inpatient
Deductible, Copayment and Coinsurance.
1. After-Hours Clinic or Urgent Care Center. Services provided in an after-hours or urgent care
center are subject to the Urgent Care Center Deductible, Copayment and Coinsurance for each visit.
2. Observation Services. Observation services are covered when ordered by a Physician.
Observation Services ordered in conjunction with an emergency room visit or outpatient visit are
subject to the Emergency Care Deductible, Copayment and Coinsurance for each visit.
3. Transfer to In-Network Hospital. Continuing or follow-up treatment for Injury or Emergency Care
is limited to care that meets Primary Coverage Criteria before you can be safely transferred, without
medically harmful or injurious consequences, to an In-Network Hospital. Services are subject to all
applicable Deductible, Copayment and Coinsurance.
4. Hospital Admissions. A Hospital admission subsequent to Emergency Care services requires the
Covered Person or the Covered Person’s treating Provider to notify the Company of an emergency
admission to a Hospital within 24 hours or the next business day. PLEASE NOTE: This does not
guarantee payment or assure coverage. All Health Interventions must still meet all other
coverage terms, conditions, and limitations. Coverage for services may still be limited or
denied if, when the claims are received by Us, investigation shows that a benefit exclusion or
limitation applies because of a difference in the Health Intervention described in the claim and
the actual Health Intervention, that the Covered Person ceased to be eligible for benefits on
the date services were provided, that coverage lapsed for non-payment of premium, that out-
of-network limitations apply, or any other basis specified in this Benefit Certificate.
5. Medical Review of Emergency Care. Emergency Care is subject to medical review. If, based upon
the signs and symptoms presented at the time of treatment as documented by attending health care
personnel, the Company determines that a visit to the emergency room fails to meet the definition of
Emergency Care as set out in this Benefit Certificate (See Subsection 9.37 - Emergency Care),
coverage shall be denied, and the emergency room charges will become the Covered Person's
liability.
6. Allowable Charge. If You need Emergency Care, the Company will cover You at the highest
Allowance or Allowable Charge that federal regulations allow. You will have to pay any charges that
exceed the Allowance or Allowable Charge as well as for any Deductibles, Coinsurance, Copayments
and amounts that exceed any benefit maximums.
3.13 Durable Medical Equipment. Subject to all terms, conditions, exclusions and limitations of the Plan as set
forth in this Benefit Certificate, coverage is provided for Durable Medical Equipment (DME) when prescribed
by an In-Network Physician according to the guidelines specified below. This benefit, together with the benefit
for equipment under Subsection 3.19, Home Health Services, is subject to the Deductible, Copayment and
Coinsurance specified in the Schedule of Benefits.
1. Durable Medical Equipment is equipment which (1) can withstand repeated use; and (2) is primarily
and customarily used to serve a medical purpose; and (3) generally is not useful to a person in the
absence of an illness or injury; and (4) is appropriate for use in the home. Coverage for Durable
Medical Equipment and Medical Supplies is provided when the Durable Medical Equipment is
provided in accordance with Coverage Policy. Examples of Durable Medical Equipment include, but
are not limited to, oxygen equipment, wheelchairs and crutches.
2. Durable Medical Equipment delivery or set up charges are included in the Allowance or Allowable
Charge for the Durable Medical Equipment.
3. For adults, a single acquisition of eyeglasses or contact lenses within the first six months following
cataract surgery is covered. (See Section 3.30 - Pediatric Vision Services for coverage of lenses for
25
children.) With respect to such eyeglasses or contact lenses, tinting or anti-reflective coating and
progressive lenses are not covered. The Allowance or Allowable Charge is based on the cost for
basic glasses or contact lenses. Eyeglass frames are subject to a $65 maximum Allowance or
Allowable Charge.
4. Replacement of DME is covered only when necessitated by normal growth or when it exceeds its
useful life. Maintenance and repairs resulting from misuse or abuse of DME are the responsibility of
the Covered Person.
5. When it is more cost effective, the Company in its discretion will purchase rather than lease
equipment. In making such purchase, the Company may deduct previous rental payments from its
purchase Allowance.
6. Coverage for Medical Supplies used in connection with Durable Medical Equipment is limited to a
90-day supply per purchase.
7. Wound Vacuum Assisted Closure (VAC) Wound VAC devices are not covered without meeting
Coverage Policy.
3.14 Medical Supplies. Subject to all terms, conditions, exclusions and limitations of the Plan as set forth in this
Benefit Certificate, Medical Supplies (See Subsection 9.63), other than Medical Supplies that can be
purchased without a prescription, are covered when prescribed by a Physician.
1. Expenses for Medical Supplies provided in a Physician’s office are included in the reimbursement for
the procedure or service for which the supplies are used.
2. Coverage for Medical Supplies is limited to a 90-day supply per purchase.
3. Coverage for Medical Supplies used in connection with Durable Medical Equipment, Subsection
3.13, is subject to the Deductible, Coinsurance and Copayment specified in the Schedule of Benefits.
4. Expenses for Medical Supplies provided in connection with home infusion therapy are included in the
reimbursement for the procedure or service for which the supplies are used.
3.15 Prosthetic and Orthotic Devices and Services. Subject to all terms, conditions, exclusions and limitations
of the Plan as set forth in this Benefit Certificate, and subject to the Deductible, Copayment and Coinsurance
specified in the Schedule of Benefits, coverage is provided for non-dental Prosthetic and Orthotic Devices,
including associated services, and its repair if such device is required for treatment of a condition arising from
an illness or Accidental Injury. Prosthetic Devices do not include dentures or other dental appliances that
replace either teeth or structures directly supporting the teeth. The Company will provide you the Allowance
or Allowable Charge for a Prosthetic Device. Replacement of a Prosthetic or Orthotic Device is covered no
more frequently than once per three-year period except when necessitated by normal growth or when the
age of the Prosthetic or Orthotic Device exceeds the device’s useful life. Maintenance and repair resulting
from misuse or abuse of a Prosthetic or Orthotic Device are the responsibility of the Covered Person.
Prosthetic Devices to assist hearing or talking devices are not generally covered. See Subsection 4.2.44.
However, subject to all terms, conditions, exclusions and limitations of the Plan as set forth in this Benefit
Certificate, coverage is provided for:
1. cochlear implant (an implantable hearing device inserted into the modiolus of the cochlea and into
cranial bone) and its associated speech processor up to a lifetime maximum benefit of one cochlear
implant per ear, per Covered Person unless replacement is necessitated because there is inadequate
response to existing component(s) that interfere with the Covered Person’s activities of daily living or
one or more components are no longer functional and cannot be repaired; and
2. one auditory brain stem implant per lifetime for an individual twelve years of age and older with a
diagnosis of Neurofibromatosis Type II (NF2) who has undergone or is undergoing removal of bilateral
acoustic tumors; and
3. surgically implantable osseointegrated hearing aid for patients with single-sided deafness and normal
hearing in the other ear. Coverage is further limited to Covered Persons with
a. congenital or surgically induced malformations (e.g., atresia) of the external ear canal or
middle ear;
26
b. chronic external otitis or otitis media;
c. tumors of the external canal and/or tympanic cavity; and
d. sudden, permanent, unilateral hearing loss due to trauma, idiopathic sudden hearing loss, or
auditory nerve tumor.
3.16 Diabetes Management Services. Subject to all terms, conditions, exclusions and limitations of the Plan as
set forth in this Benefit Certificate, the Company will pay for Diabetes Self-Management Training Program up
to an Allowance or Allowable Charge of $250. Such training program must be in compliance with the national
standards for diabetes self-management education programs developed by the American Diabetes
Association. If there is significant change in the Covered Person's symptoms or conditions which make it
necessary to change the Covered Person's diabetic management process, the Company will pay for an
additional Diabetes Self-Management Training Program. This benefit is payable for training in or out of the
Hospital that has been prescribed by a Physician.
Subject to all terms, conditions, exclusions and limitations of the Plan as set forth in this Benefit Certificate,
coverage is provided for routine foot care to treat podiatric conditions associated with metabolic (e.g.
diabetes, gout, etc), neurologic (peripheral neuropathy of any etiology), and peripheral vascular disease..
Subject to all terms, conditions, exclusions and limitations of the Plan as set forth in this Benefit Certificate,
the Plan will cover an eye examination to screen for diabetic retinopathy once per calendar year for Covered
Persons who are diagnosed with diabetes.
The Company will pay for Durable Medical Equipment, Medical Supplies and services for the treatment of
diabetes.
3.17 Ambulance Services. Subject to all terms, conditions, exclusions and limitations of the Plan as set forth in
this Benefit Certificate and applicable Coverage Policies, coverage is provided as follows. The coverage for
Ambulance Services is subject to the Copayment, Deductible and Coinsurance specified in the Schedule of
Benefits.
1. Benefits for Ambulance Services to treat a Covered Person in place if the Ambulance Service is
coordinating care through Telemedicine with a Physician for medical-based complaint or behavioral
health Provider for behavioral-based complaint; or triage and transport a Covered Person to an
Alternative Destination if the Ambulance Service is coordinating care through Telemedicine with a
Physician for medical-based complaint or a behavioral health Provider for behavioral-based
complaint; Ambulance Services only include transportation to the treatment location where the
initiation of the service is the result of a 911 call as documented in the records of the Ambulance
Service;
2. Benefits for ground Ambulance Services for local transportation to the nearest Hospital in the event
Emergency Care is needed; (See Subsection 9.33 Emergency Care.) or to the nearest neonatal
special care unit for newborn infants for treatment of Accidental Injuries, illnesses, congenital birth
defects or complication of premature birth that require that level of care.
3. Benefits for air Ambulance Services are limited to: a.) the Covered Person possessing unstable vital
signs including respiratory status or cardiac status including conditions as defined within the
Coverage Policy; b.) services requested by police or medical authorities at the scene of an Accidental
Injury or illness; c.) Those situations in which the Covered Person is in a location that cannot be
reached by ground ambulance due to weather or road conditions; or d.) transportation by ground
ambulance poses a threat to the Covered Person’s survival or seriously endangers the Covered
Person’s health due to the time or distance.
4. Non-emergent medical transportation. Non-emergent Ambulance Services are not covered.
5. Specific Ambulance Service Exclusions. No benefits will be paid for: 1.) Expenses incurred for
Ambulance Services covered by a local governmental or municipal body, unless otherwise required
by law; 2.) Non-emergency ambulance; 3.) Air ambulance: a.) outside the 50 United States and the
District of Columbia; b.) From a country or territory outside of the United States to a location within
the 50 United States or the District of Columbia; or c.) From a location within the 50 United States or
the District of Columbia to a country or territory outside of the United States; 3.) Ambulance Services
27
provided for comfort or convenience for a Covered Person, their family, caregiver, Provider or any
facility. ; or 4.) Non-emergency transportation excluding ambulances.
3.18 Skilled Nursing Facility Services. Subject to all terms, conditions, exclusions and limitations of the Plan
as set forth in this Benefit Certificate, coverage is provided for Skilled Nursing Facility services when
authorized in advance by a Physician. See Subsection 9.107 for the definition of Skilled Nursing Facility.
This benefit is subject to the Deductible, Copayment and Coinsurance specified in the Schedule of Benefits.
This Skilled Nursing Facility services benefit is subject to the following conditions:
1. The admission must be within seven days of release from an inpatient Hospital stay;
2. The Skilled Nursing Facility services are of a temporary nature and increase ability to function;
3. Custodial Care is not covered (See Subsections 4.3.7 and 9.25);
4. Coverage is provided for a maximum of sixty (60) days per Covered Person per calendar year.
3.19 Home Health Services. Subject to all terms, conditions, exclusions and limitations of the Plan as set forth
in this Benefit Certificate, including but not limited to the exclusion of Custodial Care (see Subsections 4.3.7
and 9.25), coverage is provided for Home Health Services when Coverage Policy supports the need for in-
home service and such care is prescribed or ordered by a Physician. This Home Health Services benefit is
subject to the following conditions:
1. Covered Services must be provided through and billed by a licensed home health agency.
2. Covered Services provided in the home include services of a Registered Professional Nurse (R.N.),
a Licensed Practical Nurse (L.P.N.) or a Licensed Psychiatric Technical Nurse (L.P.T.N.), provided
the nurse is not related to you by blood or marriage or does not ordinarily reside in your home.
3. Home Health visits are subject to the Deductible, Copayment and Coinsurance specified in the
Schedule of Benefits.
4. Coverage is provided for a maximum of fifty (50) visits per Covered Person per calendar year. (Home
infusion services are not covered by this Section 3.19 but are covered under Subsection 3.23.1.d.).
3.20 Hospice Care. Subject to all terms, conditions, exclusions and limitations of the Plan as set forth in this
Benefit Certificate, if the Covered Person has been diagnosed and certified by the attending Physician as
having a terminal illness with a life expectancy of six months or less, the Company will pay the Allowance or
Allowable Charge for Hospice Care. The services must be rendered by an entity licensed by the Arkansas
Department of Health or other appropriate state licensing agency and accepted by the Company as a
Provider. This benefit is subject to the Deductible, Copayment and Coinsurance specified in the Schedule of
Benefits.
3.21 Dental Care Services. Dental Care, oral surgery, orthodontic services and Prosthodontic Services are
generally not covered. However subject to all terms, conditions, exclusions and limitations of the Plan as set
forth in this Benefit Certificate, coverage is provided for certain limited and specific conditions as set forth
below in the subsections under certain limited and 3.21. Such coverage, if any, is subject to the Deductible,
Copayment and Coinsurance specified in the Schedule of Benefits and as stated in this Benefit Certificate,
all services are subject to Primary Coverage Criteria.
1. Benefits for oral surgery. Subject to all terms, conditions, exclusions and limitations of the Plan as
set forth in this Benefit Certificate, the Company will pay only for the following non-dental oral surgical
procedures:
a. Excision of tumors and cysts of the jaws, cheeks, lips, tongue, roof and floor of the mouth
when pathological examination is required;
b. Surgical procedures required to treat an Accidental Injury (See Subsection 9.1 Accidental
Injury) to jaws, cheeks, lips, tongue, roof and floor of the mouth. The Covered Person must
seek treatment within 7 days of the Accidental Injury for services to be covered. Coverage
will not be continued past twelve (12) months of the first date of treatment for the Accidental
Injury unless continuous and systematic treatment of the Accidental Injury is still ongoing.
c. Excision of exostoses of jaws and hard palate;
28
d. External incision and drainage of abscess; and
e. Incision of accessory sinuses, salivary glands or ducts.
2. Benefits for Accidental Injury. If a Covered Person has an Accidental Injury, benefits will be provided,
subject to all terms, conditions, exclusions and limitations of the Plan as set forth in this Benefit
Certificate, for Dental Care and x-rays necessary to correct damage to a Non-Diseased Tooth or
surrounding tissue caused by the Accidental Injury. The Covered Person must seek treatment within
7 days of Accidental Injury for services to be covered. Coverage will not be continued past twelve
(12) months of the first date of treatment for the Accidental Injury unless continuous and systematic
treatment of the Accidental Injury is still ongoing.
a. Only the Non-Diseased Tooth or Teeth avulsed or extracted as a direct result of the
Accidental Injury and the Non-Diseased Tooth or Teeth immediately adjacent will be
considered for replacement
b. Orthodontic services are limited to the stabilization and re-alignment of the accident-involved
teeth to their pre-accident position. Reimbursement for this service will be based on a per
tooth allowance.
c. Injury to a tooth or teeth while eating is not considered an Accidental Injury; treatment of
such injury will not be covered;
d. Any Health Intervention related to dental caries or tooth decay is not covered.
3. Dental services in connection with other Covered Services.
a. Dental services for treatment directly related to radiation treatment of a head or neck
malignancy are covered.
b. Dental services, not to include reconstruction or implants, performed at the dental infection
site when perioperative to organ transplant because infection precludes listing for a
transplant, are covered;
c. Dental services, not to include reconstruction or implants, performed at the dental infection
site when perioperative to hematopoietic stem cell transplant because infection precludes
listing for a transplant, are covered; and
d. Dental services, not to include reconstruction or implants, performed at the dental infection
site when perioperative to valve replacement or surgery because infection precludes surgery,
are covered.
4. Benefits for anesthesia services. Hospital and Ambulatory Surgery Center services and anesthesia
services related to dental procedures, including services to children, are covered in accordance with
Subsection 3.3.3.
5. Benefits for dental reconstructive surgery. Coverage is provided for the surgery performed on a Child
for the correction of cleft palate or lip when prescribed or ordered by an In-Network Physician.
Coverage is provided for surgery and orthodontics performed on a Child for the correction of a cleft
palate when prescribed or ordered by an In-Network Physician. See Subsection 3.22.3 below for
coverage of corrective surgery and related Health Interventions for a Covered Person who is
diagnosed as having a craniofacial anomaly.
6. Benefits for Prosthodontic Services. Prosthodontic Services generally are not covered. Subject to
all terms, conditions, exclusions and limitations of the Plan set forth in this Benefit Certificate including
the Deductible and Coinsurance set out in the Schedule of Benefits, and subject to Primary Coverage
Criteria that applies to all services, the only coverage is provided for Prosthodontic Services are
services which meet the criteria provided in this Section 3.21. Prosthodontic Services are not
covered when such services are due, in whole or in part, to neglect or the unintended consequence
of a felonious activity, regardless of whether there has been an arrest, any criminal charges or any
court findings of a felony, as long as the activity meets the definition of a felony under Arkansas law.
Replacement of teeth that have been absent for a period of five years or more also are not covered.
If payable, all Prosthodontic Services are subject to the Allowance or Allowable Charge.
29
3.22 Reconstructive Surgery. Cosmetic Services are not covered. (See Subsections 4.3.5 and 9.20) Subject
to all terms, conditions, exclusions and limitations of the Plan as set forth in this Benefit Certificate, and
subject to the Copayment, Deductible and Coinsurance specified in the Schedule of Benefits, coverage is
provided for the following reconstructive surgery procedures when prescribed or ordered by an In-Network
Physician:
1. Treatment provided for the correction of defects incurred in an Accidental Injury sustained by the
Covered Person. The Covered Person must seek treatment within 7 days of Accidental Injury for
services to be covered. Coverage will not be continued past twelve (12) months of the first date of
treatment for the Accidental Injury unless continuous and systematic treatment of the Accidental
Injury is still ongoing.
2. Surgery performed for removal of a port-wine stain or hemangioma (on the head, neck, or face).
3. Treatment provided for reconstructive surgery following neoplastic (cancer) surgery.
4. In connection with a mastectomy resulting from surgery, services for (a) reconstruction of the breast
on which the surgery was performed; (b) surgery to reconstruct the other breast to produce a
symmetrical appearance; and (c) prostheses and services to correct physical complications for all
stages of the mastectomy, including lymphedemas.
5. Reduction mammoplasty, if such reduction mammoplasty meets Coverage Criteriais covered. .
6. Gender Reassignment Surgery for Gender Dysphoria. Subject to all other terms, conditions,
exclusions and limitations of the Plan as set forth in this Benefit Certificate, coverage is provided for
gender reassignment surgery for Covered Persons meeting diagnostic criteria and therapeutic
Provider criteria as specified in Coverage Policy.
7. Dental services are not covered under this Subsection. See Subsection 3.21 - Dental Care, above.
3.23 Craniofacial Anomaly Services Coverage is provided for related Health Interventions for a Covered Person
who is diagnosed as having a craniofacial anomaly provided the Health Interventions meet Primary Coverage
Criteria to improve a functional impairment that results from the craniofacial anomaly as determined by a
nationally accredited cleft-craniofacial team, approved by the American Cleft Palate-Craniofacial Association
in Chapel Hill, North Carolina. A nationally accredited cleft-craniofacial team for cleft-craniofacial conditions
shall evaluate Covered Persons with craniofacial anomalies and coordinate a treatment plan for each
Covered Person. Coverage includes corrective surgery as provided below, dental care, and vision care for
the following will be provided if the Health intervention meets Primary Coverage Criteria.
1. On an annual basis: Sclera contact lenses, including coatings; an ocular impression of each eye; and
any additional tests or procedures related to treatment of the craniofacial anomaly as specified in the
approved treatment plan developed by the nationally accredited cleft-craniofacial team;
2. Every two years, two hearing aid molds, and a choice of two wearable bone conductions, two
surgically implantable bone-anchored hearing aids or two cochlear implants;
3. Every four years, a dehumidifier and
4. Covered Persons will be charged the In-Network Deductible and Coinsurance for any provider
outside the state of Arkansas. NOTE: Any out of state Provider that has not entered into a
contract with Arkansas Blue Cross and Blue Shield is not bound to accept a payment made
by Arkansas Blue Cross and Blue Shield in addition to the Covered Person’s In-Network
Deductible and Coinsurance as payment in full. Any Out-of-Network Provider, including Out-
of-Network Providers outside the state of Arkansas, may choose to seek additional
remuneration or fees from a Covered Person. Selection of an out of state Out-of-Network
Provider is solely made at the risk of the Covered Person.
5. Coverage is provided for corrective surgery and related Health Interventions for a Covered Person
who is diagnosed as having a craniofacial anomaly provided the Health Interventions meet Primary
Coverage Criteria to improve a functional impairment that results from the craniofacial anomaly as
determined by a surgical member of a nationally accredited cleft-craniofacial team, approved by the
American Cleft Palate-Craniofacial Association in Chapel Hill, North Carolina. A nationally accredited
30
cleft-craniofacial team for cleft-craniofacial conditions shall evaluate Covered Persons with
craniofacial anomalies and coordinate a treatment plan for each Covered Person.
3.24 Medications. Subject to all terms, conditions, exclusions and limitations of the Plan set forth in this Benefit
Certificate, coverage is provided for Prescription Medication. (See Subsection 9.93 - Prescription
Medication.) This coverage varies, depending upon the sites of service where the Medication is received by
the Covered Person.
1. Sites of Service
a. Hospital or Ambulatory Surgical Center. The benefit for Medications received from a
Hospital or an Ambulatory Surgical Center is included in the Allowance or Allowable Charge
for the Hospital or Ambulatory Surgical Center services. See Subsections 3.3 and 3.4.
b. Physician’s Office. The benefit for Medications administered in a Physician’s office is
covered based upon the Allowance or Allowable Charge for the Medication and subject to
the Deductible, Coinsurance and Copayment specified in the Schedule of Benefits.
Conditions of coverage set forth in Subsections 3.24.2.a, b., and c., are applicable to this
coverage.
c. Retail Pharmacy (Drug Store). The benefit for Medications received from a licensed retail
pharmacy is covered based upon the Allowable Charge for the Medication and subject to the
applicable Prescription Drug Copayment specified in the Schedule of Benefits.
i. Covered Medications. Generally, only A Medications are covered under this
Subsection 3.24.1.c. however, a limited number of B Medications are covered under
this Subsection 3.24.1.c. B Medications are covered under Subsections 3.24.1.a,
b., and d. (See Subsection 9.93 for definitions of “A Medications” and “B
Medications.”)
ii. Administration Charges. Charges to administer or inject any Medication are not
covered under this Subsection 3.24.1.c.
iii. Conditions of Coverage. Conditions of coverage set forth in Subsections 3.24.2.a.,
b., c., d., and e., are applicable to this coverage.
iv. ID Card Presentation. In order to receive benefits for a Prescription Medication
under this Subsection 3.24.1.c., a Covered Person must present his or her Arkansas
Blue Cross and Blue Shield ID card to a Participating Pharmacy at the time the
Covered Person purchases the Prescription Medication. (“Participating Pharmacy”
is defined in Subsection 9.79.) The pharmacist will electronically notify the
Company’s prescription benefits processor. The prescription benefits processor will
electronically inform the pharmacist whether the Plan provides benefits for the
Prescription Medication. If the prescription benefits processor indicates that the Plan
does not provide benefits, the Covered Person may call the Pharmacy Help Line
telephone number on the back of his or her ID card. If the Plan provides benefits,
the pharmacist will charge the Covered Person the applicable Copayment for the
Prescription Medication. Applicable Prescription Copayments are listed in Schedule
of Benefits. The Company will only accept a post-purchase or paper claim for
Prescription Medications purchased through a retail pharmacy (drug store) if such
claim is submitted (1) for an Emergency Prescription, (See Subsection 9.33.), (2) for
Prescription Medication purchased prior to the date the Covered Person received
his or her Arkansas Blue Cross and Blue Shield ID card or (3) in accordance with
Subsection 3.24.1.c.v., below.
v. Claim Submission. The presentation of a Prescription to a pharmacist in
accordance with this Subsection 3.24.1.c., is not a claim for benefits under the terms
of the Plan. However, a Covered Person may submit a claim if, upon such a
presentation, the pharmacist informs the Covered Person that, because of the
provisions of the Plan, the Plan has rejected benefits for the requested Prescription
Medication.
31
vi. Non-Participating Pharmacies. Medications purchased from a non-Participating
Pharmacy, except in an emergency situation, are not covered.
vii. Emergency. When a Covered Person receives a Prescription Medication in
connection with Emergency Care as defined in this Benefit Certificate (See
Subsection 9.38) and is unable to obtain the Medication from a Participating
Pharmacy, the Covered Person should purchase the Medication at the nearest
pharmacy and submit a prescription claim form for reimbursement. The claim
payment will be limited to the Allowable Charge, less the applicable Prescription
Copayment.
viii. Medical Supplies. Medical supplies such as, but not limited to, colostomy supplies,
bandages and similar items are not generally covered under this Subsection
3.24.1.c; however, refer to Subsections 3.14 Medical Supplies and Subsection
3.24.1.d., below. Furthermore, subject to the terms, conditions, exclusions and
limitations of the Plan as set forth in this Benefit Certificate, coverage is provided
under this Subsection 3.24.1.c., for insulin and syringes purchased at the same time
as insulin and which are to be used for the sole purpose of injecting insulin. Syringes
not meeting this standard are not covered. In addition, certain blood glucose test
meter supplies such as test strips and lancets are covered under the pharmacy
benefit.
ix. Immunizations. Immunization agents and vaccines identified as preventive care
vaccines for adults and children, see Subsection 3.2., are covered when obtained at
a retail pharmacy.
x. Durable Medical Equipment. Durable Medical Equipment, even though such
device may require a prescription, such as, but not limited to, therapeutic devices,
artificial appliances, blood glucose test meters, or similar devices, are not covered
under this Subsection 3.24.1.c. Refer to Subsection 3.13 - Durable Medical
Equipment. However, certain blood glucose test meter supplies, such as test strips
and lancets, are covered under the pharmacy benefit.
xi. Prescriptions, Excluded Providers. Prescriptions ordered or written by any
Physician or Provider who is excluded from coverage under the Plan, are not
covered. Prescriptions presented to or filled by any Pharmacy which is excluded
from coverage under the Plan, are not covered. See Subsection 4.1.
xii. Copayment Information
Each Prescription is covered only after the Covered Person pays the applicable
Copayment (listed on the Covered Person’s Schedule of Benefits) to the
Participating Pharmacy. Covered Persons will be charged the appropriate
Copayment for each Prescription or refill. An initial fill of a Maintenance Medication
Prescription is covered for one month only. A refilled Maintenance Medication
Prescription may be covered for up to a 3-month supply with one Copayment applied
for each month’s supply. (See Subsection 9.58 - Maintenance Medication.)
When a Generic Medication is dispensed, the Covered Person will pay the Generic
Medication Copayment specified in the Schedule of Benefits for each initial and refill
Prescription. If there is no generic equivalent, the Covered Person will pay the Brand
Name Medication Prescription Drug Copayment for each initial and refill
Prescription.
If a Brand Name Medication is dispensed when a Generic Medication is available,
the Covered Person will pay the Prescription Drug Copayment plus the difference in
the cost of the Brand Name Medication and Generic Medication, or the cost of the
medication, whichever is less.
32
d. Home Infusion Therapy Pharmacy. The benefit for Medications received from a licensed
retail pharmacy designated by the Company as a home infusion therapy Provider is covered
based upon the Allowance or Allowable Charge for the Medication.
i. Covered Medications. A Medications and B Medications are covered under this
Subsection 3.24.1.d. (See Subsection 9.93 for definitions of “A Medications” and “B
Medications.”) A Medications are covered subject to the Prescription Medication
Copayment as listed in the Schedule of Benefits. B Medications are covered subject
to the calendar year Deductible and Coinsurance listed in the Schedule of Benefits.
ii. FDA approved medications that exist as separate components and are intended for
reconstitution prior to administration are covered. Examples include, but are not
limited to, total parental, intravenous antibiotics and hydration therapy.
iii. Conditions of Coverage. Conditions of coverage set forth in Subsections 3.24.2.
a., b., c., d., and e., are applicable to this coverage.
iv. Medical Supplies. Medical Supplies used in connection with home infusion therapy
are covered under this Subsection 3.24.1.d. See Subsection 3.14.
v. Administration Charges. Charges to administer or inject Medication by a licensed
medical professional operating under his/her scope of practice are covered under
this Subsection 3.24.1.d., according to the allowable fee schedule for skilled nursing
under both home infusion therapy and Home Health.
2. Conditions of Coverage
a. Prior Approval. Selected Prescription Medications, as designated from time to time by the
Company, are subject to Prior Approval through criteria established by the Company as
detailed in Coverage Policy before coverage is allowed. A list of Medications for which Prior
Approval is required is available from the Company upon request or, if you have Internet
access, you may review this list on the Company’s web site at
WWW.ARKANSASBLUECROSS.COM
. This Subsection 3.24.2.a., is applicable to
Prescription Medication covered by Subsections 3.24.1.b., c., and d.
b. Specialty Medications. Selected Prescription Medications are designated by the Company
as “Specialty Medications” due to their route of administration, approved indication, unique
nature, or inordinate cost. These medications usually require defined handling and home
storage demands, crucial patient education, and careful monitoring. Such medications
include, but are not limited to growth hormones, blood modifiers, immunoglobulins, and
medications for the treatment of hemophilia, deep vein thrombosis, hepatitis C, Crohn’s
disease, cystic fibrosis, multiple sclerosis and rheumatoid arthritis. Specialty Medications
may be A Medications or B Medications. Coverage for Specialty Medications is subject to
Prior Approval and may only be purchased through a specialty pharmacy vendor under
contract with the Company. The benefit for a Specialty Medication is subject to the calendar
year Deductible and Coinsurance specified in the Schedule of Benefits. A list of Specialty
Medications is available from the Company upon request or, if you have Internet access, you
may review this list on the Company’s web site at WWW.ARKANSASBLUECROSS.COM
.
This Subsection 3.24.2.b., is applicable to Prescription Medication covered by Subsections
3.24.1.b., c., and d.
c. Formulary. Except in limited circumstances set out in this Subsection 3.24.2.c., and
elsewhere in this Benefit Certificate, a Prescription Medication must be listed in the
Formulary in order to be covered. (See Subsection 9.42 Formulary.)
i. A list of Medications on the Formulary is available from the Company upon
request or, if you have Internet access, you may review this list on the
Company’s
web site at WWW.ARKANSASBLUECROSS.COM.
ii. If a Prescription Medication in the Formulary causes or has caused adverse or
harmful reactions for a particular Covered Person, or has been shown to be
ineffective in the treatment of a Covered Person’s particular disease or condition,
33
such Covered Person may be able to obtain coverage for a Prescription Medication
not in the Formulary by requesting Prior Approval from Arkansas Blue Cross and
Blue Shield, Managed Pharmacy, FAX (501) 378-6980, or mailed to Post Office
Box 2181, Little Rock, Arkansas 72203. Alternatively, you may e-mail your request
to APPEALSCOORDINATOR@ARKBLUECROSS.COM
. The form to request
Prior Approval of a Formulary exception is located on our web site at
https://www.arkansasbluecross.com/prior-approval.
1. Standard Exception Request. If the Company is able to process your request
without requesting additional information (see Subsection 7.1.4.), it will
notify you of its determination within 72 hours from the date it received the
exception request or, in the event additional information is necessary, within
72 hours of receipt of the additional information. Any standard exception
request for a Prescription Medication not in the Formulary will be approved
for the duration of the prescription, including refills.
2. Exception Request under Exigent Circumstances. An exception request for
a Prescription Medication not in the Formulary will be considered in the
event a Covered Person is suffering from a health condition that may
seriously jeopardize the Covered Person’s life, health, or ability to regain
maximum function or when a Covered Person is undergoing a current
course of treatment using a Prescription Medication not in the Formulary. If
the Company is able to process your request without requesting additional
information (see Subsection 7.1.4.), it will notify you of its determination
within 24 hours from the date it received the request, or, in the event
additional information is necessary, within 24 hours of receipt of the
additional information. Any exception request under exigent circumstances
is approved for the duration of the exigency.
3. External Review of Denied Exception. If your request for either a standard
exception to the Formulary or for an exception under exigent
circumstances is denied, you may request an external review by an
Independent Review Organization (see Subsection 7.3.). This request may
be made through Arkansas Insurance Commissioner, 1 Commerce Way,
Suite 102, Little Rock, Arkansas 72202 or by calling (800)852-5494. A
determination will be made on your appeal within 72 hours for a standard
exception request or within 24 hours for an exception request under
exigent circumstances. (See Subsection 7.3.11. regarding Notification of
Determination.)
d. Step Therapy. Selected Prescription Medications as designated from time to time by the
Company in its discretion are subject to Step Therapy restrictions. (See Subsection 9.110 -
Step Therapy.) Such Step Therapy must be completed before coverage for the selected
Prescription Medication is provided. The Step Therapy requirements for a particular
Prescription Medication are available from the Company upon request. This Subsection
3.24.2.d., is applicable to Prescription Medication covered by Subsections 3.24.1.c., and d.
The form to request Prior Approval of a Step Therapy exception is located on our web site
at https://www.arkansasbluecross.com/prior-approval
.
1. Standard Exception Request. If the Company is able to process your request without
requesting additional information (see Subsection 7.1.4.), it will notify you of its
determination within 72 hours from the date it received the exception request or, in
the event additional information is necessary, within 72 hours of receipt of the
additional information. Any standard exception request for a Prescription Medication
subject to Step Therapy will be approved for the duration of the prescription,
including refills.
2. Exception Request under Exigent Circumstances. An exception request for a
Prescription Medication subject to Step Therapy will be considered in the event a
34
Covered Person is suffering from a health condition that may seriously jeopardize
the Covered Person’s life, health, or ability to regain maximum function or when a
Covered Person is undergoing a current course of treatment using a Prescription
Medication subject to Step Therapy. If the Company is able to process your request
without requesting additional information (see Subsection 7.1.4.), it will notify you of
its determination within 24 hours from the date it received the request, or, in the
event additional information is necessary, within 24 hours of receipt of the additional
information. Any exception request under exigent circumstances is approved for the
duration of the exigency.
3. External Review of Denied Exception. If your request for either a standard exception
to the Formulary or for an exception under exigent circumstances is denied, you may
request an external review by an Independent Review Organization (see Subsection
7.3.). This request may be made through Arkansas Insurance Commissioner, 1
Commerce Way, Suite 102, Little Rock, Arkansas 72202 or by calling (800) 852-
5494. A determination will be made on your appeal within 72 hours for a standard
exception request or within 24 hours for an exception request under exigent
circumstances. (See Subsection 7.3.11. regarding Notification of Determination.)
e. Dispensing Quantities - Limitations
A Prescription Medication will not be covered for any quantity or period in excess of that
authorized by the prescribing Physician or health care Provider.
Early refills are covered at the discretion of the Company. A prescription will not be covered
if refilled after one year from the original date of the prescription.
Coverage of selected Prescription Medications as designated from time to time by the
Company in its discretion is subject to Dose Limitations. (See Subsection 9.32 - Dose
Limitation.) The Dose Limitation for a particular Prescription Medication is available from the
Company upon request.
This Subsection 3.24.2.e., is applicable to Prescription Medication covered by Subsections
3.24.1. d.
3.25 Organ Transplant Services. Subject to all terms, conditions, exclusions and limitations of the Plan as set
forth in this Benefit Certificate, coverage is provided for human-to-human organ or tissue transplants in
accordance with the following specific conditions:
1. Not all transplants are covered. There must be a specific Coverage Policy which allows benefits for
the transplant in question, and the Covered Person must meet all of the required criteria necessary
for coverage set forth in the Coverage Policy and in this Benefit Certificate.
2. The transplant benefit is subject to the Deductible and Coinsurance specified in the Schedule of
Benefits.
3. Notwithstanding any other provisions of this Benefit Certificate, at the option of the Company, the
Allowance or Allowable Charge for an organ transplant, including any charge for the procurement of
the organ, Hospital services, Physician Services and associated costs, including costs of
complications arising from the original procedure that occur within the Transplant Global Period, shall
be limited to the lesser of (a) ninety percent (90%) of the billed charges or (b) the global payment
determined as payment in full by a Blue Cross and Blue Shield Association Blue Distinction Centers
for Transplant participating facility, if the Covered Person chooses to use that facility. If the Covered
Person receives the transplant from a facility outside of Arkansas that is not in the Blue Distinction
Centers for Transplant network but is contracted with a local Blue Cross and/or Blue Shield Plan, the
Allowable Charge shall be the price contracted by such Blue Cross and/or Blue Shield Plan. (See
Section 7.1.10 Out-of-Arkansas Services). If the Covered Person receives the transplant from a
facility that is not in the Blue Distinction Centers for Transplant network and does not contract with
the local Blue Cross and/or Blue Shield plan, the Allowance or Allowable Charge for the transplant
services provided in the Transplant Global Period is eighty (80%) percent of an amount equaling the
lesser of (a) ninety (90%) percent of billed charges or (b) the average allowable charge authorized
35
by participating facilities in the Blue Distinction Centers for Transplant network located in the
geographic region where the transplant is performed. Please note that our payments for any
transplant (whether performed within the transplant network or by a non-participating facility)
are limited to a global payment that applies to all covered transplant services; we will not pay
any amounts in excess of the global payment for services the facility or any physician or other
health care Provider or supplier may bill or attempt to bill separately, because the global
payment is deemed to include payment for all related necessary services (other than non-
covered services). If you use a facility participating in the Blue Distinction Centers for
Transplant network, that facility has agreed to accept the global payment as payment in full
and should not bill you for any excess amount above the global payment, except for
applicable Deductible, Coinsurance or non-covered services; however, a non-participating
facility may bill you for all amounts it may charge above the global payment. These charges
above the global payment could amount to thousands of dollars in additional out of pocket
expenses to you.
4. When the Covered Person is the potential transplant recipient, a living donor’s Hospital costs for the
removal of the organ are covered with the following limitations:
a. Allowance or Allowable Charges are only covered for the period beginning on the day before
the transplant to the date of discharge or 39 days, whichever is less.
b. Donor testing is covered only if the tested donor is found compatible.
5. Solid organ transplants of any kind are not covered for individuals with a malignancy that is presently
active or in partial remission (e.g., non-metastatic resectable squamous and basal cell carcinoma of
the skin are excepted.). A solid organ transplant of any kind is not covered for a Covered Person
that has had a malignancy removed or treated in the 3 years prior to the proposed transplant. For
purposes of this section, malignancy includes a malignancy of the brain or meninges, head or neck,
bronchus or lung, thyroid, parathyroid, thymus, pleura, esophagus, heart or pericardium, liver,
stomach, small or large bowel, rectum, kidney, bladder, prostate, testicle, ovary, uterus, other organs
associated with the genito-urinary tract, bones, muscle, nerves, blood vessels, leukemia, lymphoma
or melanoma, and breast. The only exception to this non-coverage is for solid organ transplant for
hepatocellular carcinoma under certain circumstances, as outlined in the Coverage Policy for
hepatocellular carcinoma.
6. Coverage for high-dose or non-myeloablative chemotherapy, allogeneic or autologous stem or
progenitor cell transplantation for the treatment of a medical condition is provided subject to the
Company’s specific Coverage Policies relative to these specific conditions.
3.26 Medical Disorder Requiring Specialized Nutrients or Formulas. Subject to all terms, conditions,
exclusions, and limitations of the Plan as set forth in this Benefit Certificate, any Deductible, Copayment, and
Coinsurance specified in the Schedule of Benefits, coverage is provided for Medical Foods and Low Protein
Modified Food Products, amino-acid-based elemental formulas, extensively hydrolyzed protein formulas,
formulas with modified vitamin or mineral content and modified nutrient content formulas for the treatment of
a Covered Person diagnosed with a Medical Disorder Requiring Specialized Nutrients or Formulas if
1. the Medical Foods and Low Protein Modified Food Products shall only be administered under the
direction of a clinical geneticist and a registered dietitian under the order of a licensed Physician; and
2. the Medical Foods and Low Protein Food Modified Products are prescribed in accordance with
Coverage Policy for the therapeutic treatment of a Medical Disorder Requiring Specialized Nutrients
or Formulas.
3.27 Prenatal Tests and Testing of Newborn Children. Subject to all terms, conditions, exclusions and
limitations of the Plan as set forth in this Benefit Certificate, coverage is provided for prenatal tests that meet
Coverage Policy and testing of newborns during the newborn hospitalization/delivery for core medical
conditions. A complete list of the prenatal and newborn core medical condition testing is available at the
Arkansas Department of Health and the US Secretary of Health and Human Services.
3.28 Testing and Evaluation. Subject to all other terms, conditions, exclusions and limitations of the Plan set
forth in this Benefit Certificate, coverage is provided for the following testing and evaluation, limited to fifteen
36
(15) hours per Covered Person per year. This benefit is further subject to the Deductible, Copayment and
Coinsurance specified in the Schedule of Benefits.
1. Psychological testing, including but not limited to, assessment of personality, emotionality and
intellectual abilities.
2. For Children under the age of six (6), childhood developmental testing, including but not limited to
assessment of motor, language, social, adaptive or cognitive function by standardized developmental
instruments.
3. Neurobehavioral status examination, including, but not limited to assessment of thinking, reasoning
and judgment.
4. Neuropsychological testing, including, but not limited to Halstead-Reitan, Luria and WAIS-R.
5. Biomarker testing for the purpose of diagnosis, treatment, appropriate management or ongoing
monitoring of cancer diagnoses. This benefit is not subject to the limitation of fifteen (15) hours per
Covered Person per year.
3.29 Complications of Smallpox Vaccine. Subject to all other terms, conditions, exclusions and limitations of
the Plan as set forth in this Benefit Certificate, coverage is provided for complications resulting from a
smallpox vaccination. This benefit is subject to the Deductible, Copayment and Coinsurance specified in the
Schedule of Benefits.
3.30 Neurologic Rehabilitation Facility Services. Subject to all terms, conditions, exclusions and limitations of
the Plan as set forth in this Benefit Certificate, coverage is provided for Neurologic Rehabilitation Facility
services. This benefit is subject to the Deductible, Copayment and/or Coinsurance specified in the Schedule
of Benefits. This Neurologic Rehabilitation Facility services benefit is subject to the following conditions:
1. The Covered Person must be suffering from Severe Traumatic Brain Injury;
2. The admission must be within 7 days of release from an inpatient Hospital stay;
3. The Neurologic Rehabilitation Facility services are of a temporary nature with a potential to increase
ability to function;
4. Custodial Care is not covered (See Subsections 4.3.7 and 9.25); and
5. Coverage is provided for a maximum of 60 days per Covered Person per lifetime.
3.31 Pediatric Vision Services. Subject to all terms, conditions, exclusions and limitations of the Plan set forth
in this Benefit Certificate, coverage is provided for the following pediatric vision services when performed or
prescribed by a Physician subject to the Deductible, Copayment and Coinsurance amounts specified in the
Schedule of Benefits.
1. Annual routine eye examinations with refraction are covered beginning at age six, or earlier if
medically indicated, through age 18.
2. One pair of lenses in a calendar year, if prescribed by a physician.
a. Lenses may be prescription glasses or contact lenses.
b. Lenses may be plastic or polycarbonate lenses.
3. One frame in a calendar year if lenses are prescribed and prescription glasses selected.
4. Eye Glass repair if glasses were originally covered by this Benefit Certificate.
5. Replacement of lost or broken glasses, only one time within a year
6. Eye prosthesis or polishing services
7. Eyeglasses for children diagnosed as having the following diagnoses must have a surgical evaluation
in conjunction with supplying eyeglasses:
a. Ptosis (droopy lid);
b. Congenital cataracts;
37
c. Exotropia or vertical tropia; or
d. Children between the ages of twelve (12) and twenty-one (21) exhibiting exotropia.
8. Vision therapy developmental testing
a. orthoptic and pleoptic training with continuing medical direction and evaluation;
b. sensorimotor examination with multiple measurements of ocular deviation (e.g., restrictive or
paretic muscle with diplopia) with interpretation and report (separate procedure);
c. developmental testing extended (includes assessment of motor, language, social, adaptive
and/or cognitive functioning by standardized developmental instruments) with interpretation
and report.
3.32 Adult Routine Eye Exams. Subject to all terms, conditions, exclusions and limitations of the Plan set forth
in this Benefit Certificate, coverage is provided for one routine vision examination every 2 years by a Provider
who is an optometrist or ophthalmologist.
3.33 Hearing Aid Benefits. Subject to all terms, conditions, exclusions and limitations of the Plan as set forth in
this Benefit Certificate, coverage is provided for a Hearing Aid sold by a professional licensed by the State of
Arkansas to dispense a Hearing Aid or hearing instrument. Coverage shall not be subject to member cost
sharing but shall be limited to $1,400 per ear, per Covered Person with no limitation on the number of hearing
aids received.
3.34 Temporomandibular Joint Benefits. Subject to all terms, conditions, exclusions and limitations of the Plan
as set forth in this Benefit Certificate the applicable Coverage Policy, coverage is provided for the Allowance
or Allowable Charges for medical treatment, including surgical and nonsurgical procedures, of
temporomandibular joint disorder and craniomandibular disorder. This coverage shall be the same as that
for treatment to any other joint in the body.
3.35 Miscellaneous Health Interventions. Subject to all other terms, conditions, exclusions and limitations of
the Plan set forth in this Benefit Certificate, coverage is provided for the following:
1. Chelation Therapy. Chelation therapy is generally not covered, see Subsection 4.214. However,
subject to all terms, conditions, exclusions and limitations of the Plan as set forth in this Benefit
Certificate and applicable Coverage Policy, chelation therapy for control of ventricular arrhythmias or
heart block associated with digitalis toxicity, emergency treatment of hypercalcemia, extreme
conditions of metal toxicity, including thalassemia intermedia with hemosiderosis, Wilson’s disease
(hepatolenticular degeneration), lead poisoning and hemochromatosis is covered.
2. Clinical Trials. Phase I, II, III or IV clinical trials or any study to determine the maximum tolerated
dose, toxicity, safety, efficacy, or efficacy as compared with a standard means of treatment or
diagnosis of a drug, device or medical treatment or procedure are not covered. See Subsection
4.3.3. However, subject to all terms, conditions, exclusions and limitations of the Plan as set forth in
this Benefit Certificate as well, Routine Patient Costs for items and services furnished in connection
with participation in the clinical trial are covered, provided the Covered Person is eligible to participate
and has been approved for participation in accordance with the protocols of the clinical trial and the
clinical trial is an Approved Clinical Trial. See Subsections 9.6 and 9.104.
3. Contraceptive Devices. Subject to all other terms, conditions, exclusions and limitations of the Plan
as set forth in this Benefit Certificate, coverage is provided for contraceptive devices when prescribed
by a Physician.
4. Crisis Stabilization Services. Subject to all other terms, conditions, exclusions and limitations of
the Plan as set forth in this Benefit Certificate, coverage is provided for services provided to a
Covered Person to address a serious behavioral health impairment during a period of detention, not
to exceed ninety-six (96) hours, at a Crisis Stabilization Unit. This coverage is limited to one period
of detention per month and a maximum of six periods of detention per Covered Person per calendar
year.
5. Dietary and Nutritional Counseling Services. Subject to all other terms, conditions, exclusions
and limitations of the Plan as set forth in this Benefit Certificate, and subject to the Deductible,
38
Copayment and Coinsurance specified in the Schedule of Benefits, coverage is provided for dietary
and nutritional counseling services when provided in conjunction with Diabetic Self-Management
Training, for services needed by Covered Persons in connection with cleft palate management and
for nutritional assessment programs provided in and by a Hospital and approved by the Company.
6. Electrotherapy stimulators. Treatment using electrotherapy stimulators are generally not covered,
see Subsection 4.2.30. However, coverage is provided for a Transcutaneous Electrical Nerve
Stimulator (TENS) to treat chronic pain due to peripheral nerve injury when that pain is unresponsive
to medication.
7. Enteral Feedings. Enteral feedings are generally not covered, see Subsection 4.2.32. However,
enteral feedings are covered when such feedings have been approved and documented by an In-
Network Physician as being the Covered Person’s sole source of nutrition.
8. Gastric Pacemaker Coverage. Subject to all terms, conditions, exclusions and limitations of the
Plan as set forth in this Benefit Certificate including the Deductible, Copayment and/or Coinsurance
set out in the Schedule of Benefits; coverage is provided for gastric pacemakers .
9. Genetic Testing. In general, genetic testing to determine: (1) the likelihood of developing a disease
or condition, (2) the presence of a disease or condition in a relative, (3) the likelihood of passing an
inheritable disease, condition or congenital abnormality to an offspring, (4) genetic testing of the
products of amniocentesis to determine the presence of a disease, condition or congenital anomaly
in the fetus, (5) genetic testing of a symptomatic Covered Person’s blood or tissue to determine if the
Covered Person has a specific disease or condition, and (6) genetic testing to determine the
anticipated response to a particular pharmaceutical, are not covered.
However, subject to the terms, conditions, exclusions and limitations of the Plan set forth in this
Benefit Certificate, applicable Coverage Policy, a limited number of specific genetic tests may be
covered for situations (3), (4) or (5) referenced above when the Company has determined that the
particular genetic test (a) is the only way to diagnose the disease or condition, (b) has been
scientifically proven to improve outcomes when used to direct treatment, and (c) will affect the
individual’s treatment plan. A limited number of specific genetic tests may be covered for situation
(6) referenced above if criteria (b) and (c) above are met. The Company has full discretion in
determining which particular genetic tests may be eligible for benefits as an exception to this
exclusion. Any published Coverage Policy regarding a genetic test will control whether or not benefits
are available for that genetic test as an exception to this exclusion.
10. High Frequency Chest Wall Oscillators. Subject to all other terms, conditions, exclusions and
limitations of the Plan as set forth in this Benefit Certificate including applicable Coverage Policy, ,
coverage is provided, to Covered Person’s with cystic fibrosis, for one high frequency chest wall
oscillator during such Covered Person’s lifetime. Coverage is subject to the Deductible, Copayment
and Coinsurance specified in the Schedule of Benefits.
11. Inotropic Agents for Congestive Heart Failure. Chronic, intermittent infusion of positive inotropic
agents for patients with severe congestive heart failure is not covered. See Subsection 4.2.52.
However, subject to all terms, conditions, exclusions and limitations of the Plan set forth in this Benefit
Certificate, where the patient is on a cardiac transplant list at a Hospital where there is an ongoing
cardiac transplantation program, the Plan will cover infusion of inotropic agents.
12. Pilot Project Coverage. Subject to all terms, conditions, exclusions and limitations of the Plan set
forth in this Benefit Certificate, from time to time, the Company may provide coverage of medical
interventions that are excluded under the terms of the Plan as set out in this Benefit Certificate, under
terms, conditions, exclusions and limitations of a Company authorized Pilot Program. You can learn
the medical interventions that are covered by a Company authorized Pilot Program, and the terms,
conditions, exclusions and limitations of such coverage by visiting the Company's website at
WWW.ARKANSASBLUECROSS.COM
or by calling Customer Service.
13. Trans-telephonic Home Spirometry. Subject to all terms, conditions, exclusions and limitations of
the Plan as set forth in this Benefit Certificate, trans-telephonic home or ambulatory spirometry is
covered for patients who have had a lung transplant.
39
14. Vision Enhancement. For persons 19 years and older vision enhancements are generally not
covered, see Subsection 4.2.99. However, subject to all other terms, conditions, exclusions and
limitations of the Plan as set forth in this Benefit Certificate, a procedure, treatment, service,
equipment or supply to correct a refractive error of the eye is covered in two instances: (1) if such
refractive error results from traumatic injury or corneal disease, infectious or non-infectious, and (2)
the single acquisition of eyeglasses or contact lenses within the first six months following cataract
surgery. The Plan does not cover the implantation of a multifocal lens; however, if a multifocal lens
is implanted after a cataract extraction, the Plan will pay the Allowance or Allowed Charge for a
monofocal lens. With respect to such eyeglasses or contact lenses, tinting or anti-reflective coating
and progressive lenses are not covered. See Subsection 3.13.4. In addition, subject to all other
terms, conditions, exclusions and limitations of the Plan as set forth in this Benefit Certificate, certain
vision enhancement is provided to Covered Persons under the age of 19. See Subsection 3.30 -
Pediatric Vision Services.
4.0 SPECIFIC PLAN EXCLUSIONS
Even if the Primary Coverage Criteria (See Section 2.0) are met, coverage of a particular service, supply or condition
may not be covered under the terms of this Benefit Certificate. This Section 4.0 describes the conditions, Provider
services, Health Interventions and miscellaneous fees or services for which coverage is excluded.
4.1 Health Care Providers.
1. Custodial Care Facility. Services or supplies furnished by an institution which is primarily a place of
rest or a place for the aged are not covered. Youth homes, boarding schools, or any similar institution
are not covered.
2. Freestanding Cardiac Care Facility. Treatment received at a Freestanding Cardiac Care Facility is
not covered.
3. Immediate Relatives. Professional services performed by a person who ordinarily resides in the
Covered Person’s home, including self, or is related to the Covered Person as a Spouse, parent,
Child, brother or sister, grandparent and grandchild, whether the relationship is by blood or exists in
law are not covered.
4. Midwives, Not Certified. Services provided by a midwife who is not a licensed certified nurse midwife
in the state where he or she renders services and who does not have a collaborative agreement with
a Physician are not covered.
5. Physical Therapy Aide. Services or supplies provided by a physical therapy aide are not covered.
6. Provider, Excluded. Health Interventions received from any Provider who has been excluded from
participation in any federally funded program, are not covered.
7. Provider, Undefined. Services or supplies provided by an individual or entity that is not a Provider
as defined in this Benefit Certificate are not covered. (See Subsection 9.97 Provider.)
8. Recreational Therapist. Services or supplies provided by a recreational therapist are not covered.
9. Residents, interns, students or fellows. Services performed or provided by a Hospital resident, intern,
student or fellow of any medical related discipline are not covered.
10. Surgical First Assistants. The Company does not recognize surgical first assistants as a covered
provider eligible for reimbursement for Covered Services. Any services performed by a surgical first
assistant will be denied.
11. Unlicensed Providers or Provider Outside Scope of Practice. Coverage is not provided for treatment,
procedures or services received from any person or entity, including but not limited to Physicians,
who is required to be licensed to perform the treatment, procedure or service, but (1) is not so
licensed, or (2) has had his license suspended, revoked or otherwise terminated for any reason, or
(3) has a license that does not, in the opinion of the Company’s Medical Director, include within its
scope the treatment, procedure or service provided.
40
4.2 Health Interventions.
1. Abortion. Abortion is not covered. However, subject to all terms, conditions, exclusions and
limitations of the Plan as set forth in this Benefit Certificate, pregnancy terminations under the
direction of a Physician are covered, but only when performed in an In-Network Hospital or In-
Network Outpatient Hospital setting.
2. Abuse of Medications. Medications, drugs or substances used in an abusive, destructive or injurious
manner are not covered, except when caused by a mental or physical illness.
3. Acupuncture. Acupuncture and services related to acupuncture are not covered.
4. Adoptive Immunotherapy. Adoptive immunotherapy, including but not limited to (lymphokine-
activated killer (LAK) therapy, tumor-infiltrating lymphocyte (TIL) therapy, autolymphocyte therapy
(ATL)) is not covered. However, subject to Coverage Policy, chimeric antigen receptor T-cell therapy
is covered in a Blue Distinction Center (BDC) approved facility.
5. Antigen immunotherapy. Antigen immunotherapy for repeat fetal loss is not covered.
6. Arthroereisis for Pes Planus (Flat Feet). This treatment is sometimes used to treat flat feet and is not
covered.
7. Bereavement services. Medical social services and outpatient family counseling and/or therapy for
bereavement, except if provided as Hospice Care, are not covered.
8. Biochemical Markers for Alzheimer’s Disease. Measurement of cerebrospinal fluid and urinary
biomarkers of Alzheimer’s disease including but not limited to tau protein, amyloid beta peptides and
neural thread proteins are not covered.
9. Biofeedback. Biofeedback and other forms of self-care or self-help training, and any related
diagnostic testing are not covered for any diagnosis or medical condition.
10. Blood Typing. Blood Typing or DNA analysis for paternity testing is not covered.
11. Bone Growth Stimulation, electrical, as an adjunct to cervical fusion surgery. Electrical Bone Growth
Stimulation used as an adjunct to cervical fusion surgery is not covered.
12. Bronchial Thermoplasty. Bronchial thermoplasty for treatment of asthma or other indications and
bronchoscopy, when performed with bronchial thermoplasty, are not covered.
13. Chelation therapy. Services or supplies provided as, or in conjunction with, chelation therapy, are
generally not covered. However, subject to all terms, conditions, exclusions and limitations of the
Plan as set forth in this Benefit Certificate, chelation therapy for control of ventricular arrhythmias or
heart block associated with digitalis toxicity, emergency treatment of hypercalcemia, extreme
conditions of metal toxicity, including thalassemia intermedia with hemosiderosis, Wilson’s disease
(hepatolenticular degeneration), lead poisoning and hemochromatosis is covered. See Subsection
3.34.1.
14. Chemical Ecology. Diagnostic studies and treatment of multiple chemical sensitivities, environmental
illness, environmental hypersensitivity disorder, total allergy syndrome or chemical ecology is not
covered.
15. Cognitive Rehabilitation. Services or supplies provided as or in conjunction with, Cognitive
Rehabilitation are not covered. See Subsection 9.13. However, subject to all terms, conditions,
exclusions and limitation of the Plan as set forth in this Benefit Certificate, coverage is provided for
Neurologic Rehabilitation Facility Services for Covered Persons with Severe Traumatic Brain Injury.
See Subsection 3.29.
16. Cold Therapy. Cold Therapy devices are used in place of ice packs. The use of active or passive,
intermittent or continuous, with or without pneumatic compression, cold therapy is not covered.
Examples of cold therapy devices include, but are not limited to, the Cryocuff device, the Polar Care
Cub device, the Autochill device, and the Game Ready device.
17. Compound Medications. Compound Medications are not covered.
41
18. Complications of non-covered treatments. Care, services or treatment required as a result of
complications from a treatment or service not covered under this Benefit Certificate are not covered.
19. Compression Garments. All types of compression garments, support hose or elastic supports are
not covered even when purchased with a Prescription. However, subject to all terms conditions,
exclusions and limitation of the Plan as set forth in this Benefit Certificate, coverage is provided for
compression garments specifically designed to treat severe burns or compression sleeves and
gloves used to treat lymphedemas following mastectomy.
20. Cord Blood. The collection and/or storage of cord or placental blood cells for an unspecified future
use as an autologous stem-cell transplant in the original donor or for some other unspecified future
use as an allogeneic stem-cell in a related or unrelated donor is not covered.
21. Coverage Policy. The Company has developed and published on its website specific Coverage
Policies in relation to certain Health Interventions. If a Coverage Policy exists for an Intervention, the
Coverage Policy shall determine whether such Intervention meets the Primary Coverage Criteria. If
a Coverage Policy determines that a Health Intervention does not meet the Primary Coverage
Criteria, this Plan does not provide coverage for that Intervention. The absence of a specific
Coverage Policy with respect to any particular Health Intervention should not be construed to mean
that the Intervention meets the Primary Coverage Criteria.
22. Cranial electrotherapy or cranial electromagnetic stimulation devices. Cranial electrotherapy is not
covered. Cranial electromagnetic or cranial magnetic stimulation devices are not covered unless a
specific Coverage Policy provides coverage..
23. Current Perception Threshold Testing. This testing performed as a substitute for standard nerve
conduction studies in diagnosing carpal tunnel or tarsal tunnel syndrome is not covered.
24. Dental Care. Dental Care, oral surgery, orthodontic services and Prosthodontic Services are
generally not covered, except as provided in the Benefit Certificate. See Subsection 3.21. More
specifically, Prosthodontic Services generally are not covered except as provided under 3.21.6.
25. Dietary and Nutritional Services. Any services or supplies provided for dietary and nutritional
services, including but not limited to medical nutrition therapy, unless such dietary supplies are the
sole source of nutrition for the Covered Person, are not covered. Baby formula or thickening agents,
whether prescribed by a Physician or acquired over the counter, is not a covered benefit. However,
subject to all terms, conditions, exclusions and limitations of the Plan as set forth in this Benefit
Certificate, coverage is provided for Medical Foods and Low Protein Modified Food Products for the
treatment of a Medical Disorder Requiring Specialized Nutrients or Formulas. See Subsection 3.25.
26. Digitization Computer Enhanced X-ray Analysis for Spinal Evaluation. Spinal visualization using
digitization of spinal x-rays and computerized analysis of the back or spine is not covered.
27. Dynamic Orthotic Cranioplasty. Dynamic orthotic cranioplasty is not covered.
28. Dynamic spinal motion visualization techniques such as Digital Motion X-ray, Cineradiography and
Videoradiography. The use of digital motion x-ray for the evaluation of musculoskeletal conditions is
not covered.
29. EKG, Signal Averaged. Signal averaged electrocardiography utilized to stratify risk for arrhythmias
following myocardial infarction, in patients with cardiomyopathy, in patients with syncope, as an
assessment of success after surgery for arrhythmia, in detection of acute rejection of heart
transplants, as an assessment of efficiency of antiarrhythmic drug therapy and in the assessment of
successful pharmacological, mechanical or surgical interventions to restore coronary blood flow is
not covered.
30. Electrotherapy and electromagnetic stimulators. All treatment using electrotherapy and
electromagnetic stimulators, including services and supplies used in connection with such
stimulators, and complications resulting from such treatment are not covered. However, subject to
all terms, conditions, exclusions and limitations of the Plan as set forth in this Benefit Certificate,
coverage is provided for a Transcutaneous Electrical Nerve Stimulator (TENS) to treat chronic pain
due to peripheral nerve injury when that pain is unresponsive to medication.
Coverage is also
42
provided for neuromuscular electrical stimulation (NMES) for treatment of disuse atrophy where
nerve supply to the muscle is intact, including but not limited to atrophy secondary to prolonged
splinting or casting of the affected extremity, contracture due to scarring of soft tissue as in burn
lesions and hip replacement surgery until orthotic training begins.
31. Enhanced External Counterpulsation. Enhanced external counterpulsation (EECP) is generally not
covered. However, subject to all terms, conditions, exclusions and limitations of the Plan as set forth
in this Benefit Certificate, coverage is provided for one course of enhanced external counterpulsation
for the treatment of disabling angina in patients who are NYHA Class III or IV, or equivalent
classification; who have experienced inadequate control of anginal symptoms with a medication
regimen that consists of optimal dosages of platelet inhibitors, beta-blockers, calcium channel
blockers, long-acting nitrates, lipid-lowering drugs and antihypertensives when these drugs are
appropriate and there is no contraindication to any of these drugs; and who are not amenable to
surgical cardiac intervention such as angioplasty or coronary artery bypass grafting. Repeat courses
of EECP are not covered.
32. Enteral Feedings. Enteral feedings are generally not covered. However, subject to all terms,
conditions, exclusions and limitations of the Plan as set forth in this Benefit Certificate, enteral
feedings are covered when such feedings have been approved and documented by an In-Network
Physician as the Covered Person’s sole source of nutrition.
33. Environmental Intervention. Services or supplies used in adjusting a Covered Person’s home, place
of employment or other environment so that it meets the Covered Person’s physical or psychological
condition are not covered.
34. Epiduroscopy/spinal myeloscopy. This service is used in the diagnosis and treatment of spinal pain
and is not covered.
35. Excessive Use. Excessive use of Medications is not covered. For purposes of this exclusion, each
Covered Person agrees that the Company shall be entitled to deny coverage of medications on
grounds of excessive use when the Company’s medical director, in his sole discretion, determines
(1.) that a Covered Person has exceeded the dosage level, frequency or duration of medications
recommended as safe or reasonable by major peer-reviewed medical journals specified by the United
States Department of Health and Human Services pursuant to section 1861(t)(2)(B) of the Social
Security Act, 42 U.S.C. §1395(x)(t)(2)(B), as amended, standard reference compendia or by the
Pharmacy & Therapeutics Committee; or (2.) that a Covered Person has obtained or attempted to
obtain the same medication from more than one Physician for the same or overlapping periods of
time; or (3.) that the pattern of Prescription purchases, changes of Physicians or pharmacy or other
information indicates that a Covered Person has obtained or sought to obtain excessive quantities of
Medications. Each Covered Person hereby authorizes the Company to communicate with any
Physician, health care Provider or pharmacy for the purpose of reviewing and discussing the Covered
Person’s Prescription history, use or activity to evaluate for excessive use.
36. Exercise programs. Exercise programs for treatment of any condition are not covered.
37. Extracorporeal Shock Wave Therapy. Extracorporeal shock wave therapy (ESWT) for any
musculoskeletal condition, including but not limited to plantar fasciitis or tennis elbow, is not covered.
38. Family Planning. The following family planning services are not covered.
a. reversal of sterilization
b. surrogate mothers providing services for a Covered Person.
39. Foot care. Non-custom shoe inserts are not covered. Services or supplies for the treatment of
subluxations of the foot, arthroeresis for flat feet, care of corns, bunions, (except capsular or bone
surgery), calluses, toenails, fallen arches, weak feet, chronic foot strain, and symptomatic complaints
of the feet are not covered.
40. Fraud or Material Misrepresentation. Health Interventions, including but not limited to Medications,
obtained by unauthorized or fraudulent use of the ID card or by material misrepresentation are not
covered.
43
41. Free Health Interventions. Health Interventions, including but not limited to Medications, provided or
dispensed without charge to the Covered Person or for which, normally (in professional practice),
there is no charge, are not covered.
42. Genetic testing. In general, genetic testing to determine: (1) the likelihood of developing a disease
or condition, (2) the presence of a disease or condition in a relative, (3) the likelihood of passing an
inheritable disease, condition or congenital abnormality to an offspring, (4) genetic testing of the
products of amniocentesis to determine the presence of a disease, condition or congenital anomaly
in the fetus, (5) genetic testing of a symptomatic Covered Person’s blood or tissue to determine if the
Covered Person has a specific disease or condition, and (6) genetic testing to determine the
anticipated response to a particular pharmaceutical, are not covered.
However, subject to the terms, conditions, exclusions and limitations of the Plan set forth in this
Benefit Certificate, applicable Coverage Policy, a limited number of specific genetic tests may be
covered for situations (3), (4) or (5) referenced above when the Company has determined that the
particular genetic test (a) is the only way to diagnose the disease or condition, (b) has been
scientifically proven to improve outcomes when used to direct treatment, and (c) will affect the
individual’s treatment plan. A limited number of specific genetic tests may be covered for situation
(6) referenced above if criteria (b) and (c) above are met. The Company has full discretion in
determining which particular genetic tests may be eligible for benefits as an exception to this
exclusion. Any published Coverage Policy regarding a genetic test will control whether or not benefits
are available for that genetic test as an exception to this exclusion.
43. Hair loss or growth. Wigs, hair transplants or any Medication (e.g., Rogaine, Minoxidil, etc.) that is
taken for hair growth, whether or not prescribed by a Physician, are not covered regardless of the
cause of hair loss. Treatment of male or female pattern baldness is not covered.
44. Hearing devices or talking aids. Regardless of the reason for the hearing or speech disability,
Prosthetic Devices to assist hearing (except for hearing aids as covered in Subsection 3.32) or talking
devices including special computers are not covered. The testing for, the fitting of or the repair of
such Prosthetic Devices to assist hearing or talking devices is not covered. However, subject to all
terms, conditions, exclusions and limitations of the Plan set forth in this Benefit Certificate, coverage
is provided for:
a. cochlear implant (an implantable hearing device inserted into the modiolus of the cochlea
and into cranial bone) and its associated speech processor up to a lifetime maximum benefit
of one cochlear implant per year per Covered Person unless replacement is necessitated
because there is inadequate response to existing component(s) that interfere with the
Covered Person’s activities of daily living or one or more components are no longer functional
and cannot be repaired; and
b. one auditory brain stem implant per lifetime for an individual twelve years of age and older
with a diagnosis of Neurofibromatosis Type II (NF2) who has undergone or is undergoing
removal of bilateral acoustic tumors.
c surgically implantable osseointegrated hearing aid for patients with single-sided deafness
and normal hearing in the other ear, limited to Covered Persons with
i. congenital or surgically induced malformations (e.g., atresia) of the external ear
canal or middle ear;
ii. chronic external otitis or otitis media;
iii. tumors of the external canal and/or tympanic cavity; and
iv. sudden, permanent, unilateral hearing loss due to trauma, idiopathic sudden hearing
loss, or auditory nerve tumor.
45. Heat Bandage. Treatment of a wound with a Warm-up Active Wound Therapy device or a noncontact
radiant heat bandage is not covered.
46. High dose Chemotherapy, Autologous Transplants, Allogeneic Transplants or Non-Myeloablative
Allogeneic Stem Cell Transplantation. High dose Chemotherapy, Autologous Transplants,
44
Allogeneic Transplants or Non-Myeloablative Allogeneic Stem Cell Transplantation are not covered
except in accordance with the Company’s specific Coverage Policies. See Subsection 3.24.
47. Hippo Therapy. Hippo therapy is not covered.
48. Home delivery. Services and supplies received in connection with childbirth in the home are not
covered regardless of the Provider.
49. Home Uterine Activity Monitor. Home uterine activity monitors or their use is not covered.
50. Hypnotherapy. Hypnotherapy is not covered for any diagnosis or medical condition.
51. Illegal Uses. Medications, drugs or substances that are illegal to dispense, possess, consume or
use under the laws of the United States or any state, or that are dispensed or used in an illegal
manner, are not covered.
52. Inotropic Agents for Congestive Heart Failure. Chronic, intermittent infusion of positive inotropic
agents for patients with severe congestive heart failure is not covered. However, subject to all terms,
conditions, exclusions and limitations of the Plan set forth in this Benefit Certificate, where the patient
is on a cardiac transplant list at a Hospital where there is an ongoing cardiac transplantation program,
the Plan will cover infusion of inotropic agents.
53. Interspinous Distraction Devices (Spacers). These devices are inserted between the spinous
processes, and they act as a spacer between the spinous processes. Their proposed use is to treat
leg and/or back pain secondary to spinal stenosis and distract the spinous processes and restrict
extension. Interspinous Distraction Devices (Spacers) are not covered. Examples include, but are
not limited to, the X-STOP interspinous Process by Medtronics, the Wallis System by Abbott Spine,
the Coflex implant by Paradigm Spine, the ExtendSure and CoRoent devices by NuVasive, the NL-
Prow by NonLinear Technologies, the Aperius by Medtronic Spine.
54. Intraoperative Neurophysiologic Monitoring (IONM). IONM is used to monitor the integrity of neural
pathways during high-risk neurosurgical cranial/spinal, orthopedic spinal, vascular, and major thyroid
procedures and is not covered unless the physician performing this service is a licensed physician
other than the operating surgeon. Coverage for IONM is provided only when the condition(s) and
criteria specified in Coverage Policy are met.
55. Laser Treatment of Spinal Intradiscal and Paravertebral Disc Disorders. Laser treatment of spinal
intradiscal and paravertebral disc disorders is not covered.
56. Learning Disabilities. Services or supplies provided for learning disabilities, i.e., reading disorder,
alexia, developmental dyslexia, dyscalculia, spelling difficulty and other learning difficulties, are not
covered.
57. Lost Medications. Replacement of previously filled Prescription Medications because the initial
Prescription Medication was lost, stolen, spilled, contaminated, etc. are not covered.
58. Measurement of Exhaled Nitric Oxide. Measurement of Exhaled Nitric Oxide used in the diagnosis
and management of asthma and other respiratory disorders is not covered.
59. Measurement of Lipoprotein-Associated Phospholipase (Lp-PLA2). Measurement of Lipoprotein-
Associated Phospholipase (Lp-PLA2), also known as platelet-activating factor acetylhydrolase is not
covered. The proposed use of this test is to assess cardiovascular risk.
60. Measurement of Novel Lipid Risk Factors in Risk Assessment and Management of Cardiovascular
Disease. Measurement of novel lipid risk factors including, but not limited to, apolipoprotein B,
apolipoprotein A-1, HDL subclass, LDL subclass, apolipoprotein E, and Lipoprotein A are not
covered.
61. Measurement of Serum intermediate Density Lipoproteins (remnant-like particles). These
lipoproteins have a density that falls between low density lipoproteins and very low-density
lipoproteins. Measurements of these "remnant-like" particles are not covered.
62. Medical Supplies. Medical Supplies that can be purchased without a prescription or over the counter,
whether or not a prescription was obtained, are not covered; for example, medication coated
45
dressings, tape and gauze are not covered even with a Physician Prescription. However, subject to
all terms, conditions, exclusions and limitations of the Plan as set forth in this Benefit Certificate,
Medical Supplies necessary for the management of diabetes mellitus or for home health services are
covered. See Subsection 3.14 Medical Supplies, Subsection 3.16 Diabetes Management Services
and Section 3.19 Home Health Services. Expenses for Medical Supplies provided in a Physician’s
office are included in the reimbursement for the procedure or service for which the supplies are used.
63. Medication Therapy Management Services. Medication therapy management services by a
pharmacist, including but not limited to a review of a Covered Person’s history and medical profile,
an evaluation of Prescription Medication, over-the-counter medications and herbal medications, are
not covered.
64. Mobile Cardiac Outpatient Telemetry (MCOT). Mobile Cardiac Outpatient Telemetry is sometimes
used in patients who experience infrequent symptoms suggestive of cardiac arrhythmias. MCOT is
not covered.
65. Naturopath/Homeopath Treatment. Naturopathic or Homeopathic treatments of any condition are
not covered.
66. Neural Therapy. Neural therapy often involves the injection of a local anesthetic into scars, trigger
points, acupuncture points, tendon insertions, ligament insertions, peripheral nerves, autonomic
ganglia, the epidural space and other tissues to treat chronic pain and illness. Neural therapy is not
covered.
67. Neurofeedback. The proposed use of Neurofeedback has been to reinforce neurobehavior
modification in patients with certain neurological and/or neurobehavioral disorders such as ADD,
ADHD, Parkinson’s Disease, epilepsy, insomnia, depression, mood disorders, post-traumatic stress
disorder, alcoholism, drug addiction, menopausal symptoms and migraine headaches.
Neurofeedback is not covered.
68. Off-Label Use. (a) Except as provided in subsection (b) (c) or (d) of this subsection, Prescription
Medications and devices that are not approved by the FDA for a particular use or purpose or when
used for a purpose other than the purpose for which FDA approval is given are not covered. (b) From
time to time a particular clinical use of a Prescription Medication may be determined to be safe and
efficacious by the Company's medical director, managed pharmacy director, or the Pharmacy and
Therapeutics Committee, even without labeling of such indication or use by the FDA. This occurs
because of clear and convincing evidence from the Medical Literature, and often in consultation with
practicing Physicians of the appropriate specialty in the community. Such "off-label" use will be
covered, though Prior Approval is often (but not always) required. Other than the list of Medications
requiring Prior Approval cited above, a complete list of Medications and their approved off-label
indications is not available. (c) “Off-label” use of intravenous immunoglobulin, also known as “IVIG”,
to treat Covered Persons diagnosed with pediatric acute-onset neuropsychiatric syndrome and
pediatric autoimmune neuropsychiatric disorders associated with streptococcal infection, or both, is
covered subject to the terms, conditions, exclusions and limitations set out in Coverage Policy. (d) A
Prescription Medication approved by the FDA for the treatment of cancer, though not approved to
treat the specific cancer for which it has been prescribed, will be covered provided:
i. the Prescription Medication has been recognized as safe and effective for treatment of that
specific type of cancer in any of the following standard reference compendia, unless the use
is identified as “not indicated” or otherwise inappropriate or not recommended, in one or more
of these standard reference compendia: (A) The American Hospital Formulary Service Drug
Information; (B) The National Comprehensive Cancer Network Drugs and Biologics
Compendium with a level 1 or 2A recommendation; (C) The Elsevier Gold Standard’s Clinical
Pharmacology; or
ii. the Prescription Medication has been recognized as safe and effective for treatment of that
specific type of cancer in two (2) articles from Medical Literature that have not had their
recognition of the Prescription Medication’s safety and effectiveness contradicted by clear
and convincing evidence presented in another article from Medical Literature; or
46
iii. other authoritative compendia as identified by the Secretary of the United States Department
of Health and Human Services or the commissioner may be used to provide coverage by the
Company at the Company’s discretion.
69. Oral, Implantable and Injectable Contraceptives. Oral, implantable and injectable contraceptive
drugs, and Prescription barrier methods that are not on the Formulary are not covered.
70. Orthoptic, Pleoptic or Vision Therapy. Orthoptic, pleoptic or vision therapy services are generally not
covered. However, subject to all terms, conditions, exclusions and limitations of the Plan as set out
in this Benefit Certificate, coverage is provided for office-based orthoptic training in the treatment of
convergence insufficiency when supported by the Coverage Policy on Orthoptic Training for the
Treatment of Vision and Learning Disabilities.
71. Out-of-Network Infertility. Testing, counseling and planning services for infertility are not covered
when provided by Out-of-Network Providers.
72. Out-of-Network Preventive Health Services. Preventive health services are not covered when
provided by Out-of-Network Provider.
73. Out-of-NetworkReconstructive Surgery. Services rendered for any Reconstructive Surgery, including
reduction mammoplasty, are not covered when rendered by an Out-of-Network Provider.
74. Out-of-Network Therapy. Services rendered Out-of-Network for physical, occupational and speech
therapy, chiropractic services and cardiac rehabilitation therapy are not covered.
75. Over the Counter Medications. Over-the-counter Medications (except insulin) are not covered
without a Prescription from a Physician.
76. Pain Pump, Disposable. Disposable pain pumps following surgery are not covered.
77. Percutaneous discectomy and Radio-frequency Thermocoagulation. Any method of percutaneous
discectomy, including, but not limited to, automated or manual percutaneous discectomy, laser
discectomy, radiofrequency nucleotomy or nucleolysis, and coblation therapy, is not covered. Radio-
frequency Thermocoagulation or Intradiscal electrothermal therapy for discogenic or other forms of
back pain are not covered.
78. Percutaneous Sacroplasty. Percutaneous sacroplasty is not covered.
79. Peripheral Vascular Disease Rehabilitation Therapy. Peripheral vascular disease rehabilitation
therapy is not covered.
80. Prolotherapy. Prolotherapy or Sclerotherapy for the stimulation of tendon or ligament tissue or for
pain relief in a localized area of musculoskeletal origin is not covered.
81. Radio-frequency Thermal Therapy for Treatment of Orthopedic Conditions. The use of radio-
frequency thermal therapy for treatment of orthopedic conditions is not covered.
82. Rest cures. Services or supplies for rest cures are not covered.
83. Seasonal Affective Disorder (SAD). Use of photo therapy or light therapy to treat seasonal affective
disorder or depression is not covered.
84. Sensory Stimulation for Coma Patients. Sensory stimulation, whether visual, auditory, olfactory,
gustatory, cutaneous or kinesthetic, for coma patients is not covered.
85. Sexual Enhancement Medications. Medications used for the treatment of sexual enhancement,
including but not limited to medications for erectile dysfunction, are not covered regardless of the
reason(s) for the sexual dysfunction.
86. Short stature syndrome. Any services related to the treatment of short stature syndrome, except for
laboratory documented growth hormone deficiency, are not covered.
87. Sleep Apnea, Portable Studies. Studies for the diagnosis, assessment or management of obstructive
sleep apnea are generally not covered. However, subject to all other terms, conditions, exclusions
and limitations of the Plan as set forth in this Benefit Certificate, coverage is provided for portable (at
47
home) sleep studies when all of the following seven channel monitoring information is included: EEG,
heart rate, Chin EMG, ECG, airflow, effort and oxygen saturations, channels to identify awake versus
asleep and apnea events. Devices used are considered portable comprehensive polysomnography
devices monitoring a minimum of seven channels.
88. Smoking cessation/Caffeine addiction. Treatment of caffeine or nicotine addiction, smoking
cessation Prescription Medication products not on our Formulary, including, but not limited to,
nicotine gum and nicotine patches without a written Prescription, are not covered
89. Snoring. Devices, procedures or supplies to treat snoring are not covered.
90. Spinal Manipulation under general anesthesia. This type of manipulation is sometimes used for
treatment of arthrofibrosis of the knee or shoulder and is intended to overcome the patient’s protective
reflex mechanism. Spinal manipulation under anesthesia is not covered.
91. Spinal Uploading Devices for treatment of low back pain. Spinal uploading devices including, but not
limited to, gravity dependent and pneumatic devices are not covered. Examples include, but are not
limited to, the Orthotrac Pneumatic Vest and other thoracic-lumbar-sacral orthotics which provide
trunk support.
92. Substance Addiction. Medications used to sustain or support an addiction or substance dependency
are not covered. However, the use of designated agonist (e.g., methadone or buprenorphine) as part
of a comprehensive substance abuse treatment plan is covered.
93. Tanning equipment or salon. The purchase or rental of tanning equipment, supplies or the services
of a tanning salon are not covered.
94. Thermography. Thermography, the measuring of self-emanating infrared radiation that reveals
temperature variation at the surface of the body, is not covered.
95. Thoracoscopic Laser Ablation of Emphysematous Pulmonary Bullae. Thoracoscopic laser ablation
of emphysematous pulmonary bullae is not covered.
96. Total Facet Arthroscopy. Facet arthroscopy refers to the implantation of a spinal prosthesis to restore
posterior element structure and function as an adjunct to neural decompression surgery. Total Facet
Arthroscopy is not covered. Examples of facet arthroplasty devices include, but are not limited to, the
ACADIA facet replacement System, the Total Facet Arthroscopy System and the Total Posterior-
element System (TOPS).
97. Transplant procedures. The following transplant procedures and services are not covered:
a. Solid organ transplants of any kind are not covered for a Covered Person with a malignancy
of any kind that is presently active, in partial remission or in complete remission less than
two years (e.g., non-metastatic resectable squamous and basal cell carcinoma of the skin
are excepted.). A solid organ transplant of any kind is not covered for a Covered Person that
has had a malignancy removed or treated in the 3 years prior to the proposed transplant.
For purposes of this section, malignancy includes a malignancy of the brain or meninges,
head or neck, bronchus or lung, thyroid, parathyroid, thymus, pleura, esophagus, heart or
pericardium, liver, stomach, small or large bowel, rectum, kidney, bladder, prostate, testicle,
ovary, uterus, other organs associated with the genito-urinary tract, bones, muscle, nerves,
blood vessels, leukemia, lymphoma or melanoma, and breast. Exceptions to this non-
coverage are (i) hepatocellular carcinoma under certain circumstances, as outlined in the
Coverage Policy for hepatocellular carcinoma, and (ii) basal cell and squamous cell
carcinomas of the skin, absent lymphatic or distant metastasis.
b. Organ transplants not authorized by Coverage Policy are not covered.
98. Ultrasounds. More than one basic level obstetrical ultrasound during Routine Prenatal Care is not
covered.
99. Viscosupplementation for treatment of Osteoarthritis. Intra-articular hyaluronan such as Synvisc,
Hyalgan, Supartz, Orthovisc and Euflexxa are not covered.
48
100. Vision enhancement. For Covered Persons age 19 or older, any procedure, treatment, service,
equipment or supply used to enhance vision by changing the refractive error of the eye is not covered.
Examples of non-covered visual enhancement services include, but are not limited to, the refraction
for and the provision of eyeglasses and contact lenses, intraocular lenses, and Refractive
Keratoplasty, with the exception of excessive, visually debilitating residual astigmatism following
anterior segment surgery, i.e., corneal transplantation, cataract extraction, etc. Laser Assisted Insitu
Keratomileusis (LASIK) and all other related refractive procedures are not covered. However, subject
to all other terms, conditions, exclusions and limitations of the Plan as set forth in this Benefit
Certificate, a procedure, treatment, service, equipment or supply to correct a refractive error of the
eye is covered in two instances: (1) if such refractive error results from traumatic injury or corneal
disease, infectious or non-infectious, and (2) the single acquisition of eyeglasses or contact lenses
within the first six months following cataract surgery. With respect to such eyeglasses or contact
lenses, tinting or anti-reflective coating and progressive lenses are not covered. Eyeglass frames
are subject to a $65 maximum Allowance or Allowable Charge. See Subsection 3.13.4. In addition,
subject to all other terms, conditions, exclusions and limitations of the Plan as set forth in this Benefit
Certificate, certain vision enhancement is provided to Covered Persons under the age of 19. See
Subsection 3.30 - Pediatric Vision Services.
101. Vitamins or Baby Formula. Vitamins or food/nutrient supplements, except those that are Prescription
Medications not available over the counter, are not covered. Baby formula and thickening agents,
even if prescribed by a Physician, is not covered. However, subject to all terms, conditions,
exclusions and limitations of the Plan as set forth in this Benefit Certificate, coverage is provided for
Medical Foods and Low Protein Modified Food Products for the treatment of Medical Disorder
Requiring Specialized Nutrients or Formulas. See Subsection 3.25.
102. Vocational rehabilitation. Vocational rehabilitation services, vocational counseling and testing,
employment counseling or services to assist a Covered Person in gaining employment, are not
covered.
103. Weight Control. Medications prescribed, dispensed or used for the treatment of obesity, or for use
in any program of, weight control, weight reduction, weight loss or dietary control are not covered.
Weight loss surgical procedures, including complications relating thereto, are not covered.
104. Whole body computed tomography. Whole body computed tomography is not covered.
105. Wilderness Therapy. Wilderness therapy is not covered
106. Wound Treatment. Blood derived growth factors are not covered.
107. Wound Vacuum Assisted Closure (VACs). Wound VAC are not covered without meeting Coverage
Policy.
4.3 Miscellaneous Fees and Services.
1. Administrative Fees. Fees incurred for acquiring or copying medical records, sales tax, preparation
of records for insurance carriers or insurance agencies, medical evaluation for life, disability or any
type of insurance coverage are not covered.
2. Appointments. Charges resulting from the failure to keep a scheduled visit with a Physician or other
Provider are not covered.
3. Clinical Trials. Phase I, II, III or IV clinical trials or any study to determine the maximum tolerated
dose, toxicity, safety, efficacy, or efficacy as compared with a standard means of treatment or
diagnosis of a drug, device or medical treatment or procedure are not covered. However, subject to
all terms, conditions, exclusions and limitations of the Plan as set forth in this Benefit Certificate,
routine patient costs for items and services furnished in connection with participation in the trial are
covered. See Subsection 3.34.2.
4. Comfort items. Personal hygiene or comfort items including but not limited to, spray nozzle, heating
pad, heating lamp, hot water bottle, ice cap, television, radio, telephone, guest meals, whirlpool bath,
adjustable bed, automobile/van conversion or addition of patient lifts, hand control, or wheelchair
ramp, and home modifications such as overhead patient lift and wheelchair ramps are not covered.
49
5. Cosmetic Services. All services or procedures related to or complications resulting from Cosmetic
Services are not covered even if coverage was provided through a previous carrier.
6. Court ordered or third party recommended treatment. Services required or recommended by third
parties, including physicals and/or vaccines/immunizations for employment, overseas travel, camp,
marriage licensing, insurance, and services ordered by a court or arranged by law enforcement
officials, unless otherwise covered by the Plan, are not covered.
7. Custodial Care. Services or supplies for custodial, convalescent, domiciliary or supportive care and
non-medical services to assist a Covered Person with activities of daily living are not covered. (See
Subsection 9.25 - Custodial Care.)
8. Donor services. Services or supplies incident to organ and tissue transplant, or other procedures
when the Covered Person acts as the donor are not covered except for Autologous services.
When the Covered Person is the potential transplant recipient, a living donor’s Hospital costs for the
removal of the organ are covered with the following limitations:
a. Allowance or Allowable Charges for the organ removal as well as any complications resulting
from the organ removal are only covered for the period beginning on the day before the
transplant to the date of discharge or 39 days, whichever is less.
b. Services for testing of a donor who is found to be incompatible are not covered.
9. Education Programs. Education programs, including but not limited to physical education programs
in a group setting, health club memberships, athletic training, back schools, Work Hardening and
Work Integration (Community) training, are not covered. However, subject to all terms, conditions,
exclusions and limitations of the Plan as set forth in this Benefit Certificate, coverage is provided for
Diabetes Self-Management Training. See Subsection 3.16.
10. Excess charges. The part of an expense for care and treatment of an illness or Accidental Injury that
is in excess of the Allowance or Allowable Charge is not covered.
11. Postage or Delivery Charges. Charges for shipping, packaging, handling or delivering Medications
are not separately covered.
12. Prescription Medications used in connection with Health Interventions Not Covered by Plan.
Prescription Medications used or intended to be used in connection with or arising from a treatment,
service, condition, sickness, disease, injury, or bodily malfunction that is not covered under this
Benefit Certificate, or for which this Benefit Certificate’s benefits have been exhausted, are not
covered.
13. Services Received Outside the United States. Services or supplies received outside of the United
States of America shall not be covered except at the sole discretion of the Company.
14. Telephone and Other Electronic Consultation. Subject to all other terms, conditions, exclusions, and
limitations of this Plan set forth in this Benefit Certificate.
i. Coverage is provided for Telemedicine services performed by a Provider licensed, certified,
or otherwise authorized by the laws of Arkansas to administer health care in the ordinary
course of the practice of his or her profession at the same rate as if it had been performed
in-person provided the Telemedicine service is comparable to the same service provided in
person.
ii. However, electronic consultations such as, but not limited to, telephonic, interactive audio,
fax, text messaging, email, or for services, which are, by their nature, hands-on (e.g.,
surgery, interventional radiology, coronary, angiography, anesthesia, and endoscopy) are
not covered. Audio-only communication is covered if it is real-time, interactive and
substantially meets the requirements for a Covered Service that would otherwise be covered
by the Plan.
iii. Communications made by a Physician responsible for the direct care of a Covered Person
in Case Management with involved health care Providers, or consultative electronic
50
communication between a Primary Care Physician and other health care Providers
regarding a Covered Person’s care, however, are covered.
15. Travel or accommodations. Travel or transportation as a treatment or to receive consultation or
treatment, except Ambulance Services covered under Subsection 3.17, are not covered.
Accommodations, while receiving treatment or consultation or for any other purpose, are not covered.
16. War. Services or supplies provided for treatment of disease or injuries sustained while serving in the
military forces of any nation are not covered.
17. Workers Compensation. Treatment of any compensable injury, as defined by the Workers'
Compensation Law is not covered, regardless of whether or not the Covered Person filed a claim for
workers' compensation benefits in a timely manner. See Subsection 5.3 Other Plans and Benefit
Programs.
5.0 PROVIDER NETWORK AND COST SHARING PROCEDURES
The plan may afford you significant savings if you obtain coverage from Providers who are Providers in our Preferred
Provider Organization (“Preferred Providers”) or other health care Providers who have contracted with the Company
(“Contracting Providers”). This Section explains how you can maximize your benefits under the Plan by using
Preferred Providers and Contracting Providers, see Subsection 5.1. Under your plan, you are responsible for part of
the costs associated with Covered Services, supplies, equipment and treatment. Your responsibilities are explained
in this Section, see Subsection 5.2. Finally, this Section explains how costs of benefits that are covered by another
benefit plan are covered by the Plan, see Subsection 5.3.
5.1 Network Procedures
1. Standard Benefits. Subject to all terms, conditions, exclusions and limitations of the Plan set forth
in this Benefit Certificate, coverage is provided for Health Interventions you receive from a Provider
as defined by the Plan. See Subsection 9.97.
2. Preferred Provider Organization (PPO). This coverage is most effective and advantageous for you
when the services of Preferred Providers are used. Claims associated with services provided by
Preferred Providers may have a more advantageous Deductible, Coinsurance and Copayment than
claims for services of Non-Preferred Providers. For the definitions and explanation of the terms
“Deductible,” “Coinsurance,” and “Copayment” please refer to Section 9.0 Glossary of Terms and
Subsection 5.2.
The PPO or In-Network Deductible, Coinsurance and Copayment set forth in the Schedule of Benefits
are applied to Allowable Charges for services and supplies you receive from a Preferred Provider,
unless the Schedule of Benefits or this Benefit Certificate shows a different Deductible, Coinsurance
or Copayment for the particular service.
3. Non-PPO Benefits. Reimbursement for services by Non- Preferred Providers generally will be less
than payment for the same services when provided by a Preferred Provider and could result in
substantial additional out-of-pocket expense. The Non-PPO or Out-of-Network Deductible,
Coinsurance and Copayment set forth in the Schedule of Benefits are applied to Allowable Charges
for services and supplies you receive from a Non-Preferred Provider unless:
a. Plan Provision. The Schedule of Benefits or this Benefit Certificate provides a different
Deductible, Coinsurance or Copayment for the particular service or supply that is the subject
of the claim;
b. Emergency Services. The intervention is for Emergency Care (see Subsection 9.37) and
initial services are provided within forty-eight (48) hours of the onset of the injury or illness,
in which case the In-Network Deductible, Coinsurance and Copayment apply;
c. Continuity of Care, Prior to Coverage. You notify the Company that prior to the effective
date of your coverage, you were engaged with a Non-Preferred Provider for a scheduled
procedure or ongoing treatment covered under the terms of this Plan, that such procedure
or treatment is for a condition requiring immediate care, and that you request PPO benefits
51
for such scheduled procedure or ongoing treatment. If the Company approves PPO
coverage for the scheduled procedure or ongoing treatment, In-Network Deductible,
Coinsurance and Copayment will apply to claims for services and supplies rendered by the
Non-Preferred Provider for such condition after the Company’s approval until the procedure
or treatment ends or until the end of ninety (90) days, whichever occurs first;
d. Continuity of Care, Pregnancy, Prior to Coverage. You notify the Company that prior to
the effective date of your coverage, you were receiving obstetrical care from a Non-Preferred
Provider for a pregnancy covered under the terms of this Benefit Certificate, that you were
in the third trimester of your pregnancy on the effective date of your coverage, and that you
request PPO benefits for continuation of such obstetrical care from this Non-Preferred
Provider. If the Company approves PPO coverage for the requested obstetrical care, In-
Network Deductible, Coinsurance and Copayment will apply to claims for services and
supplies received from this Non-Preferred Provider after the Company’s approval and will
continue to apply to claims for services and supplies rendered by the Non-Preferred Provider
until the completion of the pregnancy, including two (2) months of postnatal visits;
e. Provider Leaves PPO. You notify the Company that your Non-Preferred Provider was
formerly a Preferred Provider when your ongoing treatment for an acute condition began and
that you request PPO benefits for the continuation of such ongoing treatment. If the
Company approves PPO coverage for the ongoing treatment, In-Network Deductible,
Coinsurance and Copayment will apply to claims for services and supplies rendered by the
Non-Preferred Provider for such condition after the Company’s approval until the end of the
current episode of treatment or until the end of ninety (90) days, whichever occurs first;
f. Provider Leaves PPO, Pregnancy. You notify the Company that your Non-Preferred
Provider was formerly a Preferred Provider when you began receiving obstetrical care for a
pregnancy covered under the terms of the Plan, that you were in the third trimester of your
pregnancy on the date that the Provider left the PPO, and that you request PPO benefits for
continuation of such obstetrical care from this Non-Preferred Provider. If the Company
approves PPO coverage for the requested Obstetrical Care, In-Network Deductible,
Coinsurance and Copayment will apply to services and supplies received from this Non-
Preferred Provider after the Company’s approval and will continue to apply to claims for
services and supplies rendered by the Non-Preferred Provider until the completion of the
pregnancy, including two (2) months of postnatal visits.
g. Continuity of Care, Coverage Ends. You notif
y the Company that prior to the termination
date of the Group Plan, you were engaged with a Preferred Provider for a scheduled
procedure or ongoing treatment covered under the terms of this Plan, that such procedure
or treatment is for a condition requiring transitional care, that the provider or treatment is not
available under the new Group Plan, and that you request PPO benefits for such scheduled
procedure or ongoing treatment. If the Company approves PPO coverage for the scheduled
procedure or ongoing treatment, In-Network Deductible, Coinsurance and Copayment will
apply to claims for services and supplies rendered by the Preferred Provider for such
condition after the Company’s approval until the procedure or treatment ends or until the end
of ninety (90) days, whichever occurs first;
h. Company Approval. You noti
fy the Company prior to receiving a Health Intervention and
the Company has determined that the required Covered Services or supplies associated with
such Health Intervention are not available from a Preferred Provider and has provided you a
written approval of in-network coverage for such services or supplies, In-Network Deductible,
Coinsurance and Copayment will apply to the claims for the services that you receive from
the Non-Preferred Provider.
Notification to the Company of requests either for
payment of out-of-network services or
supplies at in-network benefit level or for transitional care due to a Group Policy termination,
should be made by writing Arkansas Blue Cross and Blue Shield, Attention: Medical Audit
and Review Services, Post Office Box 3688, Little Rock, Arkansas 72203, and should be
received at least 15 working days prior to your receipt of such services or supplies. See
52
Section 7.0 for procedures related to urgent care requests. For more information on how Prior
Approval works and its potential effect on coverage of benefits, see Subsection 7.1.3.b. and the
definition of Prior Approval in Subsection 9.95.
4. No Balance Billing from Preferred Providers and Contracting Providers. Preferred Providers
and Contracting Providers are Physicians or Hospitals who are paid directly by the Company and
have agreed to accept the Company's payment for Covered Services as payment in full except for
your Deductible, Coinsurance, Copayment and any specific benefit limitation, e.g., Home Health
visits are limited to (fifty) 50 per year (Subsection 3.19), if applicable. A Covered Person is
responsible for billed charges in excess of the Company’s payment when Physicians or
Hospitals who are neither a Preferred Provider nor a Contracting Provider render services
except in specific instances listed in 5.1.7.b. These excess charges could amount to
thousands of dollars in additional out of pocket expenses to the Covered Person.
5. Preferred Provider Directory. The determination of whether a Physician or Hospital is a Preferred
Provider, Non-Preferred Provider, Contracting Provider or Non-Contracting Provider is the
responsibility of the Company. The Company can provide a list of Preferred Providers and
Contracting Providers. You may also obtain a list of Preferred Providers and Contracting Providers
on the Company’s web site WWW.ARKANSASBLUECROSS.COM
. A Provider’s status may
change. You can verify the Provider’s status by calling Customer Service.
BlueCard PPO Program. Your
plan includes the BlueCard PPO benefit. This benefit allows you to
receive PPO in-network benefits from a Provider, as defined in Subsection 9.97, located outside of
Arkansas, provided such Provider is in the PPO network of the local Blue Cross or Blue Shield
Company. You may obtain a list of the PPO Providers in an out- of- Arkansas location or verify the
status of an out of state Provider by calling (800) 810-2583. If you are informed incorrectly by Us
prior to receiving a Covered Service, either by accessing our directory or in our response to
your request for such information (via telephone, electronic, web-based or internet-based
means), you may be eligible for cost sharing that would be no greater than if the Covered
Service had been provided by an In-Network Provider.
6. Provider Status may Change. It is possible that you might not be able to obtain services from a
particular Preferred Provider. The network of Providers is subject to change. You might find that a
particular PPO Provider may not be accepting new patients. If a Provider leaves the Network or is
otherwise not available to you, you must choose another PPO Provider to get In-Network benefits.
7. Out-of- Network Providers
a. NOTICE: Certain Services may not be In-Network Benefits. Additional costs, including
balance billing, may be incurred for a covered Health Intervention, e.g., anesthesia,
radiology, or laboratory tests, provided by a non-PPO Provider in a PPO Hospital unless it
meets the exception as provided in Subsection 5.1.7.b. These additional charges may not
count toward the In-network Annual Limitation on Cost Sharing. Do not assume that a PPO
Provider’s agreement includes all covered benefits or that all services provided at a
PPO Hospital are provided by PPO Provider Some PPO Providers contract with the
Company to provide only certain covered benefits, but not all covered benefits. Some
Providers choose to be a PPO Provider for only some of our products. Refer to the Provider
directory, ask your Provider or contact Customer Service for assistance. Your Provider
may not be In-Network for all services.
b. Balance billing by Out-of-Network Providers is prohibited in the following instances:
i. When Ancillary Services, as described in the No Surprises Act, are received at
certain In-Network facilities on a non-emergency basis from Out-of-Network
Providers.
ii. When non-Ancillary Services are received at certain In-Network facilities on a non-
emergency basis from Out-of-Network Providers who have not satisfied the notice
and consent criteria as described in the Act.
iii. When Emergency Care services are provided by an Out-of-Network Provider.
53
iv. When air Ambulance Services, as described in Subsection 3.17, are provided by an
Out-of-Network Provider.
In these instances, the Out-of-Network Provider may not bill you for amounts in excess of
your applicable Copayment, Coinsurance or Deductible (cost share). Except for air
ambulance, your cost share is based on the Recognized Amount as described in the No
Surprises Act and as set forth in the Glossary of Terms. Your cost share for air ambulance
is based on the rates that would apply if the service was provided by an In-Network Provider.
When Covered Services are received from Out-of-Network Providers as stated above,
Allowed Amounts are based upon one of the following as applicable:
• The initial payment made by Us or the amount subsequently agreed to by the Out-of-
Network Provider and Us.
• The amount determined by Independent Dispute Resolution (IDR).
8. Relation of the Company to Providers. T
he decision about whether to use a Preferred Provider
or a Contracting Provider is the sole responsibility of a Covered Person. Neither Preferred Providers
nor Contracting Providers are Policyholders or agents of the Company. The Company makes no
representations or guarantees regarding the qualification or experience of any Provider with respect
to any service. The evaluation of such factors and the decision about whether to use any Provider
is the sole responsibility of the Covered Person.
9. Scope of Provider Payment - G
lobal Payment. The Company's payment to a Provider for their
services as described in a Current Procedural Terminology ("CPT") or Healthcare Common
Procedure Coding System ("HCPCS") code and reimbursed in accordance with the Resource-Based
Relative Value System ("RBRVS") used by the Centers for Medicare & Medicaid Services ("CMS")
is an all-inclusive, global payment that covers all elements of the service as described in the particular
code billed. This means that whatever staffing, overhead costs, equipment, drugs, machinery, tools,
technology, supplies, or materials of any kind that may be required in order for the billing Provider to
perform the service or treatment described in the CPT or HCPCS code billed, the Company’s
payment to the billing Provider of the Allowance or Allowable Charge for that CPT or HCPCS code
constitutes the entire payment and the limit of benefits under this Benefit Certificate with respect to
the CPT or HCPCS code billed. A Provider who bills for a particular CPT or HCPCS code is deemed
to represent that the billing Provider has performed and is responsible for provision of all services or
treatments described in the CPT or HCPCS code and is entitled to bill for such services or treatments.
If the Company pays for a Covered Service by applying the Allowance or Allowable Charge to the bill
of a Provider who represents that the Provider has performed a service or treatment described in a
CPT or HCPCS code as submitted to the Company, the Company shall have no further obligation,
nor is there coverage under this Benefit Certificate, for bills from or payment to any other provider,
entity or person, regardless of whether they assisted the billing Provider or furnished any staffing,
equipment, drugs, machinery, tools, technology, supplies or materials of any kind to or for the benefit
of the billing Provider. In other words, benefits under this Benefit Certificate are limited to one, global
payment for all components of any services falling within the scope of any CPT or HCPCS code
service or treatment description, and the Company will make only one payment with respect to such
CPT or HCPCS code, even if multiple parties claim to have contributed a portion of the staffing,
equipment, machinery, tools, technology, supplies or materials used by the billing Provider in the
course of providing the service or treatment described in the CPT or HCPCS code.
For example, a physician who performs certain surgical procedures in the physician’s office might
choose to engage an equipment and supply company to set up the surgical table, furnish an assisting
nurse, and also furnish certain surgical instruments, devices or supplies used by the physician. When
the physician bills the Company for the physician’s performance of the surgical procedure described
in a specific CPT or HCPCS code, the Company will make a single, global payment to the physician
for Covered Services described in the CPT or HCPCS code and will not be obligated to pay for any
charges of the equipment and supply company. In such circumstances, any charge or claim of
payment due the equipment and supply company shall be the exclusive responsibility of the physician
(or other provider) who engaged the equipment and supply company and permitted or facilitated such
company’s access to the physician’s patient. In any event, as noted above, no benefits are available
54
under this Benefit Certificate for any services, drugs, materials or supplies of the equipment and
supply company. It is the Company’s policy (and this Benefit Certificate is specifically intended to
adopt the same) that no benefits shall be paid for "unbundled services" in excess of the Company’s
Allowance or Allowable Charge for any service as described in the applicable CPT or HCPCS code.
This means, for example, that if a physician and another category of provider (such as a durable
medical equipment supplier, a laboratory, a nurse practitioner, a nurse, a physician’s assistant or any
other category of provider) agree together to divide up, split or "unbundle" the components of any
CPT or HCPCS code, and attempt to bill separately for the various components each allegedly
provides for the patient, benefits under this Benefit Certificate shall nevertheless be limited to one
Allowance or Allowable Charge per CPT or HCPCS code; in such circumstances, your benefits under
this Benefit Certificate will pay only one Allowable Charge for any Covered Service described in any
single CPT or HCPCS code, and the various providers involved in any such "unbundling" action or
agreement must resolve among themselves any division of that single Allowance or Allowable
Charge between or among them. You can protect yourself from the possibility of billing in excess of
the Allowance or Allowable Charge in these circumstances by always inquiring in advance to be sure
that each provider involved in your care or treatment is a Preferred Provider.
Please note that the Company makes the following exceptions to the preceding general policy of one
global payment (Allowance) per CPT or HCPCS code: (i) where CMS has developed and published
an RBRVS policy that specifically recognizes that the Relative Value Units (RVUs) associated with a
specific CPT or HCPCS code should be divided into both a professional and a technical component;
or (ii) billing of the services of an assistant surgeon for those CPT or HCPCS codes that specifically
recognize assistant surgery services as applicable; or (iii) billing of radiopharmaceuticals used in
nuclear medicine procedures where such radiopharmaceuticals clearly are not included in the
practice expense portion of the associated RVU as published and defined by CMS; or (iv) billing of a
procedure or set of procedures that, per the applicable CPT or HCPCS code definition, is based
solely on time consumed so that it is necessary to submit multiple units of the procedure in order to
accurately report the total time devoted to the patient. In the specific four circumstances outlined in
the preceding sentence, the Company will recognize and pay more than one Allowance per CPT or
HCPCS code, provided all other terms and conditions of this Benefit Certificate are met. With respect
to the first such circumstance involving RVUs divided between a professional and a technical
component, the Company’s payment will be limited to one global payment (Allowance) for the
applicable professional component, and one global payment (Allowance) for the technical
component. In other words, even where CMS policy specifically recognizes division of an RVU into
professional and technical components, the Company will not be responsible for paying multiple
providers or multiple billings for the professional component, nor will the Company be responsible for
paying multiple providers or multiple billings for the technical component. Benefits under this Benefit
Certificate will be limited in such circumstances to one global payment (Allowance) for the
professional component and one global payment (Allowance) for the technical component.
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5.2. Covered Person’s Financial Obligations for Allowance or Allowable Charges under the Plan
1. Deductible. For those covered Health Interventions, which are specified in the Schedule of Benefits
as being subject to a Deductible, each calendar year, before the Plan makes a Coinsurance benefit
payment, a Covered Person
must pay the cost of a Covered Service equal to the Annual Deductible
Limitation specified in the Schedule of Benefits. If the Plan provides family coverage, once two family
members have met their individual Deductible, no further Deductible will be required for the balance
of the year, regardless of what member of the family incurs a claim. Deductible payments count
toward the Annual Limitation on Cost Sharing specified in the Schedule of Benefits.
Expenses incurred and applied toward the Deductible during the last three (3) months of a calendar
year may also be used to satisfy the Deductible for the succeeding calendar year.
2. Coinsurance. Once the Deductible is satisfied, a Covered Person
is responsible for Coinsurance,
which is a percentage of the Allowance or Allowable Charges paid, for claims incurred until the
payment equals the Annual Limitation on Cost Sharing specified in the Schedule of Benefits. After
the Annual Limitation on Cost Sharing is satisfied, subject to the provisions of Subsection 5.2.4 of
this Benefit Certificate, the Covered Person
will have no further responsibility with respect to
Allowances or Allowable Charges incurred during the balance of the calendar year.
3. Copayments. In order to receive certain Health Interventions from an In-Network Provider, a
Covered Person may have to pay a Copayment, which is expressed as either a dollar amount or a
percentage of the Allowance or Allowable Charge in the Schedule of Benefits. Copayments count
toward the Annual Limitation on Cost Sharing specified in the Schedule of Benefits.
4. Allowable Charges Not Applicable to Annual Limitation on Cost Sharing. No Allowance or
Allowable Charges paid for services or supplies from Non-Preferred Providers shall accumulate to or
be impacted by the satisfaction of the Annual Deductible Limitation or the Annual Limitation on Cost
Sharing, unless the Company determines that the Non-Preferred Provider should be treated as a
Preferred Provider in accordance with one of the provisions listed in Subsection 5.1.3.
5.3 Other Plans and Benefit Programs
1. Coordination of Benefits. Coordination of Benefits (COB) applies when a Covered Person has
coverage under more than one Health Benefit Plan. The Company may annually request that a
Covered Person verify the existence of other coverage.
a. Definitions. For purposes of this Subsection 5.3 only, the following words and phrases shall
have the following meanings:
i. "Allowable Expenses" means any necessary, reasonable and customary item of
expense at least a portion of which is covered under at least one of the Health Benefit
Plans covering the person for whom claim is made. When a Health Benefit Plan
provides benefits in the form of coverage for services, the reasonable cash value of
each service rendered shall be deemed to be both an Allowable Expense and a
benefit paid.
ii. "Health Benefit Plan" means any of the following which provide coverage for medical
care or treatment:
(1) Coverage under government programs, including Medicare, required or
provided by any statute unless coordination of benefits with any such
program is forbidden by law.
(2) Group coverage or any other arrangement of coverage for individuals in a
group whether on an insured or uninsured basis, including health
maintenance organization or other form of group coverage; medical care
components of group long-term care contracts; and medical benefits under
group or individual automobile contracts.
(3) An individually underwritten accident and health insurance policy which
reduces benefits because of the existence of other insurance.
56
(4) Coverage under any automobile insurance policy, including but not limited
to medical payment, personal injury protection or no-fault benefits.
The term "Health Benefit Plan" shall be construed separately with respect to:
(1) Each Policy, contract or other arrangement for benefits or services.
(2) That portion of any such Policy, contract or other arrangement which
reserves the right to take the benefits of other Health Benefit Plans into
consideration in determining its benefits and that portion which does not.
b. The Company shall have the right to coordinate benefits between this Plan and any other
Health Benefit Plan covering a Covered Person.
The rules establishing the order of benefit determination between this Benefit Certificate and
any other Health Benefit Plan covering the Covered Person on whose behalf a claim is made
are as follows:
i. The benefits of a Health Benefit Plan which does not have a "coordination of benefits
with other health plans" provision shall in all cases be determined and applied to
claims before the benefits of this Benefit Certificate.
ii. If according to the rules set forth in Subsection c. of this Section, the benefits of
another Health Benefit Plan that contains a provision coordinating its benefits with
this Plan would be determined and applied, before the benefits of this Plan have
been determined and applied, the benefits of such other Health Benefit Plan will be
considered before the determination of benefits under this Plan.
iii. Under no circumstances shall benefits payable and paid under this Plan together
with any other Health Benefit Plans exceed the total charge for services a Covered
Person received.
c. Order of Benefit Determination: The order of benefit determination as to a Covered
Person's claim shall be as follows:
i. Non-Dependent or Dependent. The benefits of a plan which covers the person on
whose expenses a claim is based other than as a dependent shall be determined
and applied before the benefits of a plan which covers such person as a dependent.
(By way of example only, if one Plan [Plan A] covers a person as a Policyholder or
an employee and the other plan covers the person as a dependent of a Policyholder
or of an employee [Plan B], then Plan A is deemed “primary” and Plan A’s benefits
will be applied and paid before any consideration of Plan B.)
ii. Child Covered Under More Than One Plan. W
hen the parents of a dependent
child are married, the benefits of a plan which covers the person on whose expenses
a claim is based as a dependent child of a person whose date of birth, excluding
year of birth, occurs earlier in a calendar year, shall be determined before the
benefits of a plan which covers such person as a dependent child of a person whose
date of birth, excluding year of birth, occurs later in a calendar year. If the other plan
does not have the provisions of this paragraph regarding coverage of dependent
children of married parents, or if both parents have the same birthday, the plan that
has covered either of the parents longer is primary.
The following rules apply to determine the order of benefit determination for a
dependent child of parents who are separated or divorced:
(1) When the parents are separated or divorced and there is a court decree
which fixes financial responsibility on one of the parents for the medical,
dental, or other health care expenses with respect to the child, the benefits
of a plan which covers the child as a dependent of the parent with such
financial responsibility shall be determined before the benefits of any other
plan which covers the child as a dependent child.
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(2) When the parents are separated or divorced and the parent with custody of
the child has not remarried, if there is no court decree fixing financial
responsibility on one of the parents for the medical, dental or other health
care expense with respect to the child, the benefits of a plan which covers
the child as a dependent of the parent with custody of the child will be
determined before the benefits of a plan which covers the child as a
dependent of the parent without custody.
(3) When the parents are divorced and the parent with custody of the child has
remarried, if there is no court decree fixing financial responsibility on one
parent for the medical, dental or other health care expense with respect to
the child, the benefits of a plan which covers the child as a dependent of the
parent with custody shall be determined before the benefits of a plan which
covers that child as a dependent of the step-parent, and the benefits of a
plan which covers that child as a dependent of the step-parent will be
determined before the benefits of a plan which covers that child as a
dependent of the parent without custody.
iii. Active or Inactive Employee. When paragraphs (i) or (ii) above do not apply so as
to establish an order of benefits determination, the plan that covers a person as an
employee who is neither laid off nor retired, is primary. The same would hold true if
a person is a dependent of a person covered as a retiree and an employee. If the
other plan does not have this rule, and if, as a result, the plans do not agree on the
order of benefits, this rule is ignored. Coverage provided to an individual as a retired
worker and as a dependent of an actively working spouse will be determined under
the rule set out in paragraph (i) above.
iv. Continuation coverage. When paragraphs (i), (ii) or (iii) above do not apply so as
to establish an order of benefits determination, if a person whose coverage is
provided under a right of continuation provided by federal or state law also is covered
under another plan, the plan covering the person as an employee, Covered Person,
subscriber policyholder or retiree (or as that person's dependent) is primary, and the
continuation coverage is secondary. If the other plan does not have this rule, and if,
as a result, the plans do not agree on the order of benefits, this rule is ignored.
v. Longer or Shorter Length of Coverage. When paragraphs (i), (ii), (iii) or (iv) above
do not appl
y so as to establish an order of benefits determination, the plan that
covered the person as an employee, policyholder, Covered Person, subscriber or
retiree longer is primary.
vi. If the preceding rules do not determine the primary plan, the allowable expenses
shall be shared equally between the plans meeting the definition of health benefit
plan, Subsection 5.3.1.a.(ii). In addition, this plan will not pay more than it would
have paid had it been primary.
2. Medicare, Military or Government Benefits. If a Covered Person is a Medicare beneficiary,
benefits will be determined in accordance with the Medicare Secondary Payer rules. Services and
benefits for treatment of military service-connected disabilities to which a Covered Person is legally
entitled from a military or government benefit plan shall in all cases be provided before the benefits
of this Benefit Certificate.
3. Workers' Compensation. There are no benefits under this Benefit Certificate for treatment of any
injury which will sustain a claim for damages from Workers' Compensation. This regardless of
whether or not the Covered Person filed a claim for workers’ compensation benefits.
The Company will presume that if the Covered Person makes a claim for worker's compensation
benefits, the injury for which the Covered Person makes any such claim is an injury which will sustain
a claim for damages under the Workers' Compensation Law. Therefore, the Company will not be
liable for payment of any benefits as to such a claim, unless the full Workers' Compensation
Commission finds that the Covered Person’s injury was not a compensable injury; and the finding is
58
not overturned on appeal. The foregoing presumption of non-coverage under this Benefit Certificate
also applies to any case in which the Covered Person’s workers' compensation benefits claim is
settled by joint petition or otherwise. In this case, no benefits will be paid under this Benefit Certificate
with respect to such a claim, regardless of the settlement amount.
Nor will the Company pay benefits for injury or illness for which the Covered Person receives any
benefits under the Workers' Compensation Law, state or federal workers' compensation, employer's
liability or occupational disease law, or motor vehicle no-fault law, regardless of any limitations in
scope or coverage amount which may apply to the Covered Person’s benefits claim under such laws.
In the event that the Company pays any claim by the Covered Person for benefits under this Benefit
Certificate, and subsequently learns that the Covered Person has filed a claim for workers'
compensation benefits as to such claim, or that the Covered Person has settled a workers'
compensation claim with any workers' compensation carrier, or has otherwise received any amount
toward payment of such a claim under the Workers' Compensation Law, state or federal workers'
compensation, employer's liability or occupational disease law, or motor vehicle no-fault law, the
Covered Person agrees to reimburse the Company to the full extent of its payments on such claim.
4. Acts of Third Parties (Subrogation/Reimbursement). If a Covered Person is injured by a third
party, the Company is subrogated to all rights the Covered Person may have against any party liable
for payment of medical treatment (including any and all insurance carriers) to the extent of payment
for the services or benefits provided as allowed by law. The Covered Person must cooperate fully
with the Company in its efforts to collect from the third party. See Subsection 5.3.5. The Covered
Person must cooperate fully with the Company in its efforts to collect from the third party. The
Company may assert its subrogation rights independently of the Covered Person. In addition to the
above-referenced subrogation rights, the Company also has reimbursement rights should the
Covered Person, or the legal representative, estate or heirs of the Covered Person recover damages
by settlement, verdict or otherwise, for an accident, injury or illness. If a recovery is made, the
Covered Person shall promptly reimburse the Plan any monetary recovery made by the Covered
Person and includes, but is not limited to, uninsured and underinsured motorist coverage, any no-
fault insurance, medical payments coverage, direct recoveries from liable parties, or any other
source.
5. Covered Person’s Cooperation. Each Covered Person shall complete and submit to the Company
such consents, releases, assignments and other documents as may be requested by the Company
in order to obtain or assure reimbursement from other health benefit plan(s), from Medicare, from
Workers' Compensation, or through subrogation. Any Covered Person who fails to so cooperate will
be liable for and agrees to pay to the Company the amount of funds the Company had to expend as
a result of such failure to cooperate, and the Company shall be entitled to withhold coverage of or
offset future claim payments for benefits, services, payments or credits due under this Benefit
Certificate in order to collect the Covered Person’s liability resulting from his or her failure to
cooperate.
6. The Company's Right to Overpayments. Whenever payments have been made by the Company
in a total amount, at any time, in excess of 100% of the amount of payment necessary at that time to
satisfy the intent of this Benefit Certificate, the Company shall have the right to recover such payment,
to the extent of such excess, from among one or more of the following as the Company shall
determine: any person or persons to, or for, or with respect to whom, such payments were made;
any insurance Company or companies; or any other organization or organizations to which such
payments were made.
6.0 ELIGIBILITY STANDARDS
Even if a Health Intervention you receive would be covered under the other coverage standards of this document,
you still must be eligible for benefits under your Plan and your coverage must be in effect at the time you receive such
Intervention in order to receive benefits. This Section sets out the standards for eligibility under the Plan, Subsection
6.1; the policies for determining a Covered Person’s effective date, Subsection 6.2; policies governing termination of
coverage, Subsection 6.3; the options a person who has lost eligibility may have under state and federal law to
59
continue coverage under the Plan, Subsection 6.4; and the rights a person who has lost eligibility may have to receive
a Conversion Plan from the Company, Subsection 6.5.
6.1 Eligibility for Coverage. The following provisions outline the eligibility requirements for Employees and
Dependents. In order to be covered by the Benefit Certificate, you must meet the eligibility requirements for
an Employee or the Employee’s Dependent.
1. Employee Coverage. To be eligible, an Employee must
a. Be a Qualified Employee of the Qualified Employer Policyholder, or
b. Be an employee of the Policyholder who
i. works on a full-time basis for the Policyholder;
ii. has completed the required Waiting Period, if applicable;
iii. is in a class of Employees who are included in the Plan; and
iv. work at least thirty (30) hours per week and forty-eight (48) weeks per year.
2. Dependent Coverage. Eligible Dependents are the Employee’s:
a. Spouse;
b. Child less than 26 years of age.
c. unmarried Child who is incapable of self-support because of intellectual and developmental
disability or physical disability, provided (1) such Child is or was under the limiting age of
dependency stated in Subsections b. above at the time of application for coverage in the
Plan or (2) if not under such limiting age, has had continuous health plan coverage, i.e., no
break in coverage greater than 63 days, at the time of application for coverage in the Plan.
NOTE: Domestic partners are not eligible for coverage as Dependents under this Benefit Certificate.
3. Additional Eligibility Requirements for Dependent Coverage. In order for an Employee's
Dependent to be eligible for coverage:
a. the Employee must be eligible for and have coverage; and
b. the Dependent must not be in active military service.
4. Proof of Intellectual and Developmental Disability or Physical Disability. In order for Dependent
coverage to be provided due to intellectual and developmental disability or physical disability, proof
of the Child's dependency and disability must be furnished to the Company, or to the Exchange if the
Policyholder is a Qualified Individual, prior to the Child’s attainment of the applicable limiting age
referenced in section 6.1.3.b., above. Such proof must at least demonstrate that the Child is unable
to obtain or continue a job or position in the course of commerce and that his or her parent(s) are
providing 50% or more of his financial support (e.g., declaring the Child as a dependent on their
federal income tax return or providing a child’s birth certificate.) Initial and subsequent evaluation for
continued intellectual and developmental disability or physical disability and dependency may be
required by the Company, at the Company’s expense, or the Exchange if the Policyholder is a
Qualified Individual, but not more frequently than once per year. A Policyholder who first becomes
eligible under the Plan may enroll a disabled Dependent Child provided the intellectual and
developmental disability or physical disability commenced before the limiting age.
5. Military Duty. If a Covered Person is called to active duty in the armed services of the United States
of America, the Covered Person’s (and any covered dependents) coverage may be continued on
COBRA for a period of 18 months or under the Uniformed Services Employment and Reemployment
Rights Act (USERRA) for a period of 24 months. However, the Covered Person must elect to
continue coverage under USERRA within sixty days of activation. A former Covered Person returning
from active military service may enroll in the Plan within 90 days of his or her return to employment,
provided the Employer continues to sponsor the Plan and payment of premium is timely made. The
effective date of coverage for the employee returning from active military service will be the first day
60
of reemployment. The Company may require a copy of the returning member’s orders terminating
the active duty or other proof of the active duty or termination date thereof.
6.2 Effective Date of Coverage. The following provisions outline the Company’s policies relative to effective
dates of coverage for you and/or your dependents.
1. Application and Effective Date. In order for an Employee’s coverage to take effect, the Policyholder
must submit Eligibility Data for Employees and Dependents. If the Policyholder is a Qualified
Employer that purchased this Benefit Certificate through the Small Business Health Options Program
(SHOP,) the Policyholder shall submit this data to the Exchange. If the Policyholder purchased this
Benefit Certificate directly from the Company, the Policyholder shall submit this Eligibility Data to the
Company by written enrollment forms or through the Electronic Data Exchange Enrollment
mechanism. The effective date(s) of coverage shall be determined in accordance with this
Subsection 6.2 and indicated by the Company on the ID card, Schedule of Benefits or letter issued
to Covered Persons by the Company.
2. Employees and Dependents on Contract Effective Date. Coverage under this Benefit Certificate
shall become effective on the Group Contract Effective Date, for all Employees, and Dependents for
whom Eligibility Data is submitted and premium is paid during the enrollment period prior to the Group
Contract effective date.
Coverage will be extended to an eligible Employee or Dependent who is an inpatient in a Hospital on
the effective date.
3. Initial Enrollment of New Employees.
a. If the Company receives a new Qualified Employee’s Eligibility Data from the SHOP, the
Employee’s coverage will become effective 12:01 a.m. on the first day of the following Policy
Month.
b. If the Company receives a new Employee’s Eligibility Data directly from the Employer within
thirty (30) days of the date the Employee is first eligible for coverage, the Employee’s
coverage will become effective 12:01 a.m. on the first day of the Policy Month following the
date the Employee is first eligible for coverage. However, if the date the Employee is first
eligible for coverage falls on the first day of the Policy Month, the Employee’s coverage will
become effective at 12:01 a.m. on that day.
4. Coverage in the Case of Late Enrollment. If an Employee or an Employee’s Dependent’s Eligibility
Data is not submitted when such Employee or Dependent is initially eligible for coverage, the
Employee or Dependent cannot subsequently obtain coverage, except during a Special Enrollment
Period or during an Open Enrollment Period.
5. Open Enrollment Period. Annually, during a period of at least 30 days designated by the Employer,
or by the SHOP in the case of Qualified Employers, Employees who are eligible for coverage may
enroll in the Plan. During the Open Enrollment Period, Employees covered in the Plan may change
their coverage, and that of their covered dependents. Unless otherwise designated in this Benefit
Certificate, enrollments and coverage changes made during the Open Enrollment Period become
effective on the anniversary date of the Group Policy.
6. Effective Date for Existing Dependents. If the Employee has eligible Dependents on the date the
Employee’s coverage begins, the Employee’s Dependents’ coverage will begin on the Employee’s
effective date if:
a. The Policyholder or the SHOP, if the Policyholder is a Qualified Employer, submits Eligibility
Data for the Employee’s Dependents’ coverage within 30 days of the Employee’s effective
date; and
b. The appropriate premium is timely paid.
7. Initial Effective Date for Newly Acquired Dependents. If an Employee acquires a new eligible
Dependent after the date the Employee’s coverage begins, coverage for a new Dependent will
become effective in accordance with the following provisions:
61
a. Spouse. When an Employee marries and wishes to have the Employee’s Spouse covered,
the Policyholder shall submit Eligibility Data within 30 days of the date of marriage. The
effective date will be the first of the month following the date of marriage. If the Policyholder
submits Eligibility Data after the 30-day period, coverage for the Spouse will become effective
in accordance with the provisions for Late Enrollment. See Subsection 6.2.4, above.
b. Newborn Children. Coverage for an Employee’s newborn Child shall become effective as
of the Child’s date of birth if the Policyholder gives the Company notice by submitting
Eligibility Data to the Company for the Child within 90 days of the Child's date of birth and
the appropriate premium to cover the newborn Child from the date of birth is paid. If the
Policyholder submits the Eligibility Data after the applicable 90-day time period, coverage for
the Employee’s newborn Child will become effective in accordance with the provisions for
Late Enrollment. See Subsection 6.2.4, above.
c. Qualified Medical Child Support Order. If a court has ordered an Employee to provide
coverage for a Child, coverage will be effective on the first day of the month following the
date the Company receives notification of the court order and the Child’s Eligibility Data from
the Policyholder or the SHOP if the Policyholder is a Qualified Employer. In the event a court
has ordered an Employee of the Employer who is not covered by the Plan to provide
coverage for a child, the Employee shall be enrolled with the child as a Dependent. The
Child’s enrollment will become effective on the first day of the month following the Company’s
receipt of the Child’s Eligibility Data.
d. Newly Adopted Children. Subject to payment of all applicable premiums, coverage for a
Child placed with an Employee for adoption or for whom the Employee has filed a petition
for adoption, shall begin on the date the Child is placed for adoption or the date of the filing
of the petition for adoption, provided Eligibility Data for the Child’s coverage is submitted to
the Company within 60 days after the placement or the filing of the petition. The coverage
shall begin from the moment of birth if the petition for adoption or placement for adoption
occurred and the Eligibility Data for coverage is submitted to the Company within 60 days of
the Child's birth. If the Policyholder submits the Eligibility Data after such 60-day period,
coverage for the adopted Child will become effective in accordance with the provisions for
Late Enrollment. See Subsection 6.2.4, above. The coverage shall terminate upon the
dismissal, denial, abandonment or withdrawal of the adoption, whichever occurs first.
e. Other Dependents. Eligibility Data for enrollment received by the Company within 30 days
of the date that any other dependent first qualifies as an eligible Dependent will result in
coverage for such dependent on the first day of the month following the date that Eligibility
Data for coverage is received by the Company. Such Dependent will not be a Late Enrollee.
If the Policyholder submits the Eligibility Data after the 30-day period, coverage for the
Dependent will become effective in accordance with the provisions for Late Enrollment. See
Subsection 6.2.4, above.
8. Employee’s Effective Date Controls. In no event will a Dependent’s coverage become effective
prior to the Employee’s Effective Date.
9. Special Enrollment Period is the 30-day period during which time an Employee or Dependent may
enroll in the Plan, after his or her initial Eligibility Date or Open Enrollment Period and not be a Late
Enrollee. Special Enrollment Periods occur in the following instances:
a. A Dependent of the Employees loses Minimum Essential Coverage under another health
plan for reasons other than failure to pay premiums or justified rescission.
b. The Employee gains a Dependent through marriage, birth, adoption or placement for
adoption. Note that the Special Enrollment Period for an adopted child is 60 days and for a
newborn child is 90 days.
c. A Dependent of the Policyholder that is a Qualified Employee who was not previously a
citizen, national or lawfully present becomes a Qualified Individual by gaining the applicable
status.
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10. Medicaid or State Child Health Insurance Program (“CHIP”) Special Enrollment Period is a 60-
day period during which time an Employee or Employee’s dependent may enroll in the Plan, after his
or her initial Eligibility Date and not be a Late Enrollee. Medicaid or CHIP Special Enrollment Periods
occur ONLY in two instances:
a. After the Termination of Medicaid or CHIP Coverage. A Medicaid or CHIP Special
Enrollment Period begins on the day an employee’s or dependent’s coverage under
Medicaid or CHIP terminates as a result of Loss of Eligibility.
b. After Eligibility for Employment Assistance under Medicaid or CHIP. A Medicaid or
CHIP Special Enrollment Period occurs for an employee or employee’s dependent who
becomes eligible for assistance, with respect to coverage under group health plans or health
insurance plans under Medicaid or CHIP (including under any waiver or demonstration
project conducted under or in relation Medicaid or CHIP).
6.3 Termination of Coverage. The following provisions outline the Company’s policies relative to termination
of coverage for the Policyholder, you and/or your dependents.
1. Termination of Coverage. Coverage is subject to all terms and conditions of the Plan, and coverage
will terminate under certain conditions described in various other places throughout this document.
If coverage is not terminated under any other provision of this document, coverage for a Covered
Person shall terminate if any of the following events occur:
a. Coverage shall terminate at 12:00 midnight Central time on the date of event when:
i. This Plan terminates.
ii. The Employer to which the Group Policy is issued, terminates or ceases to sponsor
the Plan.
b. Coverage shall terminate at 12:00 midnight Central Time on the last day of the Policy Month
in which the event occurs when:
i. The Covered Person ceases to be eligible as an Employee or Dependent for any
reason.
ii. The Covered Person is a Dependent Spouse who becomes legally separated or
divorced from the Employee.
c. Any Covered Person's coverage shall terminate at 12:00 midnight Central Standard Time on
the last day of the applicable premium period for which premium was paid if premium is not
paid on or before the next premium due date.
2. Termination of a Covered Person’s Coverage for Cause.
a. Bases for Termination. The Company may terminate coverage under this Benefit
Certificate, including termination by rescission of all coverage retroactive to the Covered
Person’s original effective date, upon thirty (30) days’ written notice for:
i. intentional misrepresentation of material fact or fraud in obtaining coverage or
ii. Intentional misrepresentation of material fact or fraud in the filing of a claim for
services, supplies or in the use of services or facilities
b. Concealment or Misrepresentation. For purposes of this termination for cause provision,
intentional misrepresentation of material facts occurs if (i) information is withheld or if
incorrect information is provided that is material to the risk assumed by the Company, or (ii)
the Company would not have issued this Benefit Certificate, would have charged a higher
premium, or would not have paid a claim in the manner it was paid had the Company known
the facts concealed or misrepresented.
c. Termination Effective Date. Rescission of coverage shall become effective on the Covered
Person’s original effective date. If the Company elects to terminate the coverage other than
by rescission, the termination shall be effective upon the later of (i) thirty (30) days after a
63
written notice of termination for cause is posted in the U.S. Mail, addressed to the Covered
Person at his or her last known address as provided by the Covered Person to the Company;
or (ii) the date stated in the termination notice letter to Covered Person.
d. Appeal Procedure. A Covered Person may appeal a termination for cause. Such an appeal
must be submitted in writing, addressed to the Appeals Coordinator of Arkansas Blue Cross
and Blue Shield, 601 S. Gaines Street, Little Rock, Arkansas 72203. In order for the appeal
to be considered the Appeals Coordinator must receive the appeal prior to the later of (i)
thirty (30) days after a written notice of termination for cause is posted in the U.S. Mail,
addressed to the Covered Person at his or her last known address as provided by Covered
Person to Company; or (ii) the termination effective date stated in the termination notice letter
to Covered Person.
3. Premium Refunds. If the Company terminates the coverage of a Covered Person, premium
payments received on account of the terminated Covered Person applicable to periods after the
effective date of termination shall be refunded to the Employer within 30 days, and the Company
shall have no further liability under this Group Policy.
If the Employer terminates coverage of a Covered Person, the Employer must request the Company
refund premiums paid for such Covered Person’s coverage within 60 days from the effective date of
termination of such coverage. Failure of the Employer to make a refund request within 60 days of
the effective date of termination of the Covered Person’s coverage shall result in the Employer
waiving refund of any premiums paid for such coverage. If claims have been paid past the
termination date, the payment amount of the claims will be deducted from premium refunds.
4. Termination of the Group Contract, Impact on Covered Persons. The coverage of all Covered
Persons shall terminate if the Group Contract is terminated.
6.4 Continuation Privileges
1. Continuation of Hospital Benefits When Group Contract is Replaced. If a Covered Person is
hospitalized on the date the Group terminates coverage with the Company and replaces the coverage
with another company, coverage for the Covered Person will continue until the date the Covered
Person is discharged or until benefits under the Plan are exhausted, whichever occurs first.
2. Continuation Rights under State Law
a. If a Covered Person’s employment terminates or dependency status changes the Covered
Person shall have the right under state law to elect continuation of coverage under the Plan
as outlined below. In order to be eligible for this option, Covered Person must:
i. have been continuously covered under this Benefit Certificate for at least three (3)
consecutive months prior to employment termination or change in dependency
status; and
ii. make the election by notifying the Company in writing no later than ten (10) days
after the employment termination or change in dependency status.
b. Continuation shall terminate on the earliest of:
i. one hundred twenty (120) days after the date the election is made;
ii. the date the Covered Person fails to make any premium payments or the
Policyholder fails to pay the premium to the Company;
iii. the date the Covered Person is or could be covered by Medicare;
iv. the date on which the Covered Person is covered for similar benefits under another
group or individual Policy;
v. the date on which the Covered Person becomes eligible for similar benefits under
another group Plan;
vi. the date on which similar benefits are provided for or available to the Covered Person
64
under any state or federal law; or
vii. the date on which the Group Policy terminates.
c. If a Covered Person qualifies for continuation of coverage, the Covered Person may elect a
conversion policy instead of continuation of group insurance. See Section 6.5 Conversion
Privileges. If a Covered Person has elected continuation under this Subsection 6.4.2, the
Covered Person shall have the option of conversion coverage at the end of the maximum
continuation period.
3. Continuation Rights under Federal Law. If Section 10001 of the Consolidated Omnibus Budget
Reconciliation Act of 1985 (COBRA) applies to the Group, the coverage of an Employee or
Dependent whose coverage ends due to a Qualifying Event may be continued while the Group
Contract remains in force subject to the terms of this Section and all terms and provisions of this
Benefit Certificate not inconsistent with this Section.
This provision shall not be interpreted to grant to any Covered Person any continuation rights under
this Benefit Certificate in excess of those required by COBRA. If the Group fails to comply with the
provisions of the Group Policy and this Benefit Certificate concerning COBRA or the notice
requirements or other standards under COBRA, the Company shall not assume the Group’s
obligation to provide COBRA continued coverage under the Plan.
a. Qualifying Events. The following is a list of events which could result in termination of a
Covered Person’s coverage under this Benefit Certificate. If such should occur, for purposes
of this Section, the event shall be called a Qualifying Event.
i. An Employee’s death.
ii. Termination of an Employee’s employment (other than by reason of the Employee's
gross misconduct), or of an Employee’s eligibility due to reduction in the Employee’s
hours of employment.
iii. An Employee’s and Spouse’s divorce or legal separation.
iv. An Employee becoming entitled to Medicare.
v. A Dependent Child ceasing to be a Dependent Child as defined in this Benefit
Certificate.
b. Requirements for COBRA Continuation. Continuation under this Subsection is subject to
a Covered Person requesting it and paying any required premium contributions to the Group
within the applicable COBRA election period. In addition, all of the following conditions must
be satisfied in order for COBRA continuation coverage to apply:
i. The Group must sponsor and maintain the Plan at the time of the qualifying event,
as well as when the Covered Person elects to continue coverage; and
ii. The Group, as Plan Administrator, must have provided the Covered Person an initial
notice of COBRA rights at the time coverage commenced under the Plan (this
Benefit Certificate); and
iii. The Plan Administrator must notify the person qualified to elect continuation of
coverage under COBRA (“Qualified Insured”) of the right to elect coverage within 14
days of receiving notice of the happening of any of the qualifying events listed above;
and
iv. The Covered Person must notify the Plan Administrator within 60 days of the
happening of Qualifying Event (iii) or (v) in Section 6.4.3.a, above; and
v. The Covered Person must elect to continue coverage under the Plan within 60 days
of the later of:
(1) the date the notification of election rights is sent, or
(2) the date coverage under the Plan terminates.
65
If an election is not made by the Covered Person within this 60-day period, the option to elect
COBRA shall end.
If an Employee with Dependent coverage requests continuation of coverage under this
Section, such request shall include the Dependent coverage, unless the Employee asks that
it be dropped. In like manner, such a request on the part of the covered Spouse of a Covered
Person shall include coverage for all Dependents of the Employee who were covered.
c. Coverage Continued. The coverage continued for a Covered Person in accordance with
this Section shall be the same as otherwise provided under this Benefit Certificate for other
Covered Persons in the same benefit class in which such Covered Person would have been
covered had his or her coverage not terminated.
d. Effective date. The effective date for COBRA continuation is the date coverage under the
Plan terminates due to a qualifying event.
e. Termination. Once in effect, COBRA continuation coverage for a Covered Person under
this Section shall terminate on the earliest to occur of the following applicable dates:
i. The date the Group Contract terminates;
ii. At the end of the last period for which premium contributions for such coverage have
been made, if the Covered Person or other responsible person does not make, when
due, the required premium contribution to the Group;
iii. The date ending the maximum period. In the Case of Qualifying Event 6.4.3.a.(ii)
above (relating to termination of employment or reduction in hours), the date ending
the maximum period shall be the date 18 months after the date of that Qualifying
Event; unless the Social Security Administration determines that the Covered
Person is disabled at the time of or within 60 days after the Qualifying Event, and
the Covered Person provides the notice of Social Security disability determination to
the Plan Administrator within 60 days of the date of the Social Security determination
and before the end of the initial 18-month period of continuation, in which case this
date shall be 29 months after the Qualifying Event. In all other cases, such date
shall be the date 36 months after the date of the applicable Qualifying Event;
iv. The date the Covered Person becomes covered under any other group health plan
that provides coverage for Preexisting Conditions;
v. The date the Covered Person becomes entitled to Medicare;
vi. The date the Covered Person’s coverage is terminated for cause. See Section 6.3.2
above.
6.5 Conversion Privileges
1. Eligibility. If a Covered Person’s coverage under the Plan terminates for any reason other than
a. failure to pay any sum required by the Group toward the cost of coverage under this Benefit
Certificate, if any, or
b. cause (see Section 6.3.2) or,
c. the Group Contract being replaced by a health benefit plan provided by an organization other
than the Company, then the Covered Person may apply for an insurance policy issued by
the Company on the individual market if
i. the Covered Person is not eligible for Medicare coverage; or
ii. the Covered Person is not eligible for coverage under any other group health plan
that provides coverage for Preexisting Conditions.
2. Benefits. The insurance policy will be provided by the Company at the rates in effect on the date
the Covered Person submits his or her application. The benefits in the individual policy will not
66
necessarily equal or match those benefits provided in the Group Contract. No evidence of good
health or insurability will be required to affect the conversion.
3. Written Application Deadline. In order to obtain an individual policy, written application and
payment of applicable premium charges must be submitted to the Company within 60 days following
the date on which the Company sends the Covered Person a notice of termination of coverage.
7.0 CLAIM PROCESSING AND APPEALS
In reviewing a claim for benefits, the Company will apply the terms, conditions, exclusions and limitations of the Plan
set out in this Benefit Certificate, including but not limited to the Primary Coverage Criteria, Section 2.0; the specific
limitations of the Plan, Section 3.0; the specific plan exclusions, Section 4.0; the cost sharing and Provider network
procedures of the Plan, Section 5.0; and the eligibility standards of the Plan, Section 6.0.
This Section 7 sets out the procedures you must follow in submitting a request for coverage, called a "claim for
benefits" or a “claim," with your Plan, Subsection 7.1. The section also describes your rights to appeal if a claim for
benefits is denied either in whole or in part, Subsections 7.2 and 7.3. Finally, this section sets out how you may have
an Authorized Representative to represent you in submitting claims or appeals, Subsection 7.4.
7.1 Claim Processing.
1. Claim for Benefits. "Claim for benefits" means (1) a request for payment for a service, supply,
prescription drug, equipment or treatment covered by the Plan or (2) a request for Prior Approval for
a service, supply, prescription drug, test, equipment or treatment covered by the Plan where the Plan
conditions receipt of payment for such service, supply, prescription drug, equipment or treatment on
approval in advance by the Company.
2. Who May Submit a Claim. A Covered Person, a Provider with an assignment of the claim that is
approved by the Company or the Covered Person’s Authorized Representative may submit a claim.
See Subsection 7.4 below concerning the Authorized Representative.
3. Classifications of Claims. There are two general types of claims for benefits possible under the
Plan. The type of claim involved affects the procedures for filing the claim and the timing of the
benefit determination by the Company.
a. Post-Service Claims. The most common claim involves post-service benefit determination.
Such a claim results when a Covered Person obtains a medical service, prescription drug,
supply, test, equipment or other treatment and then, in accordance with the terms of the Plan,
the Covered Person or the Covered Person's Authorized Representative submits a claim for
benefits to the Company. Examples of post-service claims are claims involving physician
office visits, maternity care, outpatient services, and most prescription drugs obtained
through a managed pharmacy benefit.
You must submit written proof of any service, supply, prescription drug, test, equipment or
other treatment within 180 days after such service, supply, prescription drug, test, equipment
or treatment was received. In the case of a claim for inpatient services for multiple
consecutive days, the written proof must be submitted no later than 180 days following your
date of discharge for that single admission.
Post-Service Claims may be submitted electronically in accordance with the Company's
electronic claim filing procedures, or such claims may be mailed to Arkansas Blue Cross and
Blue Shield Claims Division, Post Office Box 2181, Little Rock, Arkansas 72203.
If the Company is able to process your post-service claim without requesting additional
information, it will notify you of its claim determination within 30 days of the Company’s
receipt of the claim. The Company will forward any payment resulting from the claim
determination within 30 days of the Company’s receipt of the claim.
If the Company requires information reasonably necessary to determine whether or to what
extent benefits are covered under the Plan, as specified in Subsection 7.1.4. below, the
Company will suspend the claim and request the needed information. If you or your treating
67
Provider supplies the Company the required information within ninety (90) days of the claim
suspension, the Company will notify you of its claim determination and will forward any
payment resulting from the claim determination within 15 days of the Company’s receipt of
the required information. If the Company does not receive the required information within
the 90-day period, 15 days later, the suspended claim becomes a denied claim, subject to
appeal. See Subsection 7.2 Claim Appeals to the Plan.
b. Pre-Service Claims. The terms of the Plan condition receipt of certain benefits on Prior
Approval by the Company, whereby the Company gives approval in advance of the Covered
Person obtaining a requested medical service, drug, supply, test, or equipment that such
medical service, drug, supply, test, or equipment meets Primary Coverage Criteria. Plan
benefits requiring pre-service claims are claims for services certain Prescription Medications,
and Non-PPO Benefits (Subsection 5.1.3). Please note Prior Approval does not
guarantee payment or assure coverage, it means only that the information furnished
to the Company in the pre-service claim indicates that the Health Intervention meets
the Primary Coverage Criteria requirements set out in Subsection 2.2 and the
Applications of the Primary Coverage Criteria set out in Subsections 2.4.1.b., e., or f.
and is not subject to a Specific Plan Exclusion (see Section 4.0) All Health
Interventions must still meet all other coverage terms, conditions, and limitations, and
coverage for these services may still be limited or denied if, when the post-service
claim for the services is received by Us, investigation shows that a benefit exclusion
or limitation applies because of a difference in the Health Intervention, that the
Covered Person ceased to be eligible for benefits on the date services were provided,
that coverage lapsed for non-payment of premium, that out-of-network limitations
apply, or any other basis specified in this Benefit Certificate.
Pre-service claims for medical Health Interventions may be submitted to the Arkansas Blue
Cross and Blue Shield by (1) calling the Customer Service telephone number found on the
reverse side of your Arkansas Blue Cross ID Card, (2) sending an email to
PRESERVICEBENEFITINQUIRY@ARKBLUECROSS.COM
, (3) submitting the pre-service
claim to Arkansas Blue Cross Medical Audit and Review Services, FAX (501) 378-6647, or
(4) mailing the claim to Post Office Box 3688, Little Rock, Arkansas 72203. Pre-service
claims for Prescription Medications should be submitted to Arkansas Blue Cross and Blue
Shield Managed Pharmacy, FAX (501) 378-6980, or mailed to Post Office Box 2181, Little
Rock, Arkansas 72203.
If the Company is able to process your pre-service claim without requesting additional
information, it will notify you of its determination in a time appropriate for the medical
exigencies, but in no case later than 2 business days from the date it received the pre-service
claim.
If the Company requires information reasonably necessary to determine whether the
requested medical service, drug, supply, test or equipment meets the Primary Coverage
Criteria under the Plan, the Company will suspend the claim and request the needed
information. If you or your treating Provider supplies the Company the required information
within ninety (90) days of the claim suspension, the Company will notify you of its claim
determination within 2 business days after the Company receives such information. If the
Company does not receive the required information within the 90-day period, 15 days later,
the suspended claim will become a denied claim, subject to appeal. See Subsection 7.2.
Claim Appeals to the Plan.
After you have received the Health Intervention that was the subject of an approved pre-
service claim, you must submit a post-service claim in accordance with Subsection 7.1.3.a.,
above.
c. Provider Initiated Pre-Service Claims. A Provider treating a Covered Person may initiate
a pre-service claim to obtain an initial determinationfor a medical service, drug, supply, test,
or equipment covered by the Plan when the Plan does not condition receipt of such medical
service drug, supply, test, or equipment on Prior Approval. Pre-service claims should be
68
submitted to the Arkansas Blue Cross and Blue Shield Medical Audit and Review Services,
FAX (501) 378-6647 or mailed to Post Office Box 3688, Little Rock, Arkansas 72203. Pre-
service claims for Prescription Medications should be submitted to Arkansas Blue Cross and
Blue Shield Managed Pharmacy, FAX (501) 378-6980, or mailed to Post Office Box 2181,
Little Rock, Arkansas 72203.
If the Company is able to process the Provider initiated pre-service claim without requesting
additional information, the Company will notify the treating Provider of its determination within
10 days from the date it received the pre-service claim.
If the Company requires information reasonably necessary to determine whether the
requested medical service, drug, supply, test, or equipment meets the Primary Coverage
Criteria under the Plan, the Company will suspend the claim and request the needed
information. If the treating Provider supplies the Company the required information within
ninety (90) days of the claim suspension, the Company will notify the treating Provider of its
claim determination within 10 days after the Company receives such information. If the
Company does not receive the required information within the 90-day period, 15 days later,
the suspended claim will become a denied claim, subject to appeal. See Subsection 7.2.
Claim Appeals to the Plan.
After the Provider has performed the Health Intervention the Health Intervention that was the
subject of an approved Provider initiated pre-service claim, the treating Provider must submit
a post-service claim in accordance with Subsection 7.1.3.a., above.
d. Claims Involving Urgent Care. A claim involving urgent care must be a pre-service claim
(See Subsection 7.1.3.b. above) for which a health care professional with knowledge of the
claimant's condition certifies that the processing of the claim in the time period for making a
non-urgent pre-service claim determination (1) could seriously jeopardize the life or health of
the claimant or the ability of the claimant to maintain or regain maximum function, or (2)
would subject the claimant to severe pain that cannot be adequately managed without the
care or treatment that is the subject of the claim.
A claim involving urgent care must be submitted in writing, via mail, facsimile or e-mail, in a
format authorized by the Company’s claim filing procedures. A claim involving urgent care
must include the medical records pertinent to the urgent condition.
If the Company is able to process your claim involving urgent care without requesting
additional information, it will notify you of its determination in a time appropriate for the
medical exigencies, but in no case later than 1 business day from the date it received the
pre-service claim.
If the Company requires information reasonably necessary to determine whether the
requested medical service, drug, supply, test or equipment meets the Primary Coverage
Criteria under the Plan, the Company will notify your physician within 24 hours of receiving
the claim and request the needed information. If you or your treating Provider supplies the
Company the required information within 48 hours, the Company will notify you of its claim
determination within 1 business day after the Company receives such information. If the
Company does not receive the required information within the 48-hour period, the claim will
be denied, subject to appeal. See Subsection 7.3 Claim Appeals to the Plan.
If the urgent care claim is a request to extend previously approved benefit for ongoing
treatment, the Company shall make a determination within 24 hours after receipt of the claim,
provided the claim is received at least 24 hours prior to the expiration of the previously
approved benefit.
Please note that approval of a claim involving urgent care does not guarantee payment
or assure coverage; it means only that the information furnished to the Company at
the time indicates that the Health Intervention that is the subject of the claim involving
urgent care meets the Primary Coverage Criteria and is not subject to a Specified Plan
Exclusion (see Section 4.0) A Health Intervention receiving prior approval as a claim
involving urgent care, must still meet all other coverage terms, conditions, and
69
limitations. Coverage for any such claim may still be limited or denied if, when the
claimed Intervention is completed and the Company receives the post-service
claim(s), investigation shows that a benefit exclusion or limitation applies because of
a difference in the Health Intervention described in the prior approved claim and the
actual Health Intervention, that the Covered Person ceased to be eligible for benefits
on the date services were provided, that coverage lapsed for non-payment of
premium, that out-of-network limitations apply, or any other basis specified in this
Benefit Certificate applies to limit or exclude the claim.
After you have received the Health Intervention that was the subject of a claim involving
urgent care, you must submit a post-service claim in accordance with Subsection 7.1.3.a.,
above.
e. Claims involving Ongoing Care or Concurrent Review. The Company's termination or
reduction of a previously granted benefit under the Plan (other than by Plan amendment or
termination) results in a claim involving ongoing care or concurrent review. The Company
shall give an explanation of the reduction or termination of a benefit to the Covered Person,
as specified in Subsection 7.1.6, with sufficient time prior to the termination or reduction to
allow for an appeal under Subsection 7.2.8.d., to be completed before the termination or
reduction takes place but no later than 24 hours after receipt of the claim.
4. Information Reasonably Necessary to Process a Claim.
a. In order to be a claim, the submission must comply with the filing and coding policies and
procedures established by the Company. You may request a copy of the claim coding
policies and procedures from the Company or from your Provider. If the submission fails to
comply with the claim filing or code policies or procedures, the Company shall return the
submission to the person that submitted it. If the claim involved is a pre-service claim, the
submission shall be returned as soon as possible, but no later than 5 days (24 hours for a
claim involving urgent care), and the Company shall indicate on the returned submission the
proper procedures to be followed.
b. In addition to the claim completed in accordance with the Company's claim filing procedures,
depending upon the service, supply, prescription drug, equipment or treatment that is the
subject of the claim, the Company may require one or more of the following items of
information to enable the Company to determine whether or to what extent the claimed
benefit is covered by the Plan:
i. Information in order to determine if a limitation or exclusion of the Plan is applicable
to the claim, or
ii. Medical information in order to determine the price for a medical procedure, or
iii. Information in order to determine if the Covered Person who received the claimed
services is eligible under the terms of the Plan, or
iv. Information in order to determine if the claim is covered by another health benefit
plan, workers' compensation, a government supported program, or a liable third
party, or
v. Information in order to determine the obligation of each health benefit plan or
government program under coordination of benefits rules,
vi. Information in order to determine if there has been fraud or a fraudulent or material
misrepresentation with respect to the claim;
vii. payment from the Policyholder of premiums that were delinquent at the time the
claimed services were rendered.
5. Covered Person’s Responsibility with Respect to Claim Information. Before any benefits can
be paid, you agree, as a condition of coverage under the Plan, to authorize and direct any Provider
of medical services or supplies to furnish to the Company, its agents, or any of its affiliates, upon
request, all records, or copies thereof, relating to such services or supplies. Further, as a condition
70
of your coverage, you agree to authorize the release of such records to any third-party review person
or entity, for purposes of medical review or second opinion surgery. Finally, as a condition of
coverage, you agree to fully and truthfully respond to inquiries from the Company about your claim
or condition, including, but not limited to, your other insurance coverage, third party liability, or
workers' compensation benefits and to request that any Physician or other Provider respond to all
such inquiries. You understand and agree that your failure to respond to inquiries from the Company
or failure to cooperate fully to obtain information requested by the Company from your Physician or
other health care Provider shall be, by itself, grounds for denial of benefits under the Plan.
6. Explanation of Benefit Determination. Upon making a determination of a claim, the Company will
deliver to you the following information:
a. The specific reason or reasons for the determination with information sufficient to identify the
claim involved (including the date of service, the health care provider, the claim amount and
a way that the Covered Person may learn the diagnosis and treatment codes and their
descriptions);
b. Reference to the specific plan provision(s) on which the determination is based;
c. A description of any additional information necessary for the claim to be perfected and an
explanation of why such information is necessary;
d. A description of the Plan’s appeal process, see Subsection 7.2 below. If the claim involves
urgent care, a description of the expedited appeals process, see Subsection 7.2.7.c., below;
e. If the determination was based in whole or in part on a Company Coverage Policy an
explanation of how to obtain a copy of the Coverage Policy at no cost. See Subsection
2.4.1.f., above.
7. Informal Claim Review. If you have questions about an Explanation of Benefit Determination, you
may contact Customer Service (Telephone toll free (800) 238-8379, or write Arkansas Blue Cross
and Blue Shield, Customer Service, Post Office Box 2181, Little Rock, Arkansas 72203) and ask that
the determination be reviewed. Customer Service will respond in like manner with answers to your
request. This informal review is not an Appeal (see Subsection 7.2 below) nor a substitute for an
appeal. Nor must you ask for an informal review in order to request an appeal.
8. Informal Coverage Information. From time to time, you or your Provider may want an indication
whether a service, supply, prescription drug, equipment or treatment is an eligible benefit of the Plan.
You may make an Informal Coverage Information to Arkansas Blue Cross and Blue Shield Customer
Service Division, Post Office Box 2181 Little Rock, Arkansas 72203, or by Telephone toll free (800)
800-4298.
a. An Informal Coverage Information is not a claim. You should understand that an Informal
Coverage Information is different from a pre-service claim. In the case of an Informal
Coverage Information the Plan does not specify that receipt of the benefit in question is
conditioned upon Prior Approval of the Company (see Subsection 7.1.3.b., Pre-Service
Claims, above).
b. The Company’s response to an Informal Coverage Information is not a guarantee of
payment. The Company’s ultimate determination of a claim will be based upon the
relevant facts as applied to the terms, conditions, limitations and exclusions of the
Plan. An Informal Coverage Information is not a claim. The Company’s response to an
Informal Coverage Information is not a claim determination. The Company’s response is
based upon the information available to the Company at the time of the inquiry and such
information may not be current or accurate. The Company reserves the right to make a final
determination of the post-service claim resulting from a Health Intervention that may have
been the subject of an Informal Coverage Information after the intervention has been
completed and all relevant facts are known.
c. An Informal Coverage Information is not subject to appeal.
71
d. A Provider wanting to know whether a service, supply, prescription drug, equipment or
treatment meets the Primary Coverage Criteria and all other requirements for payment under
the Plan should submit a Provider Initiated Pre-Service Claim. (See Subsection 7.1.3.c.)
9. Covered Person’s Responsibility with Respect to Erroneous Claim Payments. Despite our best
efforts, we may make a claim payment which is not for a benefit provided under the Plan, or we may
make payment to you when payment should have gone directly to the Provider of treatment or
services instead. In the event of an erroneous or mistaken payment, you agree to refund the full
amount of such payment to Us promptly upon our request. If the Company does not receive the full
amount of the refund due, the Company will have the right to offset future payments made to you or
your Provider under this Benefit Certificate or under any other Policy you have with the Company
now or in the future.
10. Out-of-Area Services
We have a variety of relationships with other Blue Cross and/or Blue
Shield
Licensees. Generally, these relationships are called “Inter-Plan Arrangements.” These
Inter-Plan
Arrangements work based on rules and procedures issued by the Blue Cross Blue
Shield Association
(“Association”). Whenever you access healthcare services outside the
geographic area we serve, the
claim for those services may be processed
through one of these Inter-Plan Arrangements. The Inter-
Plan Arrangements are described
below. When you receive care outside of our service area, you will
receive it from one
of two kinds of providers. Most providers (“participating providers”) contract with
the local Blue
Cross and/or Blue Shield Plan in that geographic area (“Host Blue”). Some providers
(“nonparticipating providers”) don’t contract with the Host Blue. We explain
below how we pay both
kinds of providers.
a. BlueCard
®
Program
i. Under the BlueCard
®
Program, when you receive Covered
Services within the
geographic area served by a Host Blue, we will remain
responsible for doing what
we agreed to in the contract. However, the Host Blue is responsible
for contracting
with and generally handling all interactions with its participating providers. When you
receive Covered Services outside our
service area and the claim is processed
through the BlueCard Program, the amount you pay for
Covered Services is
calculated based on the lower of:
The billed charges for Covered Services;
or
The negotiated price that the Host Blue makes available to Us.
ii. Often, this “negotiated price” will be a simple discount that reflects an actual price that
the Host
Blue pays to your healthcare provider. Sometimes, it is an estimated price
that takes into account
special arrangements with your healthcare provider or
provider group that may include types of
settlements, incentive payments and/or
other credits or charges. Occasionally, it may be an
average price, based on a
discount that results in expected average savings for similar types of
healthcare
providers after taking into account the same types of transactions as with an estimated
price.
iii. Estimated pricing and average pricing also take into account adjustments to correct
for over- or
underestimation of past pricing of claims, as noted above. However, such
adjustments will not
affect the price we have used for your claim because they will
not be
applied after a claim has already been paid.
b. Special Cases: Value-Based Programs
i. BlueCard
®
Program. If you receive Covered Services under a Value-Based
Program
inside a Host Blue’s service area, you will not be responsible for paying any
of the Provider
Incentives, risk-sharing, and/or Care Coordinator Fees that are a part
of such an arrangement,
except when a Host Blue passes these fees to Us through
average pricing or fee
schedule adjustments.
72
ii. Value-Based Programs: Negotiated (non–BlueCard Program) Arrangements. If we
have entered into a Negotiated Arrangement with a Host Blue to
provide Value-
Based Programs on your behalf, we
will follow the same procedures for Value-Based
Programs administration and Care Coordinator
Fees as noted above for the
BlueCard Program.
c. Blue Cross Blue Shield Global Core. If you are outside the United States (hereinafter
“BlueCard service area”), you may be able to take advantage of Blue Cross
Blue Shield
Global Core when accessing Covered Services. Blue
Cross Blue Shield Global Core is unlike
the BlueCard Program available in the BlueCard service
area in certain ways. For instance,
although Blue Cross Blue Shield Global Core assists you with
accessing a network of
inpatient, outpatient and professional providers, the network is not served
by a Host Blue. As
such, when you receive care from providers outside the BlueCard service
area, you will
typically have to pay the provider. If you need medical assistance services (including locating
a doctor or hospital) outside the
BlueCard service area, you should call the service center at
1-(800)-810-BLUE (2583) or call collect
at 1-(804)-673-1177, 24 hours a day, seven days a
week. An assistance coordinator, working with a medical professional, can arrange a
physician appointment or hospitalization, if necessary.
i. Inpatient Services. In most cases, if you contact the service center for assistance,
hospitals will not require you
to pay for covered inpatient services, except for your
cost-share amounts/deductibles,
coinsurance, etc. In such cases, the hospital will
submit your claims to the service center to
begin claims processing. However, if you
paid in full at the time of service, you must submit a
claim to receive reimbursement
for Covered Services. You
must contact Us to obtain precertification for non-
emergency
inpatient services.
ii. Outpatient Services. Physicians, urgent care centers and other outpatient providers
located outside the BlueCard
service area will typically require you to pay in full at
the time of service. You must submit a
claim to obtain reimbursement for Covered
Services.
iii. Submitting a Blue Cross Blue Shield Global Core Claim. When you pay for
Covered Services outside the BlueCard
service area, you must submit a claim to
obtain reimbursement. For institutional and
professional claims, you should
complete a Blue Cross Blue Shield Global Core claim form
and send the claim form
with the provider’s itemized bill(s) to the service center (the address
is on the form)
to initiate claims processing. Following the instructions on the claim form will
help
ensure timely processing of your claim. The claim form is available from Us, the
service center or online at
www.bcbsglobalcore.com. If you need assistance with
your claim submission, you should call the service center at 1-(800)-810-BLUE (2583)
or
call collect at 1-(804)-673-1177, 24 hours a day, seven days a week.
11. Insurance Department. Arkansas Blue Cross and Blue Shield is an insurance company regulated
by the Arkansas Insurance Department. You have the right to file a complaint with the Arkansas
Insurance Department (AID). You may call AID to request a complaint form at (800) 852-5494 or
(501) 371-2640 or write the Department at: 1 Commerce Way, Suite 102, Little Rock, Arkansas
72202. You may also file an online complaint by visiting the Arkansas Insurance Department website
at www.insurance.arkansas.gov.
7.2 Claim Appeals to the Plan (Internal Review).
1. Legal Actions. Prior to initiating legal action, you must file an appeal of your claim in accordance
with this Subsection 7.2. No legal action shall be brought after the expiration of three (3) years from
the time that a claim is required to be submitted.
2. Who May Request a Review. A Covered Person or the Covered Person’s Authorized
Representative may file an appeal to request a review of a claim denial. See Subsection 7.4
concerning the Authorized Representative.
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3. Where and When (Deadline) to Submit an Appeal. If a claim for benefits is denied either in whole
or in part, you will receive a notice explaining the reason or reasons for the denial. See Subsection
7.1.6, above. You may request a review of a denial of benefits for any claim or portion of a claim by
sending a request marked “Appeal Request” to the Appeals Coordinator of Arkansas Blue Cross and
Blue Shield, 601 S. Gaines Street, Little Rock, Arkansas 72203. Your request must be made within
one hundred eighty (180) days after you have been notified of the denial of benefits.
4. Appeals Subject to Direct External Review. The Company may waive internal review of any claim
determination. If the Company waives internal review, the Company shall defer the claim for external
review in accordance with Section 7.3 below.
5. Documentation.
a. Written Appeals. You must submit your appeal in writing. However, an appeal related to a
claim involving urgent care may initially be submitted orally.
Although the Appeals
Coordinator will immediately commence consideration of an oral appeal, the Appeals
Coordinator requires written confirmation of the appeal.
b. Appellant’s Right to Information. The Company shall provide you free of charge and
sufficiently in advance of the date of the final internal adverse benefit determination to give
you a reasonable opportunity to respond, reasonable access to, and copies of, all documents,
records or other information that:
i. were relied upon in making the benefit determination;
ii. were submitted, considered, or generated in the course of making the benefit
determination, without regard to whether such document, record or other information
was relied upon in making the benefit determination;
iii. demonstrate compliance with the terms of the Plan.; or
iv. constitute a statement of policy or guidance with respect to the Plan concerning the
denied treatment option or benefit for your diagnosis, without regard to whether such
advice or statement was relied upon in making the benefit determination.
c. Appellant’s Right to Submit Information. You may submit with your request for review
any additional written comments, issues, documents, records and other information relating
to your claim.
d. Appeals Coordinator Right to Information. You and the treating health care professional
are required to provide the Appeals Coordinator, upon request, access to information
necessary to determine the appeal. Such information should be provided not later than five
(5) days after the date on which the Appeals Coordinator’s request for information is
received, or, in the case of a claim involving urgent care or concurrent review, at such earlier
time as may be necessary to comply with the applicable timelines. See Subsections 7.2.7.c.
and d. Your failure to provide access to such information shall not remove the obligation of
the Appeals Coordinator to make a determination on the appeal, but the Appeals
Coordinator’s determination may be affected if such requested information is not provided.
6. Conduct of Review.
a. Scope of Review. The Appeals Coordinator shall conduct a complete review of all
information relating to the claim and shall not afford deference to the initial claim
determination in conducting the review.
b. Qualifications of Appeals Coordinator. The Appeals Coordinator is an individual with
appropriate expertise who is neither the individual who denied the claim that is the subject
of the appeal, nor the subordinate of such individual.
c. Review of Medical Judgment. When reviewing a claim in which the determination was
based in whole or in part on medical judgment, including determinations with regard to the
application of the Primary Coverage Criteria or a Coverage Policy, the Appeals Coordinator
shall consult with a health care professional who has appropriate training and experience in
74
the field of medicine involved in the medical judgment. Such health care professional shall
not be an individual that was consulted in the initial claim determination, nor the subordinate
of such individual. The Appeals Coordinator shall, upon request, provide the identity of
health care professional(s) consulted in conducting the review, without regard to whether the
health care professional’s advice was relied upon in making the benefit determination.
7. Timing of Appeal Determination.
a. Post-Service Claim. The Appeals Coordinator shall render a decision on an appeal related
to a post-service claim within a reasonable period of time, but notification of the Appeals
Coordinator’s determination shall be provided to you not later than sixty (60) days after the
Appeals Coordinator received the appeal.
b. Pre-Service Claim. The Appeals Coordinator shall render a decision and provide
notification of the decision on an appeal related to a pre-service claim in accordance with the
medical exigencies of the case and as soon as possible, but in no case later than thirty (30)
days after the date the Appeals Coordinator received the appeal, unless the pre-service claim
involves hematology or oncology which requires a determination and notification within four
(4) business days after the date the Appeals Coordinator received the appeal.
c. Claims Involving Urgent Care. If you request an expedited review, and a health care
professional certifies that determination as a general pre-service claim would seriously
jeopardize your life or health or your ability to regain maximum function, the Appeals
Coordinator shall make a determination on review in accordance with the medical exigencies
of the case and as soon as possible, but in no case later than seventy-two (72) hours after
the time the Appeals Coordinator receives the request for review, unless the pre-service
claim involves hematology or oncology which requires a determination and notification within
two (2) business days after the date the Appeals Coordinator received the appeal. See
Subsection 7.2.9., below.
d. Concurrent Care Determination. The Appeals Coordinator shall administer an appeal
involving concurrent care in accordance with Subsections 7.2.7.a., b., or c., depending upon
whether the claim is a post-service claim, a pre-service claim or a claim involving urgent
care.
8. Notification of Determination of Appeal to Plan. The Appeals Coordinator shall provide notice of
the review determination in a printed form and written in a manner calculated to be understood by
the claimant. The notice shall include:
a. The specific reason or reasons for the review determination with information sufficient to
identify the claim involved (including the date of service, the health care provider, the claim
amount and a way that the Covered Person may learn the diagnosis and treatment codes
and their descriptions);
b. reference to the specific plan provision(s) on which the review determination is based;
c. a statement that the claimant is entitled to receive, upon request and free of charge,
reasonable access to, and copies of all documents, records, and other information Relevant
to the Claim for benefits;
d. a statement that any internal rule, guideline, protocol or other similar criterion relied upon by
the Plan is available upon request and free of charge;
e. a statement describing the voluntary external review procedures offered by the Plan; and
f. a statement of the claimant’s right to bring an action under the Employee Retirement Income
Security Act of 1974.
9. Expedited Appeal Procedure. An appeal of a claim involving urgent care or of a claim involving
ongoing care is conducted in accordance with this Subsection 7.2.9. Note that submission to the
Appeals Coordinator may be done electronically, FAX No. (501) 378-3366, e-mail:
APPEALSCOORDINATOR@ARKBLUECROSS.COM
. In accordance with Subsection 7.2.5.a., an
expedited appeal may be submitted by telephone, (501) 378-2025, followed by a written confirmation.
75
Please refer to Subsection 7.2.5.d., with respect to submission of information concerning a claim
involving urgent care or concurrent review to the Appeals Coordinator. In accordance with
Subsection 7.2.7.c., the Appeals Coordinator will notify you and your treating health care professional
of the determination of your expedited appeal in accordance with the medical exigencies of the case
and soon as possible, but in no case later than 72 hours after the Appeals Coordinator receives the
expedited appeal.
7.3 Independent Medical Review of Claims (External Review)
1. Claim Appeals Subject to External Review.
a. Waiver of Internal Review. If we have waived internal review, your appeal shall be to
external review in accordance with this Section 7.3.
b. Application of Primary Coverage.
If your claim has not been the subject of a prior external
review and if we have denied your claim in whole or in part because the intervention did not
meet the Primary Coverage Criteria (other than under the conditions outlined in Subsections
2.4.1.a., b., c. or d.) or because of the application of a Coverage Policy, you may request an
independent medical review by an Independent Review Organization in accordance with the
provisions of this Subsection 7.3 provided:
i. The claim denial was upheld in whole or in part as a result of the Plan’s internal
review process, or
ii. You have not requested or agreed to a delay in the Plan’s internal review process
and the Appeals Coordinator has not given you notification of the determination
involving a pre-service claim appeal within thirty (30) days following receipt of your
appeal to the Plan; or
iii. You have not requested or agreed to a delay in the Plan’s internal review process
and the Appeals Coordinator has not given you notification of the determination
involving a post-service claim appeal within sixty (60) days following receipt of your
appeal to the Plan; or
iv. Your claim meets the requirements for expedited external review, (see Subsection
7.3.13) and you have simultaneously submitted an appeal to the Plan.
2. Where and When to Submit External Review Appeal. A request for external review must be
submitted on the forms provided by the Arkansas Insurance Department. You can obtain the forms
by writing to the Arkansas Insurance Department, External Review, 1 Commerce Way, Suite 102,
Little Rock, Arkansas 72202 or by calling (800) 282-9134. The forms are also available online at the
Arkansas Insurance Department website at insurance.arkansas.gov.
Your request must be made
within four (4) months after you were notified that the claim denial was upheld in whole or in part as
a result of the Plan’s internal review process. If Subsection 7.3.1.b.ii. or 7.3.1.b.iii. apply, your request
may be made at the end of the thirty (30) day period or sixty (60) day period. If Subsection 7.3.1.b.iv.,
applies, you must file your request for external review at the same time you file your appeal to the
Plan.
3. Independent Review Organization and Independent Medical Reviewer
a. The Arkansas Insurance Commissioner shall determine if the claim is subject to external
review, and if he or she so determines, assign an Independent Review Organization from the
list of approved Independent Review Organizations compiled and maintained by the
Commissioner.
b. The Independent Review Organization is not affiliated with, owned by or controlled by the
Company. The Company pays a reasonable fee to the Independent Review Organization to
conduct the review, but such fee is not contingent upon the determination of the Independent
Review Organization or Independent Medical Reviewer.
c. An Independent Medical Reviewer is a physician that is licensed in one or more States to
deliver health care services and typically treats the condition or illness that is the subject of
the claim under review. The Independent Medical Reviewer is not an employee of the
76
Company and does not provide services exclusively for the Company or for individuals
holding insurance coverage with the Company. The Independent Medical Reviewer has no
material financial, familial or professional relationship with the Company, with an officer or
director of the Company, with the claimant or the claimant’s Authorized Representative, with
the health care professional that provided the intervention involved in the denied claim; with
the institution at which the intervention involved in the denied claim was provided; with the
manufacturer of any drug or other device used in connection with the intervention involved in
the denied claim; or with any other party having a substantial interest in the denied claim.
4. Documentation
a. Written Appeals. You must submit your appeal in writing in a form and in a manner
determined by the Arkansas Insurance Commissioner. You may submit with your request
for review any additional written comments, issues, documents, records and other information
relating to your claim. Your request for external review must be submitted on the forms
provided by the Arkansas Insurance Department. You can obtain the forms by writing to the
Arkansas Insurance Department, External Review, 1 Commerce Way, Suite 102, Little Rock,
Arkansas 72202 or by calling (800) 282-9134. The forms are also available online at the
Arkansas Insurance Department website at insurance.arkansas.gov.
b. Authorization to Release Information. In filing your request for external review, you must
include the following authorization: “I, [Covered Person’s name], authorize Arkansas Blue
Cross and Blue Shield and my healthcare Provider(s) to release all medical information or
records pertinent to this claim to the Independent Review Organization that is designated by
Arkansas Blue Cross. I further authorize such Independent Review Organization to release
such medical information to any Independent Medical Reviewer(s) selected by the
Independent Review Organization to conduct the review.”
5. Referral of Review Request to an Independent Review Organization. Upon receipt of the
documentation set out in Subsection 7.3.4, the Arkansas Insurance Commissioner shall immediately
refer the request for external review, along with the Company’s initial determination of the claim and
the Appeals Coordinator’s internal review determination (if applicable) to an Independent Review
Organization.
6. Independent Review Organization Right to Information. You and your treating health care
professional are required to provide the Independent Review Organization and the Independent
Medical Reviewer(s), upon request, access to information necessary to determine the appeal.
Access to such information shall be provided not later than seven (7) business days after the date on
which the request for information is received.
7. Rejection of Request for Review by the Independent Review Organization. The Independent
Review Organization shall reject a request for review and notify you, your Authorized Representative
and the Appeals Coordinator in writing within five (5) business days (or within 72 hours for an
Expedited Appeal) of its determination, if it determines that the appeal does meet the standards for
an appeal for external review. See Subsections 7.3.1.
8. Rejection of the Review for Failure to Submit Requested Information. The Independent Review
Organization may reject a request for review if:
a. you have not provided the authorization for release of medical records or information
pertinent to the claim required by Subsection 7.3.4.b; or
b. you or your health care professional have not provided information requested by the
Independent Review Organization in accordance with Subsection 7.3.6.
9. Independent Medical Review Determination. If the Independent Review Organization does not
reject the request for review in accordance with Subsections 7.3.7 or 7.3.8, it shall assign the request
for review to an Independent Medical Reviewer. Such Independent Medical Reviewer shall make a
determination after reviewing the documentation submitted by you, your health care professional and
the Company. The Independent Medical Reviewer shall consider the terms of this Benefit Certificate
to assure that the reviewer’s decision is not contrary to the terms of the Plan. In making the
77
determination the reviewer need not give deference to the determinations made by the Company or
the recommendations of the treating health care professional (if any).
10. Timing of Appeal Determination.
a. Standard Review. The Independent Medical Reviewer shall complete a review on an appeal
within a reasonable period of time, but in no case later than forty five (45) days after the
Independent Review Organization received the appeal.
b. Expedited Review. If you request an expedited review, and a health care professional
certifies that the time for a standard review would seriously jeopardize your life or health or
your ability to regain maximum function, the Independent Medical Reviewer shall make a
determination on review in accordance with the medical exigencies of the case and as soon
as possible, but in no case later than 72 hours after the time the Independent Review
Organization received the request for review.
11. Notification of Determination of Independent Medical Review.
a. Recipients of Notice. Upon receipt of the determination of the Independent Medical
Reviewer, the Independent Review Organization shall provide written notification of the
determination to you, your health care Provider, the Company and the Arkansas Insurance
Commissioner.
b. The Notification shall include.
i. A general description of the reason for the request for external review;
ii. The date the Independent Review Organization was notified by the Company to
conduct the review;
iii. The date the external review was conducted;
iv. The date of the Independent Medical Reviewer’s determination;
v. The principal reason(s) for the determination;
vi. The rationale for the determination; and
vii. References to the evidence or documentation, including practice guidelines,
considered in the determination.
12. Expedited External Review.
a. Requirement for Expedited Review. You may submit a pre-service claim denial or a denial
of a claim involving concurrent care for an expedited external review provided your health
care professional certifies that the time to complete a standard review would seriously
jeopardize your life or health or your ability to regain maximum function.
b. Expedited External Review without prior Appeal to Plan (internal review). You may
request an expedited review at the same time you submit a request for an appeal to the Plan
(internal review) if your health care professional certifies that the time to complete the Plan’s
expedited appeal process would seriously jeopardize your life or health or your ability to
regain maximum function. If you make such a request, the Independent Review Organization
may determine and notify you in accordance with Subsections 7.3.10.b. and 7.3.11 whether
you will be required to complete the internal review process.
c. Same procedures as standard external review. Unless otherwise specified, the provisions
of this Section 7.3 applicable to independent medical review of claims apply to expedited
external review of claims.
13. Other Rights under Plan. Your decision to submit an appeal to external review will have no effect
on your other rights and benefits under the Plan.
14 Arkansas Insurance Commissioner. You may contact the Arkansas Insurance Commissioner for
assistance. The mailing address is Arkansas Insurance Department, Attention External Review
78
Assistance, 1 Commerce Way, Suite 102, Little Rock, AR 72202. The telephone number is (501)
371-2640 or toll free (800) 852-5494. The e-mail address is insurance.consumers@arkansas.gov.
15. Binding on the Plan. The determination of an Independent Review Organization and an
Independent Medical Reviewer is binding on both the Plan and you, except to the extent that other
remedies are available under applicable federal or state law.
7.4 Authorized Representative
1. One Authorized Representative. A Covered Person may have one representative, and only one
representative at a time, to assist in submitting a claim or appealing an unfavorable claim
determination.
2. Authority of Authorized Representative. An Authorized Representative shall have the authority
to represent the Covered Person in all matters concerning the Covered Person’s claim or appeal of
a claim determination. If the Covered Person has an Authorized Representative, references to “You”
or “Covered Person” in this document refer to the Authorized Representative.
3. Designation of Authorized Representative. One of the following persons may act as a Covered
Person's Authorized Representative:
a. An individual designated by the Covered Person in writing in a form approved by the
Company;
b. The treating Provider, if the claim is a claim involving urgent care, or if the Covered Person
has designated the Provider in writing in a form approved by the Company;
c. A person holding the Covered Person's durable power of attorney;
d. If the Covered Person is incapacitated due to illness or injury, a person appointed as
guardian to have care and custody of the Covered Person by a court of competent
jurisdiction; or
e. If the Covered Person is a minor, the Covered Person's parent or legal guardian, unless the
Company is notified that the Covered Person’s claim involves health care services where the
consent of the Covered Person’s parent or legal guardian is or was not required by law and
the Covered Person shall represent himself or herself with respect to the claim.
4. Communication with Authorized Representative.
a. If the Authorized Representative represents the Covered Person because the Authorized
Representative is the Covered Person’s parent or legal guardian or attorney in fact under a
durable power of attorney, the Company shall send all correspondence, notices and benefit
determinations in connection with the Covered Person’s claim to the Authorized
Representative.
b. If the Authorized Representative represents the Covered Person in connection with the
submission of a pre-service claim, including a claim involving urgent care, or in connection
with an appeal, the Company shall send all correspondence, notices and benefit
determinations in connection with the Covered Person’s claim to the Authorized
Representative.
c. If the Authorized Representative represents the Covered Person in connection with the
submission of a post-service claim, the Company will send all correspondence, notices and
benefit determinations in connection with the Covered Person’s claim to the Covered Person,
but the Company will provide copies of such correspondence to the Authorized
Representative upon request.
5. Term of the Authorized Representative. The authority of an Authorized Representative shall
continue until
a. the claim(s) or appeal(s) for which the Authorized Representative was designated has been
fully adjudicated; or
79
b. the Covered Person is legally competent to represent himself or herself and notifies the
Company that the Authorized Representative is no longer required.
8.0 OTHER PROVISIONS
The following information is important in the administration of the Plan.
8.1 Assignment of Benefits. No assignment of benefits under this Benefit Certificate shall be valid until
approved and accepted by the Company. The Company reserves the right to make payment of benefits, with
a valid assignment, directly to the Provider of service.
8.2 Right of Rescission. The performance of an act or practice constituting fraud or intentional
misrepresentation of material fact may be used by the Company as the basis for rescission of coverage of
the Policyholder, any Employee or any Dependents. The Company must provide the Policyholder 30 days’
advance written notice of its intent to rescind the Benefit Certificate.
8.3 Claim Recoveries. There may be circumstances in which the Company recovers amounts paid as claims
expense from a Provider of services, from a Covered Person or from a third party. Such circumstances
include rebates paid to the Company by pharmaceutical manufacturers based upon amounts of claims paid
by the Company for certain specified pharmaceuticals, amounts recovered by the Company from health care
Providers or pharmaceutical manufacturers through certain legal actions instituted by the Company relating
to the claims expense of more than one Covered Person, recoveries by the Company of overpayments made
to health care Providers or to Covered Persons, and recoveries from other parties with whom the Company
contracts or otherwise relies upon for payment or pricing of claims. The following rules govern the Company’s
actions with respect to such recoveries:
1. In the event that such a recovery relates to a claim paid more than two years before the recovery, no
adjustment will be made to any Deductible or Coinsurance paid by a Covered Person and the
Company shall be entitled to retain such recoveries for its own use.
If the recovery relates to a claim paid within two years and is not otherwise addressed in this
subsection, Deductibles and Coinsurance amounts for a Covered Person will be adjusted if affected
by the recovery.
2. Only recoveries made within two years of the date of the error by the Company or overpayments to
health care Providers or to Covered Persons by the Company will be applied for the purpose of group
rating or divisible surplus calculation, if applicable. The cost actually paid by the Company to procure
such recoveries will be treated as an administrative expense in considering group rating or divisible
surplus, if applicable.
3. In the event the Company receives or will receive from pharmaceutical manufacturers rebates based
upon amounts of claims paid for certain specified pharmaceuticals, the Company shall make
adjustments to claims paid for Deductible or Coinsurance or to Deductibles or Coinsurance amounts
paid by a Covered Person at the point of sale, provided the adjustment reduces the Covered Person’s
Deductible or Coinsurance.
4. If a Covered Person is no longer covered by the Company at the time of any such recovery,
regardless of the amount or of the time of such recovery, the Company shall be entitled to retain such
recovery for its own use.
5. If such recovery amounts cannot be attributed on an individual basis, because of having been paid
as a lump sum settlement for less than the total amount of claims expense of the Company or
otherwise, no adjustments will be made to any Deductible or Coinsurance amounts paid by the
Covered Person and the Company shall be entitled to retain such recovery for its own use.
8.4 Amendment The Company reserves the right to change the benefits, conditions and premiums covered
under the Group Policy or Group Insurance Contract, including the terms of this Benefit Certificate. In the
event of a change to the Group Policy or Group Insurance Contract, We will give thirty (30) days written notice
to your Employer or its agent prior to the group’s next renewal, and the change will go into effect on the date
fixed in the notice. No agent or employee of the Company may change or modify any benefit, term, condition,
80
limitation or exclusion of this Benefit Certificate. Any change or amendment must be in writing and signed
by an officer of the Company and approved by Arkansas Insurance Department.
8.5 Notice of Provider/Physician Incentives That Could Affect Your Access to Healthcare
1. General Description and Purpose of Incentive Programs: The Company contracts with physicians
and other types of health care providers who agree to perform services for Arkansas Blue Cross and
Blue Shield Covered Persons, often at a discount from their usual charges. In contracting with
providers, including physicians, the Company sometimes offers financial incentives to encourage
providers to practice medicine in a cost-effective manner, and to improve the quality of health care
services. These incentive arrangements sometimes offered by the Company may take a variety of
forms but the main goals of the incentive arrangements are designed to do one or both of two things:
(1) give the provider (including physicians) a financial incentive to control the overall cost of treatment;
and (2) give the provider (including physicians) a financial incentive to pay increased attention to well-
established quality standards and thereby hopefully improve the overall quality of care being
provided. The financial incentives sometimes offered by the Company to providers (including
physicians) sometimes involve a financial reward if specified goals are met; at other times, the
financial incentives may include a financial penalty if the provider (including physicians) fails to
achieve specified goals. In other cases, the financial incentive program that the Company offers to
providers (including physicians) may include both the opportunity for financial rewards, as well as the
possibility of financial penalties, depending on how the provider performs.
2. Specific Types of Incentive Programs Offered: The financial incentives offered by the Company to
providers (including physicians) may change significantly over time and on short notice due to
provider preferences or larger changes taking place in the health care field; however, the following
describes a number of financial incentive programs that are either currently being offered by the
Company, or may be offered in the future:
a. Capitation: This is a system of provider (including physician) payment in which the Company
agrees to pay the provider a per-member-per-month fee as total compensation for all of the
care received by each Covered Person from the contracting provider during the month.
Sometimes, capitation involves a “withhold” feature in which a portion of the capitation
payment is withheld until the provider’s overall cost performance is determined at the end of
a defined settlement period. In such instances, if the provider’s overall cost of care for
Covered Persons is lower than a pre-determined target budget, the provider is then paid an
additional amount from the withhold fund; conversely, in some instances, if the provider’s
overall cost of care for Covered Persons is higher than a pre-determined target budget, the
provider may forfeit some or all of the withhold fund.
b. Episodes of Care: This is a system of provider (including physician) payment in which the
Company and the provider agree on a pre-determined set of cost and quality measurements
that will apply to a specific type of health care episode, such as, for example, total hip or knee
replacement surgery. In this “episodes of care” incentive payment system, a provider may
qualify for incentive bonus payments by accomplishing two things: first, the provider must
establish that certain quality standards have been met with respect to Covered Persons
treated by the provider within the applicable review period and, secondly, the provider must
keep average costs for the particular “episode of care” in question within pre-established
ranges. At the same time, if the provider’s average costs for Covered Persons treated in a
particular “episode of care” exceed an “acceptable” range that is pre-established in the
agreement with the Company, the provider will not earn bonus payments and may also be
required to refund a portion of the claims payments the provider previously received from the
Company. Please keep in mind that the Company currently applies this form of provider
payment to only a small number of health care treatments or “episodes” but may expand the
list to cover additional “episodes of care” over time. Please note as well that a provider’s
referral of Covered Persons to other providers, including specialists, could affect the
provider’s qualification for bonus payments, or the provider’s obligation to refund some
payments made by the Company. For example, if a provider makes referrals to other
providers whose costs of care are substantially higher, or who do not meet applicable quality
81
standards, the referring provider could lose bonus payments, or could incur refund
obligations to the Company under the “episodes of care” payment system.
c. Total Cost of Care or Medical Trends: In some instances, the Company may offer financial
incentives to providers (including physicians) that are tied to the total cost of care for a pre-
defined set of Covered Persons within a pre-defined period of time, offering to pay such
providers a bonus payment if, during the defined period, total costs of care for such Covered
Persons remains at or below a pre-defined target level. Sometimes this form of payment is
based on calculations of the “medical trend” during a defined period, which means whether
the cost of care for Covered Persons served by the provider during the applicable period
increased or decreased by a specific percentage.
d. Pharmacy/Drug Incentives: The Company may also offer physicians financial incentives to
encourage them to provide education to Covered Persons on the costs of Prescription
Medications, and, where appropriate in the physician’s independent medical judgment, to
write prescriptions for Prescription Medications listed as “Second Tier” on the Company's
Formulary, or to write prescriptions for Generic Medications listed as “First Tier” on the
Company's Formulary.
3. Incentive Arrangements Subject to Change. The incentive arrangements described here concern
the provider contracts that are either in place and regularly used by the Company at the time this
Benefit Certificate was issued or are being contemplated for use in the future. Because of the rapid
pace of change in health care financing in today’s marketplace, physician provider negotiating
positions, regulatory changes, or other developments, the precise content of the Company's provider
reimbursement and incentive plans may change significantly in the future. See subsection 4, below,
for ways in which you can obtain additional or updated information regarding the Company's provider
incentive programs.
4. For Further Information. If you have any concerns about how the various incentive programs offered
to the Company's-participating providers may affect your access to health care services, you should
discuss such concerns with your physician or other treating health care professional. You may ask
your Physician’s health care provider’s administrative staff about compensation methods, including
incentives, which apply to the services provided by their Physician, your health care provider. In
addition, you may or request information from the Company by writing to submit written questions to
Arkansas Blue Cross and Blue Shield, Customer Service Division, Post Office Box 2181 Little Rock,
Arkansas 72203.
8.6 Pediatric Dental Plan. Your Plan is bundled with pediatric dental coverage. A Pediatric Dental plan provides
coverage for dental services to Covered Persons under the age of nineteen (19) subject to the terms,
conditions, exclusions, and limitations of the Pediatric Dental Benefit Certificate. While coverage is provided
under this Plan, the Company will not send the Pediatric Dental Benefit Certificate and materials to any family
(i.e., Employees or their Dependents) without a Covered Person under the age of nineteen (19). If your
coverage is amended to include a Covered Person under the age of nineteen (19), you will receive a Pediatric
Dental Benefit Certificate and materials at the address currently on file with the Company.
8.7 Value Adds. We may offer You access to non-insurance benefits and services such as subscriptions to
wellness and/or meditation apps, merchandise, special offers, coupons, or other items of value through a
non-insurance program vendor. These non-insurance services may be managed by the non-insurance
program vendor’s administrator named as the program administrator. The products and services available
under these programs may provide duplicative benefits to Covered Services in this Benefit Certificate or to
another non-insurance program vendor but are not Covered Services under the Policy. As such, program
features are not guaranteed under the Policy and could be discontinued at any time. Neither We nor the
program administrator endorses any vendor, product or service associated with any non-insurance benefit or
services program. Non-insurance program vendors are solely responsible for the non-insurance products
and services You may receive.
9.0 GLOSSARY OF TERMS
These are terms used in this Group Policy and Benefit Certificate.
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9.1 Accidental Injury is defined as bodily injury sustained by a Covered Person while the insurance is in force,
and which is the direct cause of the loss, independent of disease or bodily infirmity. Injury to a tooth or teeth
while eating is not considered an Accidental Injury.
9.2 Allowance or Allowable Charge, when used in connection with Covered Services or supplies delivered in
Arkansas, will be the amount deemed by the Company, in its sole discretion, to be reasonable. The Arkansas
Blue Cross and Blue Shield customary allowance is the basic Allowance or Allowable Charge. However, the
Allowance or Allowable Charge may vary, given the facts of the case and the opinion of the Company’s
medical director.
At the option of the Company, Allowances or Allowable Charges for services or supplies received out of
Arkansas may be determined by the local Blue Cross and Blue Shield Plan, See Subsection 7.1.10 dealing
with Out-of-Arkansas Services. See Subsection 3.25.4 with respect to the Allowance or Allowable Charge
for transplants. See Subsection 3.3.2 with respect to the Allowance or Allowable Charge for Outpatient
Surgery Centers. Please note that all benefits under this Benefit Certificate are subject to and shall be
paid only by reference to the Allowance or Allowable Charge as determined at the discretion of
Arkansas Blue Cross and Blue Shield. This means that regardless of how much your health care
Provider may bill for a given service, the benefits under this Benefit Certificate will be limited by the
Allowance or Allowable Charge we establish. If you use an Arkansas Blue Cross and Blue Shield-
participating Provider, that Provider is obligated to accept our established rate as payment in full,
and should only bill you for your Deductible, Coinsurance and any non-covered services; however,
if you use a non-participating Provider, you will be responsible for all amounts billed in excess of the
Arkansas Blue Cross and Blue Shield Allowance or Allowable Charge.
The payment to a Provider for their services as described in a Current Procedural Terminology ("CPT") or
Healthcare Common Procedure Coding System ("HCPCS") code and reimbursed in accordance with the
Resource-Based Relative Value System ("RBRVS") used by the Centers for Medicare & Medicaid Services
("CMS") is an all-inclusive, global payment that covers all elements of the service as described in the
particular code billed. This means that whatever staffing, overhead costs, equipment, drugs, machinery,
tools, technology, supplies, or materials of any kind that may be required in order for the billing Provider to
perform the service or treatment described in the CPT or HCPCS code billed, the Company’s payment to the
billing Provider of the Allowance or Allowable Charge for that CPT or HCPCS code constitutes the entire
payment and the limit of benefits under this Benefit Certificate with respect to the CPT or HCPCS code billed.
A Provider who bills for a particular CPT or HCPCS code is deemed to represent that the billing Provider has
performed and is responsible for provision of all services or treatments described in the CPT or HCPCS code,
and is entitled to bill for such services or treatments. If the Company pays for a Covered Service by applying
the Allowance or Allowable Charge to the bill of a Provider who represents that the Provider has performed
a service or treatment described in a CPT or HCPCS code as submitted to the Company, the Company shall
have no further obligation, nor is there coverage under this Benefit Certificate, for bills from or payment to
any other provider, entity or person, regardless of whether they assisted the billing Provider or furnished any
staffing, equipment, drugs, machinery, tools, technology, supplies or materials of any kind to or for the benefit
of the billing Provider. In other words, benefits under this Benefit Certificate are limited to one, global payment
for all components of any services falling within the scope of any CPT or HCPCS code service or treatment
description, and the Company will make only one payment with respect to such CPT or HCPCS code, even
if multiple parties claim to have contributed a portion of the staffing, equipment, machinery, tools, technology,
supplies or materials used by the billing Provider in the course of providing the service or treatment described
in the CPT or HCPCS code.
For example, a physician who performs certain surgical procedures in the physician’s office might choose to
engage an equipment and supply company to set up the surgical table, furnish an assisting nurse, and also
furnish certain surgical instruments, devices or supplies used by the physician. When the physician bills the
Company for the physician’s performance of the surgical procedure described in a specific CPT or HCPCS
code, the Company will make a single, global payment to the physician for Covered Services described in
the CPT or HCPCS code, and will not be obligated to pay for any charges of the equipment and supply
company. In such circumstances, any charge or claim of payment due the equipment and supply company
shall be the exclusive responsibility of the physician (or other provider) who engaged the equipment and
supply company, and permitted or facilitated such company’s access to the physician’s patient. In any event,
as noted above, no benefits are available under this Benefit Certificate for any services, drugs, materials or
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supplies of the equipment and supply company. It is the Company’s policy (and this Benefit Certificate is
specifically intended to adopt the same) that no benefits shall be paid for "unbundled services" in excess of
the Company’s Allowance or Allowable Charge for any service as described in the applicable CPT or HCPCS
code. This means, for example, that if a physician and another category of provider (such as a durable
medical equipment supplier, a laboratory, a nurse practitioner, a nurse, a physician’s assistant or any other
category of provider) agree together to divide up, split or "unbundle" the components of any CPT or HCPCS
code, and attempt to bill separately for the various components each allegedly provides for the patient,
benefits under this Benefit Certificate shall nevertheless be limited to one Allowance per CPT or HCPCS
code; in such circumstances, your benefits under this Benefit Certificate will pay only one Allowance or
Allowable Charge for any Covered Service described in any single CPT or HCPCS code, and the various
providers involved in any such "unbundling" action or agreement must resolve among themselves any division
of that single Allowance or Allowable Charge between or among them. You can protect yourself from the
possibility of billing in excess of the Allowance or Allowable Charge in these circumstances by always
inquiring in advance to be sure that each provider involved in your care or treatment is a Preferred Provider.
Please note that the Company makes the following exceptions to the preceding general policy of one global
payment (Allowance) per CPT or HCPCS code: (i) where CMS has developed and published an RBRVS
policy that specifically recognizes that the Relative Value Units (RVUs) associated with a specific CPT or
HCPCS code should be divided into both a professional and a technical component; or (ii) billing of the
services of an assistant surgeon for those CPT or HCPCS codes that specifically recognize assistant surgery
services as applicable; or (iii) billing of radiopharmaceuticals used in nuclear medicine procedures where
such radiopharmaceuticals clearly are not included in the practice expense portion of the associated RVU as
published and defined by CMS; or (iv) billing of a procedure or set of procedures that, per the applicable CPT
or HCPCS code definition, is based solely on time consumed so that it is necessary to submit multiple units
of the procedure in order to accurately report the total time devoted to the patient. In the specific four
circumstances outlined in the preceding sentence, the Company will recognize and pay more than one
Allowance per CPT or HCPCS code, provided all other terms and conditions of this Benefit Certificate are
met. With respect to the first such circumstance involving RVUs divided between a professional and a
technical component, the Company’s payment will be limited to one global payment (Allowance) for the
applicable professional component, and one global payment (Allowance) for the technical component. In
other words, even where CMS policy specifically recognizes division of an RVU into professional and
technical components, the Company will not be responsible for paying multiple providers or multiple billings
for the professional component, nor will the Company be responsible for paying multiple providers or multiple
billings for the technical component. Benefits under this Benefit Certificate will be limited in such
circumstances to one global payment (Allowance) for the professional component and one global payment
(Allowance) for the technical component.
9.3 Alternative Destination means a lower-acuity facility that provides medical services, including without
limitation: a.) a federally qualified health center; b.) an urgent care center; c.) a physician office or medical
clinic selected by the patient; and d.) a behavioral or mental healthcare facility including without limitation a
Crisis Stabilization Unit. Alternative Destination does not include: a.) a critical access Hospital; b.) a dialysis
center; c.) a Hospital; d.) a private residence; or e.) a Skilled Nursing Facility.
9.4 Ambulance Service means surface or air transportation in a regularly equipped ambulance licensed by an
appropriate agency and where the use of any other means of transportation is not medically indicated. All
services provided by the ambulance personnel, including but not limited to, the administration of oxygen,
medications, life support, etc. are included in the specific Benefit Certificate limitation applied to ambulance
benefits per calendar year.
9.5 Ambulatory Surgery Center means a distinct entity that operates exclusively for the purpose of providing
surgical services to patients not requiring Hospitalization.
9.6 Ancillary Services means services provided by Out-of-Network Providers at an In-Network facility such as:
related to emergency medicine – anesthesiology, pathology, radiology and neonatology; provided by
assistant surgeons, hospitalists and intensivists; diagnostic services, including radiology and laboratory
services, unless such items and services are excluded from the definition of ancillary services as determined
by the Secretary (as that term is applied in the No Surprises Act); provided by such other specialty
practitioners as determined by the Secretary; and provided by an Out-of-Network Physician when no other
In-Network Physician is available.
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9.7 Annual Limitation on Cost Sharing means the amount of Allowance or Allowable Charges a Covered
Person must incur for claims in a calendar year before the Covered Person is relieved of the obligation to pay
Copayments, Deductible or Coinsurance for the remainder of the calendar year. The Annual Limitation on
Cost Sharing is set forth in the Schedule of Benefits.
9.8 Approved Clinical Trial means a phase I, phase II, phase III, or phase IV clinical trial that is conducted in
relation to the prevention, detection, or treatment of cancer or other life-threatening disease or condition and
is described in any of the following subparagraphs:
1. Federally Funded Trials- The study or investigation is approved or funded (which may include funding
through in-kind contributions) by one or more of the following:
a. The National Institutes of Health.
b. The Centers for Disease Control and Prevention.
c. The Agency for Health Care Research and Quality.
d. The Centers for Medicare & Medicaid Services.
e. cooperative group or center of any of the entities described in clauses a. through b. or the
Department of Defense or the Department of Veterans Affairs.
f. A qualified non-governmental research entity identified in the guidelines issued by the
National Institutes of Health for center support grants.
2. The study or investigation is conducted under an investigational new drug application reviewed by
the Food and Drug Administration.
3. The study or investigation is a drug trial that is exempt from having such an investigational new drug
application.
9.9 Benefit Certificate means this certificate of insurance containing the benefits, conditions, limitations and
exclusions of the Group Insurance Contract plus the Schedule of Benefits and any amendments signed by
an Officer of the Company.
9.10 Brand Name Medication means any Prescription Medication that has a patented trade name separate from
its generic or chemical designation.
9.11 Case Management is a program in which a registered nurse employed by Arkansas Blue Cross and Blue
Shield, known as a Case Manager, assists a Covered Person through a collaborative process that assesses,
plans, implements, coordinates, monitors and evaluates options and health care benefits available to a
Covered Person. Case management is instituted at the sole option of the Company when mutually agreed
to by the Covered Person and the Covered Person’s Physician.
9.12 Chemotherapy means Chemotherapy for the treatment of a malignant neoplastic disease by chemical
agents that affect the disease-causing agent unfavorably. High dose Chemotherapy is Chemotherapy
several times higher than the standard dose for malignant disease (as determined in recognized medical
compendia) and which would automatically require the addition of drugs and procedures (e.g., Granulocyte
Colony-Stimulating Factor, Granulocyte-Macrophage Colony-Stimulating Factor, re-infusion of stem cells, re-
infusion of autologous bone marrow transplantation, or allogeneic bone marrow transplantation) in any patient
who received this high dose Chemotherapy, to prevent life-threatening complications of the Chemotherapy
on the patient’s own progenitor blood cells.
9.13 Child means an Employee's natural Child, legally adopted Child or Stepchild. “Child” also means a Child
that has been placed with the Employee for adoption. "Child" also means a Child for whom the Employee
must provide medical support under a qualified medical child support order or for whom the Employee has
been appointed the legal guardian.
9.14 Cognitive Rehabilitation means a treatment modality designed specifically for the remediation of disorders
of perception, memory and language in brain-injured persons. Services or supplies provided as or in
conjunction with, Cognitive Rehabilitation are not covered. See Subsection 4.2.15.
9.15 Coinsurance means the obligation of a Covered Person to pay a certain portion of an Allowable Charge.
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Coinsurance is expressed as a percentage in the Schedule of Benefits. The Schedule of Benefits sets forth
the Coinsurance for services or supplies received from a Preferred Provider and the Coinsurance for services
and supplies from Non-Preferred Provider.
9.16 Company means Arkansas Blue Cross and Blue Shield.
9.17 Complication of Pregnancy means
1. Hospital confinement required to treat conditions, such as the following, in a pregnant female: acute
nephritis, nephrosis, cardiac decompensation, HELLP syndrome, uterine rupture, amniotic fluid
embolism, chorioamnionitis, fatty liver in pregnancy, septic abortion, placenta accrete, gestational
hypertension, puerperal sepsis, peripartum cardiomyopathy, cholestasis in pregnancy,
thrombocytopenia in pregnancy, placenta previa, placental abruption, acute cholecystitis and
pancreatitis in pregnancy, postpartum hemorrhage, septic pelvic thrombophlebitis, retained placenta,
venous air embolus associated with pregnancy, miscarriage or an emergency c-section required
because of (a) fetal or maternal distress during labor, or (b) severe pre-eclampsia, or (c) arrest of
descent or dilatation, or (d) obstruction of the birth canal by fibroids or ovarian tumors, or (e)
necessary because of the sudden onset of a medical condition manifesting itself by acute symptoms
of sufficient severity that, in the absence of immediate medical attention, will result in placing the life
of the mother or fetus in jeopardy. For purposes of this subsection, a c-section delivery is not
considered to be an emergency c-section if it is merely for the convenience of the patient and/or
doctor or solely due to a previous c-section.
2. Treatment, diagnosis or care for conditions, including the following, in a pregnant female when the
condition was caused by, necessary because of, or aggravated by the pregnancy: hyperthyroidism,
hepatitis B or C, HIV, Human papilloma virus, abnormal PAP, syphilis, chlamydia, herpes, urinary
tract infections, thromboembolism, appendicitis, hypothyroidism, pulmonary embolism, sickle cell
disease, tuberculosis, migraine headaches, depression, acute myocarditis, asthma, maternal
cytomegalovirus, urolithiasis, DVT prophylaxis, ovarian dermoid tumors, biliary atresia and/or
cirrhosis, first trimester adnexal mass, hydatidiform mole or ectopic pregnancy.
3. Management of a difficult pregnancy is not a Complication of Pregnancy.
9.18 Compound Medication means a non-FDA approved medication prescribed by a Physician that is mixed by
a pharmacist using multiple ingredients which may or may not be FDA approved individually. FDA approved
medications that exist as separate components and are intended for reconstitution prior to administration are
not Compound Medications.
9.19 Contracting Provider means a Provider who has signed a Contract with this Company to provide the
services covered by this Benefit Certificate to Covered Persons. The Company will pay the Contracting
Provider directly.
9.20 Copayment means the amount required to be paid to a Preferred Provider by or on behalf of a Covered
Person in connection with Covered Services.
9.21 Cosmetic Service means any treatment or corrective surgical procedure performed to reshape structures of
the body in order to alter the individual’s appearance or to alter the manifestation of the aging process. Breast
augmentation, mastopexy, breast reduction for cosmetic reasons, otoplasty, rhinoplasty, collagen injection
and scar reversals are examples of Cosmetic Services. Cosmetic Services also includes any procedure
required to correct complications caused by or arising from prior Cosmetic Services. Cosmetic Services do
not include the following services in connection with a mastectomy eligible for coverage under this Benefit
Certificate: (a) reconstruction of the breast on which the surgery has been performed, and (b) surgery to
reconstruct the other breast to produce a symmetrical appearance. The following procedures are not
considered Cosmetic Services: correction of a cleft palate or cleft lip, removal of a port-wine stain or
hemangioma on the head, neck, or face.
9.22 Coverage Policy means a statement developed by the Company that sets forth the medical criteria for
coverage under an Arkansas Blue Cross and Blue Shield Benefit Certificate or insurance policy. Some
limitations of benefits related to coverage, of a drug, treatment, service equipment or supply are also outlined
in the Coverage Policy. A copy of a Coverage Policy is available from the Company, at no cost, upon request,
or a Coverage Policy can be reviewed on the Company’s web site at WWW.ARKANSASBLUECROSS.COM
.
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9.23 Covered Person means an Employee or Dependent who is insured under this Benefit Certificate.
9.24 Covered Services means services for which a Covered Person is entitled to benefits under the terms of this
Group Policy and Benefit Certificate.
9.25 Crisis Stabilization Unit means a public or private facility, licensed and certified as a Crisis Stabilization Unit
by the Arkansas Department of Human Services, that serves as an alternative to jail, where law enforcement
officers can place people experiencing mental health crises who have been arrested for nonviolent offenses
9.26 Custodial Care means care rendered to a Covered Person (1) who is disabled mentally or physically and
such disability is expected to continue and be prolonged, and (2) who requires a protected, monitored, or
controlled environment whether in an institution or in a home, and (3) who requires assistance to support the
essentials of daily living, and (4) who is not under active and specific medical, surgical, or psychiatric
treatment that will reduce the disability to the extent necessary to enable the patient to function outside the
protected, monitored, or controlled environment. A custodial determination is not precluded by the fact that
a Covered Person is under the care of a supervising or attending Physician and that services are being
ordered or prescribed to support and generally maintain the Covered Person’s condition, or provide for the
Covered Person’s comfort, or ensure the manageability of the Covered Person. Further, a Custodial Care
determination is not precluded because the ordered and prescribed services and supplies are being provided
by an R.N., L.P.N., or L.V.N. or the ordered and prescribed services and supplies are being performed in a
Hospital, Nursing Home, a skilled nursing facility, an extended care facility or in the home. The determination
of Custodial Care in no way implies that the care being rendered is not required by the Covered Person; it
only means that it is a type of care that is not covered under this Benefit Certificate.
9.27 Deductible means the amount of out-of-pocket expense a Covered Person must incur for Covered Services
each calendar year before any expenses are paid by the Company under the Plan. This amount is calculated
from the Allowance or Allowable Charges, not the billed charges. Once the Deductible has been met, subject
to all other terms, conditions, limitations and exclusions in the Plan, Coinsurance payments for Covered
Services begin.
9.28 Dental Care means the treatment or repair of the teeth, bones and tissues of the mouth and defects of the
human jaws and associated structures and shall include surgical procedures involving the mandible and
maxilla where such is done for the purpose of correcting malocclusion of the teeth or for the purpose, at least
in part, of preparing such bony structure for dentures or the attachment of teeth, artificial or natural. Dental
Care shall include any related supplies or oral appliances used in the treatment, diagnosis or prevention of
any defects in the teeth or supporting tissues of the mouth. Expenses for such treatment or repair are
considered Dental Care regardless of the reason for the services. Generally, hospital services and
administration of anesthetic in connection with Dental Care are not covered except in limited circumstances,
as provided in Subsection 3.3.3.
9.29 Dependent means any member of an Employee’s family who meets the eligibility requirements of Section
6.0, who is enrolled in the Plan, and for whom the Company has received premium.
9.30 Developmental Service Visit means one hour of Developmental Services provided by a licensed or certified
provider. A Developmental Service Visit may include services provided by more than one provider.
9.31 Developmental Services means assistance activities that are coordinated with physical, occupational and
speech therapy to reinforce impact of such therapy provided in connection with Habilitation.
9.32 Diabetes Self-Management Training means instruction, including medical nutrition therapy relating to diet,
caloric intake and diabetes management (excluding programs the primary purpose of which is weight
reduction) which enables diabetic patients to understand the diabetic management process and daily
management of diabetic therapy as a means of avoiding frequent Hospitalizations and complications when
the instruction is provided in accordance with a program in compliance with the National Standards for
Diabetes Self-Management Education Program as developed by the American Diabetes Association.
9.33 Dose Limitation means a limitation in the number of doses of a Prescription Medication in a single
prescription or a limit in the number of doses over a defined period of time. For example, a Dose Limitation
for a particular medication may be set at no more than 10 doses in a dispensed prescription and no more
than 20 doses during a 30-day period.
9.34 Durable Medical Equipment (DME) means equipment which (1) can withstand repeated use; and (2) is
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primarily and customarily used to serve a medical purpose; and (3) generally is not useful to a person in the
absence of an illness or injury; and (4) is appropriate for use in the home.
9.35 Electronic Data Exchange Enrollment means the process by which a Policyholder submits eligibility data
electronically to the Company for the purposes of adding, deleting or modifying the Company’s enrollment
records. Electronic data submitted to the Company will be relied upon in determining eligibility, effective
dates and termination dates of coverage under the terms of the employee health benefit plan.
9.36 Eligibility Data means information demonstrating that an Employee or Employee’s Dependent is eligible for
coverage under the Plan.
9.37 Eligibility Date means:
For an Employee, the latest of the following dates:
1. the policy effective date for an Employee who has selected coverage and is working for the Employer
on that date; or
2. the date the required Waiting Period is completed for any Employee hired after the policy effective
date.
For a Dependent, the latest of the following dates:
1. the date the Employee becomes eligible for coverage under the Plan;
2. the date a person becomes a Dependent; or
3. the date this Benefit Certificate is amended to include the Employee's class as being eligible for
Dependent coverage.
9.38 Emergency Care means health care services required to evaluate and treat medical conditions of a recent
onset and severity, including, but not limited to, severe pain that would lead a prudent layperson, possessing
an average knowledge of medicine and health, to believe that a condition, sickness, or injury is of such a
nature that failure to get immediate medical care could result in (i) placing the patient’s health in serious
jeopardy; (ii) serious impairment to bodily functions; or (iii) serious dysfunction of any bodily organ or part.
Emergency health care services, with respect to emergency medical condition, means a medical screening
examination within the capability of an emergency department of a hospital or an independent freestanding
emergency department including ancillary services routinely available to evaluate the emergency medical
condition. This includes emergency services to stabilize the patient within any department of the hospital in
which further examination or treatment is provided. Emergency services will include items and services
provided by an Out-of-Network provider or facility within any department of the hospital where such items or
services are provided after the patient is stabilized and as part of outpatient observation or an inpatient or
outpatient stay with respect to stabilizing the patient. In order to qualify as Emergency Care, health care
services must be sought within forty-eight (48) hours of the onset of the illness or Accidental Injury. In order
to qualify as Emergency Care, health care services must be sought in a facility licensed by the state to provide
emergency services within forty-eight (48) hours of the onset of the illness or Accidental Injury.
9.39 Emergency Prescription means any Prescription Medication prescribed in conjunction with Emergency
Care and deemed necessary by a Physician to be immediately needed by the Covered Person.
9.40 Employee means a person who is directly employed by the Employer for Full-Time Employment. This person
must reside in the United States and be paid for full-time work in the conduct of the Employer's regular
business. No director or officer of the Employer shall be considered an Employee unless he meets the above
conditions.
9.41 Employer means a sole proprietorship, partnership, or corporation which is the Policyholder. Employer,
Group, Member and Policyholder shall have a common meaning when used herein.
9.42 Exchange means a governmental agency or non-profit entity, which meets the applicable standards of the
federal Affordable Care Act of 2010 and implementing rules, that makes Qualified Health Plans available to
Qualified Individuals.
9.43 Formulary means a specified list of Prescription Medications covered by the Company. The services of an
independent National Pharmacy and Therapeutics Committee (P&T Committee) are utilized to approve sage
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and clinically effective drug therapies on the Formulary. The P&T Committee is an external advisory body of
experts from across the United States. The P&T Committee’s voting members include physicians,
pharmacists, a pharmacoeconomist and a medical ethicist, all of whom have a broad background of clinical
and academic expertise regarding prescription drugs.
Prescription Medications on the Formulary are classified into various cost tier designs based on the benefit.
Prescription Medication tiers are classified as Preventive Medications, Generic Medications, Brand Name
Medications, and Specialty Medications. The list of Prescription Medications that make up the Formulary
and the tier classification of a Prescription Medication on the Formulary are subject to change by the
Company and the Pharmacy and Therapeutics Committee. In recommending whether to place a Prescription
Medication on the Formulary or to place a Prescription Medication in a tier classification in the Formulary, the
Pharmacy and Therapeutics Committee compares a Prescription Medication’s safety, effectiveness, cost
efficiency and uniqueness with other Prescription Medications in the same category. Prescription
Medications including new Prescription Medications approved by the FDA are not covered under this
Benefit Certificate unless or until the Company places the medication on the Formulary.
9.44 Freestanding Facility means an entity that furnishes health care services and that is neither integrated with,
nor a department of, a Hospital. Physically separate facilities on the campus of a Hospital are considered
freestanding unless they are integrated with, or a department of, the Hospital. Examples of Freestanding
Facilities include, but are not limited to, Free-Standing Cardiac Care Facilities and Free-Standing Residential
Treatment Centers. Ambulatory Surgery Centers performing Covered Services provided in 3.4 are not
considered Freestanding Facilities. Laboratories are not considered Freestanding Facilities.
9.45 Full-Time Employment, full-time active Employee, and like terms, mean a job with the Employer:
1. on a permanent and active basis;
2. for compensation; and
3. for at least thirty (30) hours a week, forty-eight (48) weeks per year.
9.46 Generic Medication means any US Food and Drug Administration (“FDA”) approved, chemically identical,
reproduction of a Brand Name Medication for which the patent has expired. A Prescription Medication must
have a price at least twenty percent (20%) lower than the Brand Name Medication in order to qualify as a
Generic Medication for reimbursement purposes.
9.47 Group Policy or Group Insurance Contract means the insurance policy issued by the Company to the
Employer.
9.48 Habilitation means health care services provided in order for a person to attain and maintain a skill or function
that was never learned or acquired and is due to a disabling condition.
9.49 Health Intervention or Intervention means an item, Medication or service delivered or undertaken primarily
to diagnose, detect, treat, palliate or alleviate a medical condition or to maintain or restore functional ability
of the mind or body.
9.50 Hearing Aid means an instrument or device, including repair and replacement parts, that
1. is designed and offered for the purpose of aiding persons with or compensating for impaired hearing;
2. is worn in or on the body; and
3. is generally not useful to a person in the absence of a hearing impairment.
9.51 Homeopathic means healing the underlying cause of disease not simply eliminating the symptoms caused
by the disease. Some forms of homeopathic treatment may include, but are not limited to diet therapy,
environment services, minimum doses of natural medications. Homeopathic treatments are not covered.
See Subsection 4.2.65.
9.52 Hospice Care means an autonomous, centrally administered, medically directed, coordinated program
providing a continuum of home, outpatient and home-like inpatient care for the terminally ill patient and family.
Hospice Care provides palliative and supportive care to meet the special needs arising out of the physical,
emotional, spiritual, social and economic stresses which are experienced during the final stages of illness
and during dying and bereavement.
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9.53 Hospital means an acute general care Hospital and a Rehabilitation Hospital licensed as such by the
appropriate state agency. It does not include any of the following, unless required by applicable law or
approved by the Board of Directors of the Company: Hospitals owned or operated by state or federal
agencies, convalescent homes or Hospitals, homes for the aged, sanitariums, long term care facilities,
infirmaries, or any institution operated mainly for treatment of long-term chronic diseases.
9.54 In-Network Provider means a Preferred Provider or a Contracting Provider who has signed a contract with
the Company to provide the Covered Services by this Benefit Certificate to Covered Persons. The Company
pays an In-Network Provider directly.
9.55 Laboratory means an entity furnishing biological, microbiological, serological, chemical,
immunohematological, hematological, biophysical, cytological, pathological or other examination of materials
derived from the human body for the purpose of providing information for the diagnosis, prevention, or
treatment of any disease or impairment of, or the assessment of the health of, human beings. These
examinations also include procedures to determine, measure or otherwise describe the presence or absence
of various substances or organisms in the body. Entities only collecting or preparing specimens (or both) or
only serving as a mailing service and not performing testing are not considered laboratories.
9.56 Late Enrollee means a Covered Person who submits an application for coverage other than during:
1. the first period in which the Covered Person is eligible to enroll in the Plan; or
2. a Special Enrollment Period.
9.57 Long-Term Acute Care means the medical and nursing care treatment of medically stable but fragile patients
over an extended period of time, anticipated to be at least 25 days. Long Term Acute Care includes, but is
not limited to, treatment of chronic cardiac disorders, ventilator dependent respiratory disorder, post-operative
complications and total parenteral nutrition (TPN) issues.
9.58 Low Protein Modified Food Products means a food product that is specifically formulated to have less than
one (1) gram of protein per serving and intended to be used under the direction of a Physician for the dietary
treatment of a Medical Disorder Requiring Specialized Nutrients or Formulas.
9.59 Maintenance Medication means a specific Prescription Medication: (1) for ongoing therapy of a chronic
illness; and (2) that has been designated as a Maintenance Medication by the Company. You may obtain a
list of Maintenance Medications by calling Customer Service.
9.60 Maternity Care and Obstetrical Care means Health Interventions necessary because of or related to the
following conditions: premature rupture of membranes; false labor; occasional spotting in pregnancy; pre-
term labor; pre-term birth; physician prescribed rest during the pregnancy; morning sickness; hyperemesis
gravidarum; cephalopelvic disproportion; intrauterine growth retardation; analysis for fetal down syndrome,
analysis for hepatitis C, trisomy 18 or neural tube defect; congenital diaphragmatic hernia; hydrops fetalis;
group B strep prophylaxis in pregnancy; isoimmunization in pregnancy; antepartum fetal surveillance;
management of hyperemesis; cervical incompetence; fetal urethral obstruction; twin or greater gestation with
prior uterine atony; macrosomia; incompetent cervix; forceps deliver; fetal fibronectin; cytotec for induction of
labor; sudden onset of polyhydramnios; prophylactic cesarean delivery of HIV positive mother; Klippel-
Trenaunay Syndrome; caudal regression syndrome; Hospitalization to postpone delivery until the fetus is
further developed; biophysical profiles; fetal monitoring; non-routine ultrasounds; vaginal delivery;
antepartum and postpartum care; or services related to c-sections scheduled because of (a) multiple
gestation, (b) previous c-section delivery, (c) patient or physician convenience, (d) cephalopelvic
disproportion or (e) abnormal presentations such as breech, shoulder dystonia, transverse and compound.
9.61 Medical Disorder Requiring Specialized Nutrients or Formulas means the following inherited metabolic
disorders involving a failure to properly metabolize certain nutrients: nitrogen metabolism disorder;
phenylketonuria; maple syrup urine disease; homocystinuria; citrullinemia; argininosuccinic academia;
tyrosinemia, type 1; very-long-chain acyl-CoA dehydrogenase deficiency long-chain 3 hydroxyacyl-CoA
dehydrogenase deficiency; trifunctional protein deficiency; glutaric academia, type 1; methylcrotonyl CoA
carboxylase deficiency, propionic academia; methylmalonic academia due to mutase deficiency;
methlmalonic academia due to cobalamin A,B defect; isovaleric academia; ornithine transcarbamylase
deficiency; non-ketotic hyperglycinemia; glycogen storage diseases; disorders of creatine metabolism;
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malonic aciduria; carnitine palmitoyl transferase deficiency type II; glutaric aciduria type II; and sulfite oxidase
deficiency.
9.62 Medical Food means a food that is intended for dietary treatment of a Medical Disorder Requiring Specialized
Nutrients or Formulas for which nutritional requirements are established by recognized scientific principles
and formulated to be consumed or administered enterally under the direction of a Physician.
9.63 Medical Literature means articles from major peer-reviewed medical journals specified by the United States
Department of Health and Human Services pursuant to section 1861(t)(2)(B) of the Social Security Act, 42
U.S.C. §1395(x)(t)(2)(B), as amended.
9.64 Medical Supply or Supplies means an item which (1) is consumed or diminished with use so that it cannot
withstand repeated use; and (2) is primarily or customarily used to serve a medical purpose; and (3) generally
is not useful to a person in the absence of an illness or injury.
9.65 Medicare means the two programs cited as the "Health Insurance for the Aged Act," Title I, Part I, of Public
Law 89-97, as amended. Part A refers to Hospital insurance. Part B covers physician services and other
clinical services.
9.66 Mental Illness means and includes (whether organic or non-organic, whether of biological, non-biological,
chemical or non-chemical origin, and irrespective of cause, basis or inducement) mental disorders, mental
illnesses, psychiatric illnesses, mental conditions, and psychiatric conditions. This includes, but is not limited
to schizophrenic spectrum and other psychotic disorders, bipolar and related disorders, depressive disorders,
anxiety disorders, obsessive-compulsive and related disorders, trauma and stressor-related disorders,
dissociative disorders, somatic symptom and related disorders, feeding and eating disorders, elimination
disorders, sleep-wake disorders, sexual dysfunctions, gender dysphoria, disruptive, impulse-control and
conduct disorders, substance-related and addictive disorders, neurocognitive disorders, personality
disorders, paraphilic disorders, and psychological or behavioral abnormalities associated with transient or
permanent dysfunction of the brain or related neurohormonal systems. (This is intended to include only
illnesses classified in the current edition of the Diagnostic and Statistical Manual of Mental Disorders of the
American Psychiatric Association, Washington, D.C.)
9.67 Minimum Essential Coverage means coverage provided by any of the following:
1 A government sponsored plan such as Medicare, Medicaid, Department of Defense coverage for
uniformed services, or the Department of Veterans Affairs;
2. An employer sponsored health benefit plan;
3. Comprehensive health coverage in the individual market;
4. Other coverage, such as a State health benefits risk pool, recognized by the Secretary of Health and
Human Services.
9.68 Naturopathic means a system of therapeutics in which neither surgical or medicine agents are used,
dependence placed only on natural (non-medicinal) focus. Naturopathic treatments are not covered. See
Subsection 4.2.64.
9.69 Neurologic Rehabilitation Facility means an institution licensed as such by the appropriate state agency.
A Neurological Rehabilitation Facility must:
1. be operated pursuant to law;
2. be accredited by the Joint Commission on Accreditation of Healthcare Organizations and the
Commission on Accreditation of Rehabilitation Facilities;
3. be primarily engaged in providing, in addition to room and board accommodations, rehabilitation
services for Severe Traumatic Brain Injury under the supervision of a duly licensed Physician (M.D.
or D.O.); and
4. maintain a daily progress record for each patient.
9.70 Non-Contracting Provider means a Provider who has declined to sign a contract with this Company to
provide to Covered Persons services covered by this Benefit Certificate. Non-Contracting Providers are free
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to bill and collect from you charges for Covered Services which are in excess of the Company’s Allowance
or Allowable Charge.
9.71 Non-Diseased Tooth means a 1.) virgin or unrestored tooth or 2.) a tooth that had no decay, no filling on
more than two surfaces, no gum disease associated with any bone loss, no root canal therapy, no dental
implant, and previously functioned normally in chewing and speech.
9.72 Non-Preferred Provider means a Provider that does not participate in the Preferred Provider Organization.
9.73 Open Enrollment Period means the period annually, that is designated by the Employer and set forth in the
Group Application, when Employees who are eligible for coverage may enroll in the Plan. During the Open
Enrollment Period, Employees covered in the Plan may change their coverage, and that of their covered
Dependents. Unless otherwise designated in this Benefit Certificate, enrollments and coverage changes
made during the Open Enrollment Period become effective on the anniversary date of the Group Policy. If
for any reason, Employer fails to designate an Open Enrollment Period, or the Group Application fails to
indicate it, the Open Enrollment Period shall be the month prior to the anniversary of the effective date of the
Group Policy.
9.74 Orthotic Device means a support, brace, or splint used to support, align, prevent, or correct the function of
movable parts of the body.
9.75 Out-of-Network Provider means a Non-Contracting Provider who does not have a contract with the
Company to provide Covered Services by this Benefit Certificate to Covered Persons. Out-of-Network
Providers are free to bill and collect from you charges for Covered Services which are in excess of the
Company’s Allowance or Allowable Charge except in the limited situations outlined in Subsection 5.1.7.b,
above.
9.76 Outpatient Hospital means a portion of a Hospital which provides diagnostic, therapeutic (both surgical and
nonsurgical), and rehabilitation services by, or under the supervision of, a Physician to patients treated on an
outpatient basis for a variety of medical conditions and not kept overnight or otherwise admitted as inpatients
to the Hospital.
9.77 Outpatient Surgery Center or Radiation Therapy Center means a facility licensed as such by the
appropriate state agency.
9.78 Outpatient Therapy Visit means one unit of therapeutic service (usually one hour or less) provided by
licensed Provider(s). An Outpatient Therapy Visit may include services provided by more than one Provider
and in the case of physical therapy, up to four modalities of treatment. Any physical therapy or occupational
therapy modality, regardless of who provides the service, is included in the visit limit. Outpatient therapy visit
applies to therapy provided in a physician’s office or in a physical therapy setting.
9.79 Partial Day Treatment Program means treatment for a Covered Person who is not at imminent risk of
significant harm to self or others but requires a structured and monitored environment with access to the full
spectrum of Health Interventions. Physicians normally prescribe services for at least 4 hours, but not more
than 8 hours in any 24-hour period.
9.80 Participating Pharmacy means a licensed pharmacy that has contracted directly or indirectly with the
Company to provide pharmacy services to Covered Persons subject to all terms, conditions, exclusions and
limitations of the Plan set forth in this Benefit Certificate.
9.81 Physician means a Doctor of Medicine (M.D.) or a Doctor of Osteopathy (D.O.) duly licensed and qualified
to practice medicine and perform surgery at the time and place a claimed intervention is rendered. Physician
also means a Doctor of Podiatry (D.P.M.), a Chiropractor (D.C.), a Psychologist (Ph.D.), a Dentist
(D.D.S./D.M.D.) or an Optometrist (O.D.) duly licensed and qualified to perform the claimed Health
Intervention at the time and place such intervention is rendered.
9.82 Physician Service means such services as are rendered by a licensed Physician within the scope of his
license.
9.83 Placement, or being placed, for adoption means the assumption and retention of a legal obligation for total
or partial support of a Child by a person with whom the Child has been placed in anticipation of the Child's
adoption. The Child's Placement for adoption with such person terminates upon the termination of such legal
obligation.
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9.84 Plain Film Radiograph means a routine film x-ray performed in a Specialty Care Physician's office and
provided in accordance with Coverage Policy established by the Company.
9.85 Plan means the Employee Health Benefit Plan established by your Employer. The terms of the Plan are set
forth in the Group Policy or Group Insurance Contract between the Company and your Employer.
9.86 Plan Administrator means the Employer.
9.87 Plan Year means the Plan Year stated in the Employee Health Benefit Plan Summary Plan Description, or if
not stated in that document, or if that document does not exist, the twelve-month period ending on the day
before the anniversary date of the effective date of this Benefit Certificate.
9.88 Policy means the Group Policy or Group Insurance Contract.
9.89 Policy Month means a month commencing on the first day of a calendar month and expiring on the last day
of that calendar month or commencing on the fifteenth day of a month and expiring on the fourteenth day of
the following month, depending upon the billing cycle applied by the Company.
9.90 Policyholder means the Employer that established and maintains the Plan, as shown in the Application of
the Group Insurance Policy.
9.91 Preferred Provider means a Contracting Provider who has agreed to participate in the Preferred Provider
Organization and meets all applicable credentialing and contractual standards associated with the Preferred
Provider Organization.
9.92 Preferred Provider Organization means a panel of Providers (Hospitals and Physicians) who have agreed
to accept reimbursement for their services covered under this Plan at reduced charges.
9.93 Prescription means an order for Medications by a Physician or health care Provider authorized by applicable
law to issue a Prescription, to a pharmacy for the benefit of and use by a Covered Person.
9.94 Prescription Medication or Medication means any pharmaceutical that has been approved by the FDA and
can be obtained only through a Prescription. The Company has classified selected Prescription Medications,
primarily Medications intended for self-administration as “A Medications.” The Company has classified Intra-
muscular injections, Intravenous injections and other pharmaceuticals that are primarily intended for
professional administration as “B Medications.” You can determine whether a Medication is an A Medication
or a B Medication by contacting Customer Service.
9.95 Primary Care Physician means a Preferred Provider Physician who provides primary medical care in one
of these medical specialties: General Practice, Pediatrics, Family Practice, Obstetrics/Gynecology (when
providing Preventive Health Services) or Internal Medicine. This also includes advanced practice nurses or
physician’s assistants who provide primary medical care in these medical specialties and are performed in
the Primary Care Physician’s office.
9.96 Prior Approval means the process initiated by the Company as a result of a pre-service claim (see
Subsection 7.1.3.b.) to determine in advance of the Covered Person obtaining a requested medical service,
Medication, supply, test, or equipment if such medical service, Medication, supply, test, or equipment initially
meets Primary Coverage Criteria requirements set out in Subsection 2.4.1.b., e., or f., and is not subject to a
Specified Plan Exclusion (see Section 4.0). Ongoing therapy of a prior authorized Medication may require
periodic assessments that could include an efficacy measure intended to demonstrate positive outcomes for
continuation of therapy. Plan benefits requiring the submission of a pre-service claim are described more fully
below. Failure of the Covered Person's treating Provider to obtain Prior Approval with respect to a
pre-service claim will result in a denial of coverage but in all such instances involving a Contracting
Provider who is contracted with the Company for participation in the Company’s networks in
Arkansas, the Covered Person shall have no payment obligation to such Contracting Provider, whose
network contract requires waiver of provider charges for failure to obtain Prior Approval. In addition,
if a Non-Contracting Provider or nonparticipating provider, in any state, pursues recovery of any
amounts alleged to be due or payable under this Benefit Certificate with regard to services subject to
Prior Approval, failure of such Non-Contracting Provider or nonparticipating provider to obtain Prior
Approval with respect to a pre-service claim will result in a denial of coverage but in all such
instances, a Non-Contracting Provider or a nonparticipating provider who requires or takes an
assignment of benefits from the Covered Person or their authorized representative shall, by doing
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so, relieve the Covered Person from any payment obligations to such Non-Contracting Provider or
nonparticipating provider, and the assignment shall be deemed to have waived all associated charges
with respect to any such pre-service claim. Pre-service claims for services obtained outside of
Arkansas from BlueCard participating providers are subject to the same Prior Approval requirements
and any such claims lacking a required Prior Approval will be denied; however, whether the BlueCard
participating provider’s charges in such instances are waived when Prior Approval is not obtained
by the BlueCard participating provider will depend, in each instance, on the terms of each Host Blue
Plan’s network participation agreement for the applicable BlueCard participating provider. PLEASE
NOTE: Prior Approval does not mean that the service, supply or treatment will be covered regardless
of other terms, conditions or limitations outlined in this Benefit Certificate, but means only that the
information furnished to the Company in the pre-service claim indicates that the requested medical
service, Medication, supply, test or equipment meet the Primary Coverage Criteria requirements set
out in Subsection 2.2 and the Applications of the Primary Coverage Criteria set out in Subsections
2.4.1.b., e., or f. and is not subject to a Specific Plan Exclusion (see Section 4.0). All Health
Interventions receiving Prior Approval must still meet all other coverage terms, conditions, and
limitations, and coverage for these services may still be limited or denied if, when the post-service
claim for the services is received by the Company, investigation shows that a benefit exclusion or
limitation applies because of a difference in the Health Intervention described in the pre-service claim
and the actual Health Intervention, that the Covered Person ceased to be eligible for benefits on the
date the services were provided, that coverage lapsed for non-payment of premium, that out-of-
network limitations apply, or any other basis specified in this Benefit Certificate. For more information
about Prior Approval, please see Subsection 7.3.1b.
Plan benefits requiring pre-service claims are certain Prescription Medications, (Subsection 3.23); and Non-
PPO Benefits (Subsection 5.1.3)
9.97 Prosthetic Device
means a device used to replace, correct, or support a missing portion of the body, to
prevent or correct a physical deformity or malfunction, or to support a weak or deformed portion of the body.
Prosthetic Devices do not include dentures or other dental appliances that replace either teeth or structures
directly supporting the teeth.
9.98 Prosthodontic Services means Dental Care services for the diagnosis, treatment planning and rehabilitation
of the oral function and health of patients with clinical conditions associated with missing or deficient teeth or
oral and maxillofacial tissues, or both, using biocompatible substitutes. All Prosthodontic Services are paid
as dental benefits.
9.99 Provider means an advance practice nurse; an athletic trainer; an audiologist; a certified orthotist; a
chiropractor; a community mental health center or clinic; a dentist, a Hospital; a licensed ambulatory surgery
center; a licensed certified social worker; a licensed dietician; a licensed durable medical equipment provider;
a licensed professional counselor; a licensed psychological examiner; a long-term care facility; a non-Hospital
based medical facility providing clinical diagnostic services for sleep disorders; a non-Hospital based medical
facility providing magnetic resonance imagining, computed axial tomography, or other imaging diagnostic
testing; an occupational therapist; an optometrist; a pharmacist; a physical therapist; a physician or surgeon
(M.D. and D.O.); a podiatrist; a prosthetist; a psychologist; a respiratory therapist; a rural health clinic; a
speech pathologist and any other type of health care Provider which the Company, in its sole discretion,
approves for reimbursement for services rendered.
9.100 Psychiatric Residential Treatment Center means a facility, or a distinct part of a facility, for psychiatric care
which provides a total 24-hour therapeutically planned and professionally staffed group living and learning
environment.
9.101 Qualified Employee means an individual employed by a qualified employer who has been offered health
insurance coverage by such qualified employer through the Small Health Options Program (“SHOP”).
9.102 Qualified Employer means a small employer that elects to make, at a minimum, all full-time employees of
such employer eligible for a QHP in the small group market offered through the SHOP
9.103 Qualified Health Plan or QHP means a health plan that has in effect a certification issued by the Exchange.
9.104 Recognized Amount is the amount which your cost sharing is based on for the following Covered Services
when provided by Out-of-Network Providers: Out-of-Network Emergency Care; non-Emergency Care
94
received at certain In-Network facilities by Out-of-Network Providers, when such services are either Ancillary
Services, or non-Ancillary Services that have not satisfied the notice and consent criteria of section 2799B-
2(d) of the Public Service Act. For the purpose of this provision, "certain In-Network facilities" are limited to a
hospital (as defined in 1861(e) of the Social Security Act), a hospital outpatient department, a critical access
hospital (as defined in 1861(mm)(1) of the Social Security Act), an ambulatory surgical center described in
section 1833(i)(1)(A) of the Social Security Act, and any other facility specified by the Secretary. The
Recognized Amount is based on the qualifying payment amount as determined under applicable law.
Note: Covered Services that use the Recognized Amount to determine your cost sharing may be
higher or lower than if cost sharing for these Covered Services were determined based upon an
Allowed Amount.
9.105 Relevant to the Claim means a document, record or other information that:
1. was relied upon in making the benefit determination;
2. was submitted, considered, or generated in the course of making the benefit determination, without
regard to whether such document, record or other information was relied upon in making the benefit
determination;
3. demonstrates compliance with the administrative processes and safeguards required by 7.2.5.b.; and
4. constitutes a statement of policy or guidance with respect to the Plan concerning the denied treatment
option or benefit for the Covered Person’s diagnosis, without regard to whether such advice or
statement was relied upon in making the benefit determination.
9.106 Routine Patient Costs in connection with an Approved Clinical Trial mean the costs for health interventions
covered by the Plan except:
1. the investigational item, device or service, itself;
2. items and services that are provided solely to satisfy data collection and analysis needs and that are
not used in direct clinical management of the individual undergoing the clinical trial; or
3. a service that is clearly inconsistent with widely accepted and established standards of care for the
particular diagnosis.
9.107 Routine Prenatal Care means outpatient antepartum care and laboratory testing that has been approved as
routine based on a Coverage Policy established by the Company. A copy of the Routine Prenatal Care
Coverage Policy is available from the Company, at no cost, upon request, or may be reviewed on the
Company’s web site at WWW.ARKANSASBLUECROSS.COM
.
9.108 Severe Traumatic Brain Injury means a sudden trauma causing damage to the brain as a result of the head
suddenly and violently hitting an object or an object piercing the skull and entering brain tissue with an
extended period of unconsciousness or amnesia after the injury or a Glasgow Coma Scale below 9 within
the first 48 hours of injury.
9.109 Skilled Nursing Facility means an institution licensed as such by the appropriate state agency. A Skilled
Nursing Facility must:
1. be operated pursuant to law;
2. be approved for payment of Medicare benefits or be qualified to receive such approval, if so
requested;
3. be primarily engaged in providing, in addition to room and board accommodations, skilled nursing
care under the supervision of a duly licensed Physician (M.D. or D.O.);
4. provide continuous 24 hours a day nursing service by or under the supervision of a registered
graduate professional nurse (R.N.) for at least 8 hours per day and a registered graduate professional
nurse (R.N.) or licensed practical nurse (L.P.N.) for the remaining 16 hours; and
5. maintain a daily medical record of each patient.
However, a Skilled Nursing Facility does not include:
95
1. any home, facility or part thereof used primarily for rest;
2. a home or facility for the aged or for the care of drug addicts or alcoholics; or
3. a home or facility primarily used for the care and treatment of mental diseases, or disorders, or
Custodial Care or educational care.
9.110 Specialty Care Physician means a Preferred Provider Physician with any specialty other than primary care
who practices such specialty and who has met the participation standards of the Company. (Specialty Care
Physicians do not include the following: Family Practice, General Practice, Internal Medicine, Pediatrics or
Obstetrics/Gynecology – when providing Preventive Health Services.)
9.111 Spouse means an individual who is the husband or wife of an Employee as a result of a marriage that is
legally recognized in a jurisdiction within the United States of America.
9.112 Step Therapy means a process that establishes a required order of use for a specific Prescription Medication.
For example, a Step Therapy may require that medication “X” be used for a period of time before medication
“Y” or that a weaker strength of a medication be used for a period before a stronger strength of the same
medication.
9.113 Stepchild means a natural or adopted Child of the Spouse of the Employee.
9.114 Substance Use Disorder means a maladaptive pattern of substance use manifested by recurrent and
significant adverse consequences related to the repeated use of substances.
9.115 Substance Use Disorder Residential Treatment Center means a facility that provides treatment for
substance (alcohol and drug) use disorders to live-in residents who do not require acute medical care.
Services include individual and group therapy and counseling, family counseling, laboratory tests, drug and
supplies, psychological testing, and room and board.
9.116 Telemedicine means the use of information and communication technology to deliver healthcare services,
including without limitation to the assessment, diagnosis, consultation, treatment, education, care
management, and self-management. Telemedicine includes store-and-forward technology and remote
patient monitoring but does not include audio-only communication unless it is real-time, interactive and
substantially meets the requirements for a Covered Service that would otherwise be covered by the Plan,
including without limitation a facsimile machine, text messaging, or electronic mail systems.
9.117 Transplant Global Period means a period of time that begins on or prior to the day of the transplant
procedure and extends for a number of days after the transplant procedure. The length of the Transplant
Global Period varies, depending upon the type of transplant involved.
9.118 Waiting Period means the time beginning with the Employee's most recent date of continuous employment
with the Employer and ending on the date he is eligible for insurance. The Employer establishes the Waiting
Period, but for purposes of coverage or eligibility determinations under this Benefit Certificate, the Waiting
Period shall be such period as is reflected in the enrollment records of the Company.
9.119 We, Our and Us mean the Company.
9.120 Work Hardening means a highly specialized rehabilitation program that spans the transition from traditional
rehabilitation therapies to return to work by simulating the workplace activities and surroundings in a
monitored environment. Programs may be developed and carried out by an occupational therapist and/or
physical therapist. The goal is to create an environment in which returning workers can rebuild psychological
self-confidence and physical reconditioning by replicating their work routine.
9.121 Work Integration (Community) means training in shopping, transportation, money management, vocational
activities and/or work environment/modification analysis, and/or work task analysis. This is not considered
medical treatment.
9.122 You and Your mean a Covered Person.
10.0 YOUR RIGHTS UNDER ERISA
96
The following information is provided to you in accordance with the Employee Retirement Income Security Act of
1974 (ERISA). This information and the information contained in this Benefit Certificate, constitute the Summary Plan
Description required by ERISA.
10.1 Information about the Plan As a participant in the Plan described in this Benefit Certificate, you are entitled
to certain rights and protections under the Employee Retirement Income Security Act of 1974, as amended
(ERISA). ERISA provides that all plan participants shall be entitled to:
1. Examine, without charge, at the Plan Administrator’s office all plan documents, including insurance
company contracts, and copies of all documents filed by the plan with the U.S. Department of Labor
such as detailed annual reports and plan descriptions.
2. Obtain copies of all applicable plan documents and other plan information upon written request to
the Plan Administrator. The administrator may make a reasonable charge for the copies.
3. Receive a summary of the plan’s annual financial report. The Plan Administrator is required by law
to furnish each participant with a copy of this summary annual report.
10.2 Continuation of Coverage The Plan provides an opportunity to continue coverage for yourself, spouse,
dependents if there is a loss of coverage under the Plan as a result of a qualifying event. See Subsection
6.4.3.a. You or your dependents may have to pay for such coverage. Review this Benefit Certificate,
Subsection 6.4.3 and the documents governing the Plan on the rules governing your COBRA continuation
coverage rights.
10.3 Creditable Coverage The Plan provides a reduction or elimination of exclusionary periods of coverage for
Preexisting Conditions under your group health plan, if you have creditable coverage from another plan. You
should be provided a certificate of creditable coverage, free of charge, from your group health plan or health
insurance issuer when you lose coverage under the plan, when you become entitled to elect COBRA
continuation coverage, when your COBRA continuation coverage ceases, if you request it up to 24 months
after losing coverage. You may also request a certificate of creditable coverage at any time during your
coverage period by writing Arkansas Blue Cross and Blue Shield, Customer Service Division, Post Office Box
2181 Little Rock, Arkansas 72203, or by Telephone to (501) 378-2070 or toll free (800) 421-1112. Without
evidence of creditable coverage, you may be subject to Preexisting Condition exclusion for 12 months after
your enrollment in your coverage.
10.4 Prudent Actions by Plan Fiduciaries
1. In addition to creating rights for plan participants, ERISA imposes duties upon the people who are
responsible for the operation of the employee benefit plan. The people who operate your plan, called
“fiduciaries” of the plan, have a duty to do so prudently and in the interest of you and other participants
and beneficiaries.
2. No one, including your employer, or any other person, may fire you or otherwise discriminate against
you in a way to prevent you from obtaining a benefit or exercising your rights under ERISA.
10.5 Enforce your Rights
1. If your claim for a benefit is denied, in whole or in part, you must receive a written explanation of the
reason for the denial. You have the right to have the plan review and reconsider your claim.
2. Under ERISA, there are steps you can take to enforce the above rights. For instance, if you request
materials from the Plan and do not receive them within 30 days, you may file suit in a federal court.
In such a case, the court may require the Plan Administrator to provide the materials and pay you
per day until you receive the materials, unless the materials were not sent because of reasons
beyond the control of the administrator. If you have a claim for benefits which is denied or ignored,
in whole or in part, you may file suit in a state or federal court. If it should happen that Plan fiduciaries
misuse the plan’s money, or if you are discriminated against for asserting your rights, you may seek
assistance from the U.S. Department of Labor, or you may file suit in a federal court. The court will
decide who should pay court costs and legal fees. If you are successful, the court may order the
person you have sued to pay these costs and fees. If you lose, the court may order you to pay these
costs and fees for example, if it finds your claim is frivolous.
97
10.6 Assistance with Your Questions If you have any questions about your Plan, you should contact the Plan
Administrator. If you have any questions about this statement or your rights under ERISA, you should contact
the nearest area office of the Employee Benefits Security Administration, U.S. Department of Labor listed in
your telephone directory or the Division of Technical Assistance and Inquiries, Employee Benefits Security
Administration, U.S. Department of Labor, 200 Constitution Avenue, N.W., Washington, D.C. 20210.
10.7 Claim and Appeal Procedures The Plan rules and procedures for filing claims and seeking review of
adverse claim determinations are set forth in Section 7.0 of this Benefit Certificate.
Curtis Barnett, President and Chief Executive Officer
ARKANSAS BLUE CROSS AND BLUE SHIELD
601 S. Gaines Street
Little Rock, Arkansas 72201
98
ARKANSAS CONSUMERS INFORMATION NOTICE
For additional information regarding your Arkansas Blue Cross and Blue Shield benefits,
please feel free to contact us at:
Arkansas Blue Cross and Blue Shield
Customer Service
Post Office Box 2181
Little Rock, Arkansas 72203
Telephone toll free (800) 238-8379
If we at Arkansas Blue Cross and Blue Shield fail to provide you with reasonable and
adequate service, you should feel free to contact:
Arkansas Insurance Department
Consumer Services Division
1 Commerce Way, Suite 102
Little Rock, Arkansas 72202
Telephone (501) 371-2640 or toll free (800) 852-5494
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LIMITATIONS AND EXCLUSIONS UNDER THE
ARKANSAS LIFE AND HEALTH INSURANCE
GUARANTY ASSOCIATION ACT
Residents of this state who purchase life insurance, annuities or health insurance should know that the insurance
companies licensed in this state to write these types of insurance are members of the Arkansas Life and Health
Insurance Guaranty Association ("Guaranty Association"). The purpose of the Guaranty Association is to assure that
policy and contract owners will be protected, within certain limits, in the unlikely event that a member insurer becomes
financially unable to meet its obligations. If this should happen, the Guaranty Association will assess its other member
insurance companies for the money to pay the claims of policy and contract owners who live in this state and, in some
cases, to keep coverage in force. Please note that the valuable extra protection provided by the member insurers
through the Guaranty Association is limited. This protection is not a substitute for a consumers' careful consideration
in selecting insurance companies that are well managed and financially stable.
DISCLAIMER
The Arkansas Life and Health Insurance Guaranty Association ("Guaranty Association")
provides coverage of claims under some types of policies or contracts if the insurer or health
maintenance organization becomes impaired or insolvent. COVERAGE MAY NOT BE
AVAILABLE FOR YOUR POLICY. Even if coverage is provided, there are significant limits
and exclusions. Coverage is always conditioned on residence in the State of Arkansas. Other
conditions may also preclude coverage.
The Guaranty Association will respond to any questions you may have which are not
answered by this document. Your insurer or health maintenance organization and agent are
prohibited by law from using the existence of the association or its coverage to sell you an
insurance policy or health maintenance organization coverage.
You should not rely on availability of coverage under the Guaranty Association when selecting
an insurer or health maintenance organization.
The Arkansas Life and Health Insurance Guaranty Association
c/o The Liquidation Division
1023 West Capitol, Suite 2
Little Rock, Arkansas 72201
Arkansas Insurance Department
1 Commerce Way, Suite 102
Little Rock, Arkansas 72202
The state law that provides for this safety net is called the Arkansas Life and Health Insurance Guaranty Association
Act ("Act"), which is codified at Ark. Code Ann. §§ 23-96-101, et seq. Below is a brief summary of the Act's coverage,
exclusions and limits. This summary does not cover all provisions of the Act, nor does it in any way change any
person's rights or obligations under the Act or the rights or obligations of the Guaranty Association.
COVERAGE
Generally, individuals will be protected by the Guaranty Association if they live in this state and hold a life, annuity or
health insurance contract or policy, or if they are insured under a group insurance contract issued by a member
insurer. The beneficiaries, payees or assignees of policy or contract owners are protected as well, even if they live in
another state.
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EXCLUSIONS FROM COVERAGE
However, persons owning such policies are NOT protected by the Guaranty Association if:
• They are eligible for protection under the laws of another state (this may occur when the insolvent insurer was
incorporated in another state whose guaranty association protects insureds who live outside that state);
• The insurer was not authorized to do business in this state; or
• Their policy or contract was issued by a hospital or medical service organization, a fraternal benefit society, a
mandatory state pooling plan, a mutual assessment company or similar plan in which the policy or contract owner
is subject to future assessments, or by an insurance exchange.
The Guaranty Association also does NOT provide coverage for:
• Any policy or contract or portion thereof which is not guaranteed by the insurer or for which the owner has
assumed the risk, such as non-guaranteed amounts held in a separate account under a variable life or variable
annuity contract;
• Any policy of reinsurance (unless an assumption certificate was issued);
• Interest rate yields that exceed an average rate;
• Dividends, voting rights, and experience rating credits;
• Credits given in connection with the administration of a policy by a group contract holder;
• Employer plans to the extent they are self-funded (that is, not insured by an insurance company, even if an
insurance company administers them);
• Unallocated annuity contracts (which give rights to group contract holders, not individuals);
• Unallocated annuity contracts issued to or in connection with benefit plans protected under the Federal Pension
Benefit Corporation ("FPBC"), regardless of whether the FPBC is yet liable;
• Portions of an unallocated annuity contract not owned by a benefit plan or a government lottery (unless the owner
is a resident) or issued to a collective investment trust or similar pooled fund offered by a bank or other financial
institution;
• Portions of a policy or contract to the extent assessments required by law for the Guaranty Association are
preempted by state or federal law;
• Obligations that do not arise under the policy or contract, including claims based on marketing materials or side
letters, riders, or other documents which do not meet filing requirements, claims for policy misrepresentations,
and extra-contractual or penalty claims; or
• Contractual agreements establishing the member insurer's obligations to provide book value accounting
guarantees for defined contribution benefit plan participants by reference to a portfolio of assets owned by a
nonaffiliated benefit plan or its trustee(s).
LIMITS ON AMOUNT OF COVERAGE
The Act also limits the amount the Guaranty Association is obligated to cover: The Guaranty Association cannot pay
more than what the insurance company would owe under a policy or contract. Also, for any one insured life, the
Guaranty Association will pay a maximum of $300,000 in life insurance death benefits without regard to the number
of policies and contracts there were with the same company, even if they provided different types of coverages. The
Guaranty Association will pay a maximum of $500,000 in health benefits, provided that coverage for disability
insurance benefits and long-term care insurance benefits shall not exceed $300,000. The Guaranty Association will
pay $300,000 in present value of annuity benefits, including net cash surrender and net cash withdrawal values.
There is a $1,000,000 limit with respect to any contract holder for unallocated annuity benefits. These are limitations
under which the Guaranty Association is obligated to operate prior to considering either its subrogation and
assignment rights or the extent to which those benefits could be provided from assets of the impaired or insolvent
insurer.
