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Gold Bluechoice Open Access Point of Service Evidence Of GOLD BLUECHOICE OPEN ACCESS POINT OF SERVICE EVIDENCE OF COVERAGE IMPORTANT NOTICE COVERED BENEFITS RECEIVED FROM AN OUT-OF-NETWORK PROVIDER, EXCEPT IN CERTAIN CIRCUMSTANCES (SEE SECTION 5.0.), ARE PAID AT A RATE LESS THAN LIKE COVERED BENEFITS RECEIVED FROM AN IN-NETWORK PROVIDER. (SEE YOUR SCHEDULE OF BENEFITS) HMO PARTNERS, INC. d/b/a HEALTH ADVANTAGE 320 WEST CAPITOL AVENUE LITTLE ROCK, ARKANSAS 72201 31-17 1/14 Gold 1000.1/1000.2/1500.1/1500.2 TABLE OF CONTENTS SCHEDULE OF BENEFITS.........................................................................................................................................4 PATIENT PROTECTIONS ...........................................................................................................................................5 1.0 HOW THE COVERAGE UNDER YOUR INSURANCE PLAN WORKS ........................................................6 2.0 PRIMARY COVERAGE CRITERIA ................................................................................................................8 2.1 Purpose and Effect of Primary Coverage Criteria. .......................................................................8 2.2 Elements of the Primary Coverage Criteria. ..................................................................................8 2.3 Primary Coverage Criteria Definitions. ..........................................................................................9 2.4 Application and Appeal of Primary Coverage Criteria. ..............................................................10 3.0 BEN EFITS AND SPECIFIC LIMITATIONS IN YOUR PLAN .......................................................................11 3.1 Professional Services. ...................................................................................................................11 3.2 Preventive Health Services. ..........................................................................................................12 3.3 Hospital Services. ..........................................................................................................................13 3.4 Ambulatory Surgery Center. .........................................................................................................13 3.5 Outpatient Diagnostic Services. ...................................................................................................14 3.6 Advanced Diagnostic Imaging Services. .....................................................................................14 3.7 Maternity. ........................................................................................................................................14 3.8 Therapy and Developmental Services. ........................................................................................15 3.9 Mental Illness and Substance Abuse Services (Alcohol and Drug Abuse). ............................16 3.10 Autism Spectrum Disorder Benefits. ...........................................................................................17 3.11 Emergency Care Services. ............................................................................................................17 3.12 Durable Medical Equipment. .........................................................................................................18 3.13 Medical Supplies. ...........................................................................................................................18 3.14 Prosthetic and Orthotic Devices and Services. ..........................................................................19 3.15 Diabetes Management Services. ..................................................................................................19 3.16 Ambulance Services. .....................................................................................................................20 3.17 Skilled Nursing Facility Services..................................................................................................20 3.18 Home Health Services. ..................................................................................................................20 3.19 Hospice Care. .................................................................................................................................20 3.20 Oral Surgery....................................................................................................................................20 3.21 Dental Care or Orthodontic Services. ..........................................................................................20 3.22 Reconstructive Surgery.................................................................................................................21 3.23 Medications.....................................................................................................................................21 3.24 Organ Transplant Services. .........................................................................................................24 3.25 Medical Foods and Low Protein Modified Food Products.........................................................26 3.26 Prenatal Tests and Testing of Newborn Children. ......................................................................26 3.27 Testing and Evaluation. .................................................................................................................26 3.28 Complications of Smallpox Vaccine. ...........................................................................................26 3.29 Neurologic Rehabilitation Facility Services. ...............................................................................26 3.30 Pediatric Vision Services. .............................................................................................................27 3.31 Adult Vision Services. ...................................................................................................................27 3.32 Hearing Aid Benefits. .....................................................................................................................27 3.33 Temporomandibular Joint Benefits. ............................................................................................28 3.34 Miscellaneous Health Interventions. ............................................................................................28 2 4.0 SPECIFIC PLAN EXCLUSIONS ..................................................................................................................29 4.1 Health Care Providers....................................................................................................................29 4.2 Health Interventions.......................................................................................................................30 4.3 Miscellaneous Fees and Services. ...............................................................................................38 5.0 PROVIDER NETWORK AND COST SHARING PROCEDURES................................................................40 5.1 Network Procedures ......................................................................................................................40 5.2. Policyholder’s Financial Obligations for Allowance or Allowable Charges under the Plan ..44 5.3 Other Plans and Benefit Programs...............................................................................................44 6.0 ELIGIBILITY STANDARDS ..........................................................................................................................47 6.1 Eligibility for Coverage. .................................................................................................................47 6.2 Effective Date of Coverage............................................................................................................48 6.3 Termination of Coverage. ..............................................................................................................50 6.4 Continuation Privileges .................................................................................................................51 6.5 Conversion Privileges ...................................................................................................................53 7.0 CLAIM PROCESSING AND APPEALS .......................................................................................................54 7.1 Claim Processing. ..........................................................................................................................54 7.2 Complaints ......................................................................................................................................59 7.3 Claim Appeals to the Plan (Internal Review). ..............................................................................60 7.4 Independent Medical Review of Claims (External Review)........................................................62 7.5 Authorized Representative............................................................................................................65 8.0 NOTICE OF PHYSICIAN INCENTIVES .......................................................................................................66 8.1 Definitions. ......................................................................................................................................66 8.2 Health Advantage In-Network Provider Incentives. ....................................................................66 8.3 Individual Physician’s
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