Individual HMO Base Benefit Book On Exchange azblue.com IND HMO 01/19 22241 0119 ACA ON HMO BENEFIT BOOK FOR INDIVIDUALS ON EXCHANGE Important Notice New Members: Please read this book, which is part of your contract with Blue Cross® Blue Shield® of Arizona (BCBSAZ) and all accompanying documents when you receive them. If this Benefit Plan is unsatisfactory for any reason, you may cancel your policy by sending BCBSAZ written notice of cancellation within ten (10) days following receipt of this book. You may also contact BCBSAZ to discuss your options for obtaining coverage through another BCBSAZ Plan. If you choose to cancel and you prepaid any premium, BCBSAZ will refund that premium and cancel the contract for your Benefit Plan as though it was never in effect. Renewing Members: This provision does not apply if you are already a BCBSAZ Member and are receiving this book other than at the time of original enrollment in this Plan. If you are a current BCBSAZ Member and want to cancel this Plan, please follow the instructions in “Voluntary Termination of Coverage.” IND HMO 01/19 1 ACA ON TABLE OF CONTENTS CUSTOMER SERVICE INFORMATION .............................................................................................................5 DEFINITIONS ......................................................................................................................................................7 UNDERSTANDING THE BASICS .....................................................................................................................11 Your Responsibilities ......................................................................................................................................11 BCBSAZ ID Card ............................................................................................................................................11 Changes..........................................................................................................................................................12 Covered Services............................................................................................................................................12 Dental Coverage Guidelines...........................................................................................................................12 Dentally Necessary.........................................................................................................................................12 Experimental or Investigational Services........................................................................................................12 Medically Necessary.......................................................................................................................................13 Medical Necessity Guidelines and Criteria .....................................................................................................13 PROVIDERS ......................................................................................................................................................14 Network Providers...........................................................................................................................................14 Out-of-Network Providers ...............................................................................................................................14 Differences in Financial Responsibility ...........................................................................................................14 Locating a Network Provider...........................................................................................................................14 Precertifications for Out-of-Network Providers ...............................................................................................15 Continuing Care from an Out-of-Network Provider.........................................................................................15 Out-of-Area Services ......................................................................................................................................15 Services Received on Cruise Ships................................................................................................................17 PRECERTIFICATION ........................................................................................................................................18 Precertification ................................................................................................................................................18 When Is Precertification Required and What Happens If You Don’t Obtain It................................................18 How to Obtain Precertification ........................................................................................................................18 Factors BCBSAZ Considers in Evaluating a Precertification Request for Services or Medications ..............18 Prescription Medication Exception..................................................................................................................18 Precertification of Network Cost Share for Services from an Out-of-Network Provider .................................18 If BCBSAZ Precertifies Your Service..............................................................................................................18 If BCBSAZ Denies Your Precertification Request ..........................................................................................18 CLAIMS INFORMATION ...................................................................................................................................20 Filing Claims ...................................................................................................................................................20 Time Limit for Claim Filing ..............................................................................................................................20 Claim Forms....................................................................................................................................................20 Complete Claims.............................................................................................................................................20 Medical and Dental Records and Other Information Needed to Process a Claim .........................................20 Explanation of Benefits (EOB) Form and Monthly Member Health Statement...............................................21 Notice of Determination ..................................................................................................................................21 Pharmacy Prescriptions; Submission of Claims by Members ........................................................................21 Time Period for Claim Decisions ....................................................................................................................21 Urgent Requests for Precertification...............................................................................................................22 Concurrent Care Decisions.............................................................................................................................22 GENERAL PROVISIONS ..................................................................................................................................23 Appeal and Grievance Process ......................................................................................................................23 Billing Limitations and Exceptions ..................................................................................................................23 Blue Cross and Blue Shield Association.........................................................................................................23 Broker Commissions.......................................................................................................................................23 Claim Editing Procedures and Pricing Guidelines ..........................................................................................23 Identity Protection Services ............................................................................................................................24 Confidentiality and Release of Information.....................................................................................................24 Court or Administrative Orders Concerning Dependent Children ..................................................................24 Access to Information Concerning Dependent Children.................................................................................24 Discretionary Authority....................................................................................................................................24 Provider Treatment Decisions and Disclaimer of Liability ..............................................................................24 Lawsuits against BCBSAZ..............................................................................................................................24 Legal Action and Applicable Law....................................................................................................................25 Non-Assignability of Benefits ..........................................................................................................................25