UC2004 查看數據表（PDF） - Unspecified

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UC2004

Behavioral Health Benefits for Blue Cross PLUS

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Table of Contents

Schedule of Benefits ......................................................................................................................................................... 1

Effective Date of this Plan........................................................................................................................................... 1

Behavioral Health Benefits .......................................................................................................................................... 1

Eligibility, Enrollment and Termination Provisions ............................................................................................... 3

Eligibility....................................................................................................................................................................... 3

Enrollment ..................................................................................................................................................................... 5

Termination of Coverage.............................................................................................................................................. 7

Behavioral Health Benefits ............................................................................................................................................ 8

What This Plan Pays ..................................................................................................................................................... 8

Telemedicine ................................................................................................................................................................. 8

Notification Requirements and Utilization Review................................................................................................... 9

Emergency Care............................................................................................................................................................ 9

Copayments and Deductibles....................................................................................................................................... 9

Mental Health Office Visit Copayment .................................................................................................................... 10

Substance Abuse Inpatient and Intermediate Care Calendar Year Deductible....................................................... 10

Out-of-Pocket Feature ............................................................................................................................................... 10

Individual Mental Health Out-of-Pocket Maximum ................................................................................................ 10

Family Mental Health Out-of-Pocket Maximum..................................................................................................... 10

Out-of-Network Calendar Year Deductible.............................................................................................................. 10

Non-Notification Deductible..................................................................................................................................... 10

What’s Not Covered - Exclusions ............................................................................................................................. 10

Network Provider Charges Not Covered.................................................................................................................. 12

Claims Information ........................................................................................................................................................ 13

How to File a Claim.................................................................................................................................................... 13

When Claims Must be Filed....................................................................................................................................... 13

How and When Claims are Paid................................................................................................................................. 14

Benefit Determinations .............................................................................................................................................. 15

Appeal Process............................................................................................................................................................ 17

Appeals Determinations ............................................................................................................................................. 17

Independent Medical Review..................................................................................................................................... 18

Legal Actions .............................................................................................................................................................. 18

Incontestability of Coverage ...................................................................................................................................... 18

Coordination of Benefits ............................................................................................................................................... 19

Definitions................................................................................................................................................................... 19

How Coordination Works .......................................................................................................................................... 20

Which Plan Pays First ................................................................................................................................................ 20

Medicare Coordination .............................................................................................................................................. 21

Facility of Payment..................................................................................................................................................... 21

Right of Recovery....................................................................................................................................................... 21

Recovery Provisions ...................................................................................................................................................... 21

Refund of Overpayments............................................................................................................................................ 21

Reimbursement of Benefits Paid .............................................................................................................................. 21

Subrogation.................................................................................................................................................................. 22

Plan Administration ....................................................................................................................................................... 22

Plan Administration.................................................................................................................................................... 22

Sponsorship and Administration of the Plan ............................................................................................................ 22

Mental Health & Substance Abuse Benefits............................................................................................................. 22

Group Policy Number ................................................................................................................................................ 22

Type of Plan................................................................................................................................................................. 22

Plan Year...................................................................................................................................................................... 22

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