UC2004 查看數據表（PDF） - Unspecified

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UC2004

Behavioral Health Benefits for Blue Cross PLUS

Unspecified 

**The percentage payable is 100% when the Mental Health Out-of-Pocket Maximum is met each Calendar Year.

Schedule of Benefits (continued)

All benefits are paid in accordance with the Reasonable Charge. Refer to the Glossary for the definition of Reasonable

Charge.

1. In order to be a covered In-Network benefit, all services must be clinically necessary, be provided by a UBH

Network Provider and be pre-approved by a UBH Intake Counselor. “UBH Network Provider” includes

providers for which a case-specific accommodation is made by UBH.

2. $100 Calendar Year Deductible applies to each Covered Person. Amounts credited to this deductible do not

count toward the $500 out-of-network deductible.

3. Preauthorization required.

4. Emergency care is treated as In-Network if UBH is notified within 48 hours of admission. Emergency care is

defined as “Immediate Mental Disorder Treatment when the lack of treatment could reasonably be expected to

result in the patient harming him/herself or another person(s).

5. Penalty is applied before the Covered Person accumulates covered expenses toward the individual deductible

and the penalty does not apply toward the individual deductible. If the individual deductible is satisfied, the

penalty is applied prior to the Plan’s percentage payment of 70%. Outpatient penalty is applied per course of

treatment per covered problem or condition. Inpatient penalty is applied per admission.

Notes

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Out-of-Network outpatient mental health services are not subject to preauthorization, but must be

clinically necessary to be covered and are subject to retrospective review. Expenses determined not

clinically necessary will not be covered.

The preauthorization penalty applies when preauthorization is not requested. If preauthorization is sought

and not approved, no coverage is provided..

In and Out-of-Network member expenses for Substance Abuse do not apply to the Out of Pocket

Maximums.

In-Network and Out-of-Network Annual Out of Pocket Maximums are exclusive of each other.

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