Determine Benefits. Our Responsibilities We make administrative decisions regarding whether this Benefit plan will pay for any portion of the cost of a health care service you intend to receive or have received. Our decisions are for payment purposes only. We do not make decisions about the kind of care you should or should not receive. You and your providers must make those treatment decisions. We have the discretion to do the following: Interpret Benefits and the other terms, limitations and exclusions set out in this Certificate, the Schedule of Benefits and any Riders and/or Amendments. Make factual determinations relating to Benefits. We may delegate this discretionary authority to other persons or entities that may provide administrative services for this Benefit plan, such as claims processing. The identity of the service providers and the nature of their services may be changed from time to time in our discretion. In order to receive Benefits, you must cooperate with those service providers. Pay for Our Portion of the Cost of Covered Health Services We pay Benefits for Covered Health Services as described in Section 1: Covered Health Services and in the Schedule of Benefits, unless the service is excluded in Section 2: Exclusions and Limitations. This means we only pay our portion of the cost of Covered Health Services. It also means that not all of the health care services you receive may be paid for (in full or in part) by this Benefit plan. Pay Network Providers It is the responsibility of Network Physicians and facilities to file for payment from us. When you receive Covered Health Services from Network providers, you do not have to submit a claim to us. Pay for Covered Health Services Provided by Non-Network Providers In accordance with any state prompt pay requirements, we will pay Benefits after we receive your request for payment that includes all required information. See Section 5: How to File a Claim. Review and Determine Benefits in Accordance with our Reimbursement Policies We develop our reimbursement policy guidelines, in our sole discretion, in accordance with one or more of the following methodologies: As indicated in the most recent edition of the Current Procedural Terminology (CPT), a publication of the American Medical Association, and/or the Centers for Medicare and Medicaid Services (CMS). As reported by generally recognized professionals or publications. As used for Medicare. As determined by medical staff and outside medical consul...
Determine Benefits. Our Responsibilities We do not make decisions about the kind of care you should or should not receive. You and your Providers must make those treatment decisions. We will determine the following: Interpret Benefits and the other terms, limitations and exclusions set out in this Policy, the Schedule of Benefits and any Riders and/or Amendments. • Make factual determinations relating to Benefits. We may assign this authority to other persons or entities that may provide administrative services for this Policy, such as claims processing. The identity of the service Providers and the nature of their services may be changed from time to time as we determine. In order to receive Benefits, you must cooperate with those service Providers. Pay for Our Portion of the Cost of Covered Health Care Services We pay Benefits for Covered Health Care Services as described in Section 1: Covered Health Care Services and in the Schedule of Benefits, unless the service is excluded in Section 2: Exclusions and Limitations. This means we only pay our portion of the cost of Covered Health Care Services. It also means that not all of the health care services you receive may be paid for (in full or in part) by this Policy. SAMPLE Pay Network Providers It is the responsibility of Network Physicians and facilities to file for payment from us. When you receive Covered Health Care Services from Network Providers, you do not have to submit a claim to us. Pay for Covered Health Care Services Provided by Out-of-Network Providers
Determine Benefits. We make administrative decisions regarding whether this benefit plan will pay for any portion of the cost of a health care service you intend to receive or have received. Our decisions are for payment purposes only. We do not make decisions about the kind of care you should or should not receive. You and your providers must make those treatment decisions. We have the discretion to do the following: • Interpret benefits and the other terms, limitations and exclusions set out in this Individual Plan Agreement, the Schedule of Benefits and any Riders and/or Amendments. • Make factual determinations relating to benefits. We may delegate this discretionary authority to other persons or entities that may provide administrative services for this benefit plan, such as claims processing. The identity of the service providers and the nature of their services may be changed from time to time in our discretion. In order to receive benefits, you must cooperate with those service providers. Pay for Our Portion of the Cost of Covered Services We pay benefits for Covered Services as described in Description of Covered Services and in the Schedule of Benefits, unless the service is excluded in Exclusions and Limitations. This means we only pay our portion of the cost of Covered Services. It also means that not all of the health care services you receive may be paid for (in full or in part) by this benefit plan. Pay Network Providers It is the responsibility of our Network Providers to file for payment from us.
