Benefits, Exclusions and Limitations. 2. Urgent Care Services outside of our Service Area, as described in Section 3:
Benefits, Exclusions and Limitations is Medically Necessary and our decision is final and conclusive subject to your right to appeal as set forth in Section 5:
Benefits, Exclusions and Limitations. Your Benefits The benefits described in this section are covered only when:
Benefits, Exclusions and Limitations. 3. Approved Referrals, as described in this section under the Getting a Referral, including referrals for Clinical Trials as described in Section 3:
Benefits, Exclusions and Limitations. Emergency Services are available from Plan Hospital emergency departments, which are open 24/7. Emergency Services, with respect to an Emergency Medical Condition, means:
Benefits, Exclusions and Limitations. Unless exemptions are specifically made elsewhere in this Evidence of Coverage and Health Service Agreement, these pediatric vision benefits exclude the following:
Benefits, Exclusions and Limitations. Appeal: A protest filed by a Member or his or her Authorized representative with the Health Plan under its internal appeal process regarding a Coverage Decision concerning a Member. An Appeal does not include a verbal request for reconsideration of a benefit and/or eligibility determination. Appeal Decision: A final determination by the Health Plan that arises from an Appeal filed with the Health Plan under its Appeal process regarding a Coverage Decision concerning a Member.
Benefits, Exclusions and Limitations. For benefits that enrollees are entitled to, but are not available through the HCO, a written description on how and where to obtain benefits and a description of procedures for requesting disenrollments/changes.
Benefits, Exclusions and Limitations. 3. Continuity of Care for New Members, as described in Section 2: How to Get the Care You Need;
Benefits, Exclusions and Limitations. Emergency and Urgent Care Services, in addition to Services associated with pre-authorized referrals are the only Services a Member may seek outside of the Service Area.
