Common use of BlueCard Worldwide® Program Clause in Contracts

BlueCard Worldwide® Program. If you are outside the United States (hereinafter “BlueCard service area”), you may be able to take advantage of the BlueCard Worldwide® Program when accessing covered health care services/Covered Services. The BlueCard Worldwide Program is unlike the BlueCard Program available in the BlueCard service area in certain ways. For instance, although the BlueCard Worldwide Program assists you with accessing a network of inpatient, outpatient and professional providers, the network is not served by a Host Blue. As such, when you receive care from providers outside the BlueCard service area, you will typically have to pay the providers and submit the claims yourself to obtain reimbursement for these services. If you need medical assistance services (including locating a doctor or hospital) outside the BlueCard service area, you should call the BlueCard Worldwide Service Center at 0.000.000.XXXX (2583) or call collect at 0.000.000.0000, 24 hours a day, seven days a week. An assistance coordinator, working with a medical professional, can arrange a physician appointment or hospitalization, if necessary. • Inpatient Services In most cases, if you contact the BlueCard Worldwide Service Center for assistance, hospitals will not require you to pay for covered inpatient services, except for your cost-share amounts]/deductibles, coinsurance, etc. In such cases, the hospital will submit your claims to the BlueCard Worldwide Service Center to begin claims processing. However, if you paid in full at the time of service, you must submit a claim to receive reimbursement for [covered healthcare services/Covered Services. Preauthorization is recommended for non-emergency inpatient services. • Outpatient Services Physicians, urgent care centers and other outpatient providers located outside the BlueCard service area will typically require you to pay in full at the time of service. You must submit a claim to obtain reimbursement for covered health care services. Preauthorization is recommended for outpatient services. • Submitting a BlueCard Worldwide Claim When you pay for [covered health care services outside the BlueCard service area, you must submit a claim to obtain reimbursement. For institutional and professional claims, you should complete a BlueCard Worldwide International claim form and send the claim form with the provider’s itemized xxxx(s) to the BlueCard Worldwide Service Center (the address is on the form) to initiate claims processing. Following the instructions on the claim form will help ensure timely processing of your claim. The claim form is available from BCBSRI, the BlueCard Worldwide Service Center or online at xxx.xxxxxxxxxxxxxxxxx.xxx. If you need assistance with your claim submission, you should call the BlueCard Worldwide Service Center at 0.000.000.XXXX (2583) or call collect at 0.000.000.0000, 24 hours a day, seven days a week.

BlueCard Worldwide® Program. If you are outside the United States (hereinafter “BlueCard service area”)States, the Commonwealth of Puerto Rico and the U.S. Virgin Islands, you may be able to take advantage of the BlueCard Worldwide® Worldwide Program when accessing covered health care services/Covered Services. The BlueCard Worldwide Program is unlike the BlueCard Program available in the BlueCard service area United States, the Commonwealth of Puerto Rico and the U.S. Virgin Islands in certain ways. For instance, although the BlueCard Worldwide Program assists you with accessing a network of inpatient, outpatient and professional providers, the network is not served by a Host Blue. As such, when you receive care from providers outside the BlueCard service areaUnited States, the Commonwealth of Puerto Rico and the U.S. Virgin Islands, you will typically have to pay the providers and submit the claims yourself to obtain reimbursement for these services. If you need medical assistance services (including locating a doctor or hospital) outside the BlueCard service areaUnited States, the Commonwealth of Puerto Rico and the U.S. Virgin Islands, you should call the BlueCard Worldwide Service Center at 0.000.000.XXXX (2583) or call collect at 0.000.000.0000, 24 hours a day, seven days a week. An assistance coordinator, working with a medical professional, can will arrange a physician appointment or hospitalization, if necessary. • S Inpatient Services In most cases, if you contact the BlueCard Worldwide Service Center for assistance, hospitals will not require you to pay for covered inpatient services, except for your cost-cost- share amounts]/deductiblesamounts/deductibles, coinsurance, etc. In such cases, the hospital will submit your claims to the BlueCard Worldwide Service Center to begin claims processing. However, if you paid in full at the time of service, you must submit a claim to receive reimbursement for [covered healthcare services/Covered Services. Preauthorization is recommended You must contact Blue Cross and Blue Shield of Texas to obtain preauthorization for non-non- emergency inpatient services. • S Outpatient Services Physicians, urgent care centers and other outpatient providers located outside the BlueCard service area United States, the Commonwealth of Puerto Rico and the U.S. Virgin Islands will typically require you to pay in full at the time of service. You must submit a claim to obtain reimbursement for covered health care servicesCovered Services. Preauthorization is recommended for outpatient services. • S Submitting a BlueCard Worldwide Claim When you pay for [covered health care services Covered Services outside the BlueCard service area, you must submit a claim to obtain reimbursement. For institutional and professional claims, you should complete a BlueCard Worldwide International claim form and send the claim form with the provider’s itemized xxxx(sbill(s) to the BlueCard Worldwide Service Center (the address is on the form) to initiate claims processing. Following the instructions on the claim form will help ensure timely processing of your claim. The claim form is available from BCBSRIBlue Cross and Blue Shield of Texas, the BlueCard Worldwide Service Center or online at xxx.xxxxxxxxxxxxxxxxx.xxx. If you need assistance with your claim submission, you should call the BlueCard Worldwide Service Center at 0.000.000.XXXX (2583) or call collect at 0.000.000.0000, 24 hours a day, seven days a week.. Handbook HANDBOOK0803 Blue Cross and Blue Shield of Texas (herein called “BCBSTX” or “HMO”) This plan is offered by the following organization, which operates under Chapter 843 of the Texas Insurance Code: BLUE CROSS AND BLUE SHIELD OF TEXAS, A DIVISION OF HEALTH CARE SERVICE CORPORATION 0000 X. Xxxxxxx Xxxxx Xxxxxxxxxx, XX 00000 Plan Description and Member Handbook The following is a brief summary of your benefits and describes your rights and responsibilities under this plan. You can find more complete information about this plan in the Certificate of Coverage documents (COC) which you will receive after you enroll. We want you to be satisfied with your new health care program. If you would like more information about the plan, a Customer Service representative will be happy to help you. Call Customer Service Monday through Friday from 7:30 a.m. to 6:00 p.m. CST at 0-000-000-0000. You may also write HMO at: HMO Customer Service P.O. Box 660044 Dallas, Texas 75266- 0044 Again, thank you for considering us for your health care coverage. A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association TX- G- H- PD- HB- 16- LG 1 LG- SMGF TABLE OF CONTENTS MEDICALLY NECESSARY COVERED SERVICES AND BENEFITS Hospitalization 3 Other Medical Services 3 Preventive Care 3 Behavioral Health Care 3 EMERGENCY CARE, AFTER HOURS CARE AND URGENT CARE Medical Emergencies 4 After Hours Care 4 Urgent Care Services 4 Out-of-Area Services and Benefits 5 YOUR FINANCIAL RESPONSIBILITIES 5 LIMITATIONS AND EXCLUSIONS 6 PREAUTHORIZATION REQUIREMENTS, REFERRAL PROCEDURES AND OTHER REVIEW REQUIREMENTS 6 CONTINUITY OF TREATMENT IN THE EVENT OF TERMINATION OF A NETWORK PROVIDER 6 COMPLAINT PROCEDURE: APPEAL OF ADVERSE DETERMINATION; INDEPENDENT REVIEW ORGANIZATION PROCESS; AND NON-RETALIATION 7 NETWORK PROVIDERS 10 SERVICE AREA 11 GENERAL INFORMATION Identification (ID) Cards 11 RECEIVING CARE Your Primary Care Physician (PCP) ......................................................... 12 Changing PCPs 12 ADDITIONAL INFORMATION Status Changes 13 Duplication of Coverage and Coordination of Benefits 13 Continuation of Benefits New Medical Technology ................................................................... 14 .................................................................. 14 YOUR RIGHTS AND RESPONSIBILITIES Your Rights 14 Your Responsibilities 15 CONFIDENTIALITY AND ACCESS TO RECORDS 15

BlueCard Worldwide® Program. If you are outside the United States (hereinafter “BlueCard service area”), you may be able to take advantage of the BlueCard Worldwide® Program when accessing covered health care services/Covered Services. The BlueCard Worldwide Program is unlike the BlueCard Program available in the BlueCard service area in certain ways. For instance, although the BlueCard Worldwide Program assists you with accessing a network of inpatient, outpatient and professional providers, the network is not served by a Host Blue. As such, when you receive care from providers outside the BlueCard service area, you will typically have to pay the providers and submit the claims yourself to obtain reimbursement for these services. If you need medical assistance services (including locating a doctor or hospital) outside the BlueCard service area, you should call the BlueCard Worldwide Service Center at 0.000.000.XXXX (2583) or call collect at 0.000.000.0000, 24 hours a day, seven days a week. An assistance coordinator, working with a medical professional, can arrange a physician appointment or hospitalization, if necessary. • Inpatient Services In most cases, if you contact the BlueCard Worldwide Service Center for assistance, hospitals will not require you to pay for covered inpatient services, except for your cost-share amounts]/deductibles, amounts/deductibles and coinsurance, etc. In such cases, the hospital will submit your claims to the BlueCard Worldwide Service Center to begin claims processing. However, if you paid in full at the time of service, you must submit a claim to receive reimbursement for [covered healthcare services/Covered Services. Preauthorization is recommended for non-emergency inpatient services. • Outpatient Services Physicians, urgent care centers and other outpatient providers located outside the BlueCard service area will typically require you to pay in full at the time of service. You must submit a claim to obtain reimbursement for covered health care services. Preauthorization is recommended for outpatient services. • Submitting a BlueCard Worldwide Claim When you pay for [covered health care services outside the BlueCard service area, you must submit a claim to obtain reimbursement. For institutional and professional claims, you should complete a BlueCard Worldwide International claim form and send the claim form with the provider’s itemized xxxx(s) to the BlueCard Worldwide Service Center (the address is on the form) to initiate claims processing. Following the instructions on the claim form will help ensure timely processing of your claim. The claim form is available from BCBSRI, the BlueCard Worldwide Service Center or online at xxx.xxxxxxxxxxxxxxxxx.xxx. If you need assistance with your claim submission, you should call the BlueCard Worldwide Service Center at 0.000.000.XXXX (2583) or call collect at 0.000.000.0000, 24 hours a day, seven days a week.

BlueCard Worldwide® Program. If you are outside the United States (hereinafter “BlueCard service area”), you may be able to take advantage of the BlueCard Worldwide® Program when accessing covered health care services/Covered Services. The BlueCard Worldwide Program is unlike the BlueCard Program available in the BlueCard service area in certain ways. For instance, although the BlueCard Worldwide Program assists you with accessing a network of inpatient, outpatient and professional providers, the network is not served by a Host Blue. As such, when you receive care from providers outside the BlueCard service area, you will typically have to pay the providers and submit the claims yourself to obtain reimbursement for these services. If you need medical assistance services (including locating a doctor or hospital) outside the BlueCard service area, you should call the BlueCard Worldwide Service Center at 0.000.000.XXXX (2583) or call collect at 0.000.000.0000, 24 hours a day, seven days a week. An assistance coordinator, working with a medical professional, can arrange a physician appointment or hospitalization, if necessary. • Inpatient Services In most cases, if you contact the BlueCard Worldwide Service Center for assistance, hospitals will not require you to pay for covered inpatient services, except for your cost-share amounts]/deductiblesamounts/deductibles, coinsurance, etc. In such cases, the hospital will submit your claims to the BlueCard Worldwide Service Center to begin claims processing. However, if you paid in full at the time of service, you must submit a claim to receive reimbursement for [covered healthcare services/Covered Services. Preauthorization is recommended for non-emergency inpatient services. • Outpatient Services Physicians, urgent care centers and other outpatient providers located outside the BlueCard service area will typically require you to pay in full at the time of service. You must submit a claim to obtain reimbursement for covered health care services. Preauthorization is recommended for outpatient services. • Submitting a BlueCard Worldwide Claim When you pay for [covered health care services outside the BlueCard service area, you must submit a claim to obtain reimbursement. For institutional and professional claims, you should complete a BlueCard Worldwide International claim form and send the claim form with the provider’s itemized xxxx(s) to the BlueCard Worldwide Service Center (the address is on the form) to initiate claims processing. Following the instructions on the claim form will help ensure timely processing of your claim. The claim form is available from BCBSRI, the BlueCard Worldwide Service Center or online at xxx.xxxxxxxxxxxxxxxxx.xxx. If you need assistance with your claim submission, you should call the BlueCard Worldwide Service Center at 0.000.000.XXXX (2583) or call collect at 0.000.000.0000, 24 hours a day, seven days a week.

BlueCard Worldwide® Program. If you are outside the United States (hereinafter “BlueCard service area”), you may be able to take advantage of the BlueCard Worldwide® Program when accessing covered health care healthcare services/Covered Services. The BlueCard Worldwide Program is unlike the BlueCard Program available in the BlueCard service area in certain ways. For instance, although the BlueCard Worldwide Program assists you with accessing a network of inpatient, outpatient and professional providers, the network is not served by a Host Blue. As such, when you receive care from providers outside the BlueCard service area, you will typically have to pay the providers and submit the claims yourself to obtain reimbursement for these services. If you need medical assistance services (including locating a doctor or hospital) outside the BlueCard service area, you should call the BlueCard Worldwide Service Center at 0.000.000.XXXX (2583) or call collect at 0.000.000.0000, 24 hours a day, seven days a week. An assistance coordinator, working with a medical professional, can arrange a physician appointment or hospitalization, if necessary. • Inpatient Services In most cases, if you contact the BlueCard Worldwide Service Center for assistance, hospitals will not require you to pay for covered inpatient services, except for your cost-share amounts]/deductiblesdeductibles, coinsurance, etc. In such cases, the hospital will submit your claims to the BlueCard Worldwide Service Center to begin claims processing. However, if you paid in full at the time of service, you must submit a claim to receive reimbursement for [covered healthcare services/Covered Services. Preauthorization is recommended You must contact CareFirst to obtain precertification for non-emergency inpatient services. • Outpatient Services Physicians, urgent care centers and other outpatient providers located outside the BlueCard service area will typically require you to pay in full at the time of service. You must submit a claim to obtain reimbursement for covered health care healthcare services. Preauthorization is recommended for outpatient services. • Submitting a BlueCard Worldwide Claim When you pay for [covered health care services outside the BlueCard service area, you must submit a claim to obtain reimbursement. For institutional and professional claims, you should complete a BlueCard Worldwide International claim form and send the claim form with the provider’s itemized xxxx(s) to the BlueCard Worldwide Service Center (the address is on the form) to initiate claims processing. Following the instructions on the claim form will help ensure timely processing of your claim. The claim form is available from BCBSRI, the BlueCard Worldwide Service Center or online at xxx.xxxxxxxxxxxxxxxxx.xxx. If you need assistance with your claim submission, you should call the BlueCard Worldwide Service Center at 0.000.000.XXXX (2583) or call collect at 0.000.000.0000, 24 hours a day, seven days a week/Covered Services.

BlueCard Worldwide® Program. If you are outside the United States (hereinafter “BlueCard service area”), you may be able to take advantage of the BlueCard Worldwide® Program when accessing covered health care services/Covered Services. The BlueCard Worldwide Program is unlike the BlueCard Program available in the BlueCard service area in certain ways. For instance, although the BlueCard Worldwide Program assists you with accessing a network of inpatient, outpatient and professional providers, the network is not served by a Host Blue. As such, when you receive care from providers outside the BlueCard service area, you will typically have to pay the providers and submit the claims yourself to obtain reimbursement for these services. If you need medical assistance services (including locating a doctor or hospital) outside the BlueCard service area, you should call the BlueCard Worldwide Service Center at 0.000.000.XXXX (2583) or call collect at 0.000.000.0000, 24 hours a day, seven days a week. An assistance coordinator, working with a medical professional, can arrange a physician appointment or hospitalization, if necessary. • Inpatient Services In most cases, if you contact the BlueCard Worldwide Service Center for assistance, hospitals will not require you to pay for covered inpatient services, except for your cost-share amounts]/deductiblesamounts/deductibles, coinsurance, etc. In such cases, the hospital will submit your claims to the BlueCard Worldwide Service Center to begin claims processing. However, if you paid in full at the time of service, you must submit a claim to receive reimbursement for [covered healthcare services/Covered Services. Preauthorization is recommended for non-emergency inpatient services. • Outpatient Services Physicians, urgent care centers and other outpatient providers located outside the BlueCard service area will typically require you to pay in full at the time of service. You must submit a claim to obtain reimbursement for covered health care services. Preauthorization is recommended for outpatient services. • Submitting a BlueCard Worldwide Claim When you pay for [covered health care services outside the BlueCard service area, you must submit a claim to obtain reimbursement. For institutional and professional claims, you should complete a BlueCard Worldwide International claim form and send the claim form with the provider’s itemized xxxx(sbill(s) to the BlueCard Worldwide Service Center (the address is on the form) to initiate claims processing. Following the instructions on the claim form will help ensure timely processing of your claim. The claim form is available from BCBSRI, the BlueCard Worldwide Service Center or online at xxx.xxxxxxxxxxxxxxxxx.xxx. If you need assistance with your claim submission, you should call the BlueCard Worldwide Service Center at 0.000.000.XXXX (2583) or call collect at 0.000.000.0000, 24 hours a day, seven days a week.