Common use of Concurrent Review Clause in Contracts

Concurrent Review. Once you have been admitted to a Hospital as an Inpatient, your length of stay will be reviewed by the Participating IPA/Participating Medical Group. The pur­ pose of that review is to ensure that your length of stay is appropriate given your diagnosis and the treatment that you are receiving. This is known as Concurrent Review. If your Hospital stay is longer than the usual length of stay for your type of condi­ tion, the Participating IPA/Participating Medical Group will contact your Primary Care Physician or Woman's Principal Health Care Provider to determine whether there is a medically necessary reason for you to remain in the Hospital. Should it be determined that your continued stay in the Hospital is not medically necessary, you will be informed of that decision, in writing, and of the date that your benefits for that stay will end. EXCLUSIONS — WHAT IS NOT COVERED Expenses for the following are not covered under your benefit program: — Services or supplies that are not specifically stated in this Certificate. — Services or supplies that were not ordered by your Primary Care Physician or Woman's Principal Health Care Provider except as explained in the EMERGENCY CARE BENEFITS section, SUBSTANCE USE DIS­ ORDER TREATMENT BENEFITS section, HOSPITAL BENEFITS section and, for Mental Illness (other than Serious Mental Illness) or routine vision examinations, in the PHYSICIAN BENEFITS section of this Certi­ ficate. — Services or supplies that were received prior to the date your coverage be­ gan or after the date that your coverage was terminated. — Services or supplies for which benefits have been paid under any Workers' Compensation Law or other similar laws whether or not you make a claim for such compensation or receive such benefits. However, this exclusion shall not apply if you are a corporate officer of any business or enterprise, defined as a “small business” under paragraph (b), Section 3 or the Illinois Small Business Purchasing Act, as amended, and are employed by the cor­ poration and elect to withdraw yourself from the operation of the Illinois Workers' Compensation Act according to the provisions of the Act. — Services or supplies that are furnished to you by the local, state or federal government and services or supplies to the extent payments or benefits for such services or supplies are provided by or available from the local, state or federal government (for example, Medicare) whether or not those payments or benefits are received, except, however, this exclusion shall not be appli­ cable to medical assistance benefits under Article V, VI, or VII of the Illinois Public Aid Code (Ill. Rev. Stat. ch. 23 § 1‐1 et seq.) or similar legislation of any state, benefits provided in compliance with the Tax Equity and Fiscal Responsibility Act or as otherwise provided by law. — Services or supplies rendered to you as the result of an injury caused by another person to the extent that you have collected damages for such injury and that the Plan has provided benefits for the services or supplies rendered in connection with such injury. — Services or supplies that do not meet accepted standards of medical or dental practice including, but not limited to, services which are Experimental/In­ vestigational in nature. This exclusion however does not apply to a) the cost of routine patient care associated with Investigational treatment if you are a qualified individual participating in an Approved Clinical Trial program, if those services or supplies would otherwise be covered under this Certificate if not provided in connection with an Approved Clinical Trial program and

Concurrent Review. Once you have been admitted to a Hospital as an Inpatient, your length of stay will be reviewed by the Participating IPA/Participating Medical Group. The pur­ pose of that review is to ensure that your length of stay is appropriate given your diagnosis and the treatment that you are receiving. This is known as Concurrent Review. If your Hospital stay is longer than the usual length of stay for your type of condi­ tion, the Participating IPA/Participating Medical Group will contact your Primary Care Physician or Woman's Principal Health Care Provider to determine whether there is a medically necessary reason for you to remain in the Hospital. Should it be determined that your continued stay in the Hospital is not medically necessary, you will be informed of that decision, in writing, and of the date that your benefits for that stay will end. EXCLUSIONS — WHAT IS NOT COVERED Expenses for the following are not covered under your benefit program: — Services or supplies that are not specifically stated in this Certificate. — Services or supplies that were not ordered by your Primary Care Physician or Woman's Principal Health Care Provider except as explained in the EMERGENCY CARE BENEFITS section, SUBSTANCE USE DIS­ ORDER TREATMENT BENEFITS section, HOSPITAL BENEFITS section and, for Mental Illness (other than Serious Mental Illness) or routine vision examinations, in the PHYSICIAN BENEFITS section of this Certi­ ficate. — Services or supplies that were received prior to the date your coverage be­ gan or after the date that your coverage was terminated. — Services or supplies for which benefits have been paid under any Workers' Compensation Law or other similar laws whether or not you make a claim for such compensation or receive such benefits. However, this exclusion shall not apply if you are a corporate officer of any business or enterprise, defined as a “small business” under paragraph (b), Section 3 or the Illinois Small Business Purchasing Act, as amended, and are employed by the cor­ poration and elect to withdraw yourself from the operation of the Illinois Workers' Compensation Act according to the provisions of the Act. — Services or supplies that are furnished to you by the local, state or federal government and services or supplies to the extent payments or benefits for such services or supplies are provided by or available from the local, state or federal government (for example, Medicare) whether or not those payments or benefits are received, (except in the case of Medicare), except, however, this exclusion shall not be appli­ cable applicable to medical assistance benefits under Article V, VI, or VII of the Illinois Public Aid Code (Ill. Rev. Stat. ch. 23 § 1‐1 et seq.) or similar legislation of any state, benefits provided in compliance com­ pliance with the Tax Equity and Fiscal Responsibility Act or as otherwise provided by law. — Services or supplies rendered to you as the result of an injury caused by another person to the extent that you have collected damages for such injury and that the Plan has provided benefits for the services or supplies rendered in connection with such injury. — Services or supplies that do not meet accepted standards of medical or dental practice including, but not limited to, services which are Experimental/In­ vestigational in nature. This exclusion however does not apply to a) the cost of routine patient care associated with Investigational treatment if you are a qualified individual participating in an Approved Clinical Trial program, if those services or supplies would otherwise be covered under this Certificate if not provided in connection with an Approved Clinical Trial program and

Concurrent Review. Once you have been admitted to a Hospital as an Inpatient, your length of stay will be reviewed by the Participating IPA/Participating Medical Group. The pur­ pose of that review is to ensure that your length of stay is appropriate given your diagnosis and the treatment that you are receiving. This is known as Concurrent Review. If your Hospital stay is longer than the usual length of stay for your type of condi­ tion, the Participating IPA/Participating Medical Group will contact your Primary Care Physician or Woman's Principal Health Care Provider to determine whether there is a medically necessary reason for you to remain in the Hospital. Should it be determined that your continued stay in the Hospital is not medically necessary, you will be informed of that decision, in writing, and of the date that your benefits for that stay will end. EXCLUSIONS — WHAT IS NOT COVERED Expenses for the following are not covered under your benefit program: — Services or supplies that are not specifically stated in this Certificate. — Services or supplies that were not ordered by your Primary Care Physician or Woman's Principal Health Care Provider except as explained in the EMERGENCY CARE BENEFITS section, SUBSTANCE USE DIS­ ORDER DISORDER TREATMENT BENEFITS section, HOSPITAL BENEFITS section and, for Mental Illness (other than Serious Mental Illness) or routine vision examinations, in the PHYSICIAN BENEFITS section of this Certi­ ficateCertificate. — Services or supplies that were received prior to the date your coverage be­ gan began or after the date that your coverage was terminated. — Services or supplies for which benefits have been paid under any Workers' Compensation Law or other similar laws whether or not you make a claim for such compensation or receive such benefits. However, this exclusion shall not apply if you are a corporate officer of any business or enterprise, defined as a “small business” under paragraph (b), Section 3 or the Illinois Small Business Purchasing Act, as amended, and are employed by the cor­ poration corporation and elect to withdraw yourself from the operation of the Illinois Workers' Compensation Act according to the provisions of the Act. — Services or supplies that are furnished to you by the local, state or federal government and services or supplies to the extent payments or benefits for such services or supplies are provided by or available from the local, state or federal government (for example, Medicare) whether or not those payments or benefits are received, (except in the case of Medicare), except, however, this exclusion shall not be appli­ cable applicable to medical assistance benefits under Article V, VI, or VII of the Illinois Public Aid Code (Ill. Rev. Stat. ch. 23 § 1‐1 et seq.) or similar legislation of any state, benefits provided in compliance with the Tax Equity and Fiscal Responsibility Act or as otherwise provided by law. — Services or supplies rendered to you as the result of an injury caused by another person to the extent that you have collected damages for such injury and that the Plan has provided benefits for the services or supplies rendered in connection with such injury. — Services or supplies that do not meet accepted standards of medical or dental practice including, but not limited to, services which are Experimental/In­ vestigational Investigational in nature. This exclusion however does not apply to a) the cost of routine patient care associated with Investigational treatment if you are a qualified individual participating in an Approved Clinical Trial program, if those services or supplies would otherwise be covered under this Certificate if not provided in connection with an Approved Clinical Trial program andand b) applied behavior analysis used for the treatment of Autism Spectrum Disorder(s).

Concurrent Review. Once you have been admitted to a Hospital as an Inpatient, your length of stay will be reviewed by the Participating IPA/Participating Medical Group. The pur­ pose of that review is to ensure that your length of stay is appropriate given your diagnosis and the treatment that you are receiving. This is known as Concurrent Review. If your Hospital stay is longer than the usual length of stay for your type of condi­ tion, the Participating IPA/Participating Medical Group will contact your Primary Care Physician or Woman's Principal Health Care Provider to determine whether there is a medically necessary reason for you to remain in the Hospital. Should it be determined that your continued stay in the Hospital is not medically necessary, you will be informed of that decision, in writing, and of the date that your benefits for that stay will end. GB‐16 HCSC 67 EXCLUSIONS — WHAT IS NOT COVERED Expenses for the following are not covered under your benefit program: — Services or supplies that are not specifically stated in this Certificate. — Services or supplies that were not ordered by your Primary Care Physician or Woman's Principal Health Care Provider except as explained in the EMERGENCY CARE BENEFITS section, SUBSTANCE USE DIS­ ORDER TREATMENT BENEFITS section, HOSPITAL BENEFITS section and, for Mental Illness (other than Serious Mental Illness) or routine vision examinations, in the PHYSICIAN BENEFITS section of this Certi­ ficate. — Services or supplies that were received prior to the date your coverage be­ gan or after the date that your coverage was terminated. — Services or supplies for which benefits have been paid under any Workers' Compensation Law or other similar laws whether or not you make a claim for such compensation or receive such benefits. However, this exclusion shall not apply if you are a corporate officer of any business or enterprise, defined as a “small business” under paragraph (b), Section 3 or the Illinois Small Business Purchasing Act, as amended, and are employed by the cor­ poration and elect to withdraw yourself from the operation of the Illinois Workers' Compensation Act according to the provisions of the Act. — Services or supplies that are furnished to you by the local, state or federal government and services or supplies to the extent payments or benefits for such services or supplies are provided by or available from the local, state or federal government (for example, Medicare) whether or not those payments or benefits are received, except, however, this exclusion shall not be appli­ cable to medical assistance benefits under Article V, VI, or VII of the Illinois Public Aid Code (Ill. Rev. Stat. ch. 23 § 1‐1 et seq.) or similar legislation of any state, benefits provided in compliance with the Tax Equity and Fiscal Responsibility Act or as otherwise provided by law. — Services or supplies rendered to you as the result of an injury caused by another person to the extent that you have collected damages for such injury and that the Plan has provided benefits for the services or supplies rendered in connection with such injury. — Services or supplies that do not meet accepted standards of medical or dental practice including, but not limited to, services which are Experimental/In­ vestigational Investigational in nature. This exclusion however does not apply to , except as specifically provided for in this Certificate for a) the cost of routine patient care associated with Investigational treatment if you are a qualified individual participating in an Approved Clinical Trial program, if those services or supplies would otherwise be covered under this Certificate if not provided in connection with an Approved Clinical Trial program and

Concurrent Review. Once you have been admitted to a Hospital as an Inpatient, your length of stay will be reviewed by the Participating IPA/Participating Medical Group. The pur­ pose of that review is to ensure that your length of stay is appropriate given your diagnosis and the treatment that you are receiving. This is known as Concurrent Review. If your Hospital stay is longer than the usual length of stay for your type of condi­ tion, the Participating IPA/Participating Medical Group will contact your Primary Care Physician or Woman's Principal Health Care Provider to determine whether there is a medically necessary reason for you to remain in the Hospital. Should it be determined that your continued stay in the Hospital is not medically necessary, you will be informed of that decision, in writing, and of the date that your benefits for that stay will end. GB‐16 HCSC 68 EXCLUSIONS — WHAT IS NOT COVERED Expenses for the following are not covered under your benefit program: — Services or supplies that are not specifically stated in this Certificate. — Services or supplies that were not ordered by your Primary Care Physician or Woman's Principal Health Care Provider except as explained in the EMERGENCY CARE BENEFITS section, SUBSTANCE USE DIS­ ORDER TREATMENT BENEFITS section, HOSPITAL BENEFITS section and, for Mental Illness (other than Serious Mental Illness) or routine vision examinations, in the PHYSICIAN BENEFITS section of this Certi­ ficate. — Services or supplies that were received prior to the date your coverage be­ gan or after the date that your coverage was terminated. — Services or supplies for which benefits have been paid under any Workers' Compensation Law or other similar laws whether or not you make a claim for such compensation or receive such benefits. However, this exclusion shall not apply if you are a corporate officer of any business or enterprise, defined as a “small business” under paragraph (b), Section 3 or the Illinois Small Business Purchasing Act, as amended, and are employed by the cor­ poration and elect to withdraw yourself from the operation of the Illinois Workers' Compensation Act according to the provisions of the Act. — Services or supplies that are furnished to you by the local, state or federal government and services or supplies to the extent payments or benefits for such services or supplies are provided by or available from the local, state or federal government (for example, Medicare) whether or not those payments or benefits are received, except, however, this exclusion shall not be appli­ cable to medical assistance benefits under Article V, VI, or VII of the Illinois Public Aid Code (Ill. Rev. Stat. ch. 23 § 1‐1 et seq.) or similar legislation of any state, benefits provided in compliance with the Tax Equity and Fiscal Responsibility Act or as otherwise provided by law. — Services or supplies rendered to you as the result of an injury caused by another person to the extent that you have collected damages for such injury and that the Plan has provided benefits for the services or supplies rendered in connection with such injury. — Services or supplies that do not meet accepted standards of medical or dental practice including, but not limited to, services which are Experimental/In­ vestigational Investigational in nature. This exclusion however does not apply to , except as specifically provided for in this Certificate for a) the cost of routine patient care associated with Investigational treatment if you are a qualified individual participating in an Approved Clinical Trial program, if those services or supplies would otherwise be covered under this Certificate if not provided in connection with an Approved Clinical Trial program and

Concurrent Review. Once you have been admitted to a Hospital as an Inpatient, your length of stay will be reviewed by the Participating IPA/Participating Medical Group. The pur­ pur- pose of that review is to ensure that your length of stay is appropriate given your diagnosis and the treatment that you are receiving. This is known as Concurrent Review. If your Hospital stay is longer than the usual length of stay for your type of condi­ condi- tion, the Participating IPA/Participating Medical Group will contact your Primary Care Physician or Woman's Principal Health Care Provider to determine whether there is a medically necessary reason for you to remain in the Hospital. Should it be determined that your continued stay in the Hospital is not medically necessary, you will be informed of that decision, in writing, and of the date that your benefits for that stay will end. GB‐16 HCSC 69 EXCLUSIONS — WHAT IS NOT COVERED Expenses for the following are not covered under your benefit program: — Services or supplies that are not specifically stated in this Certificate. — Services or supplies that were not ordered by your Primary Care Physician or Woman's Principal Health Care Provider except as explained in the EMERGENCY CARE BENEFITS section, SUBSTANCE USE DIS­ DIS- ORDER TREATMENT BENEFITS section, HOSPITAL BENEFITS section and, for Mental Illness (other than Serious Mental Illness) or routine vision examinations, in the PHYSICIAN BENEFITS section of this Certi­ Certi- ficate. — Services or supplies that were received prior to the date your coverage be­ be- gan or after the date that your coverage was terminated. — Services or supplies for which benefits have been paid under any Workers' Compensation Law or other similar laws whether or not you make a claim for such compensation or receive such benefits. However, this exclusion shall not apply if you are a corporate officer of any business or enterprise, defined as a “small business” under paragraph (b), Section 3 or the Illinois Small Business Purchasing Act, as amended, and are employed by the cor­ cor- poration and elect to withdraw yourself from the operation of the Illinois Workers' Compensation Act according to the provisions of the Act. — Services or supplies that are furnished to you by the local, state or federal government and services or supplies to the extent payments or benefits for such services or supplies are provided by or available from the local, state or federal government (for example, Medicare) whether or not those payments or benefits are received, except, however, this exclusion shall not be appli­ appli- cable to medical assistance benefits under Article V, VI, or VII of the Illinois Public Aid Code (Ill. Rev. Stat. ch. 23 § 1‐1 et seq.) or similar legislation of any state, benefits provided in compliance with the Tax Equity and Fiscal Responsibility Act or as otherwise provided by law. — Services or supplies rendered to you as the result of an injury caused by another person to the extent that you have collected damages for such injury and that the Plan has provided benefits for the services or supplies rendered in connection with such injury. — Services or supplies that do not meet accepted standards of medical or dental practice including, but not limited to, services which are Experimental/In­ In- vestigational in nature. This exclusion however does not apply to a) the cost of routine patient care associated with Investigational treatment if you are a qualified individual participating in an Approved Clinical Trial program, if those services or supplies would otherwise be covered under this Certificate if not provided in connection with an Approved Clinical Trial program andor

Concurrent Review. Once you have been admitted to a Hospital as an Inpatient, your length of stay will be reviewed by the Participating IPA/Participating Medical Group. The pur­ pose of that review is to ensure that your length of stay is appropriate given your diagnosis and the treatment that you are receiving. This is known as Concurrent Review. If your Hospital stay is longer than the usual length of stay for your type of condi­ tion, the Participating IPA/Participating Medical Group will contact your Primary Care Physician or Woman's Principal Health Care Provider to determine whether there is a medically necessary reason for you to remain in the Hospital. Should it be determined that your continued stay in the Hospital is not medically necessary, you will be informed of that decision, in writing, and of the date that your benefits for that stay will end. IL‐G‐H‐OF‐2016 88 EXCLUSIONS — WHAT IS NOT COVERED Expenses for the following are not covered under your benefit program: — Services or supplies that are not specifically stated in this Certificate. — Services or supplies that were not ordered by your Primary Care Physician or Woman's Principal Health Care Provider except as explained in the EMERGENCY CARE BENEFITS section, SUBSTANCE USE DIS­ ORDER TREATMENT BENEFITS section, HOSPITAL BENEFITS section, PEDIATRIC VISION CARE BENEFITS section, PEDIATRIC DENTAL CARE BENEFITS section and, for Mental Illness (other than Serious Se­ rious Mental Illness) or routine vision examinations, examinations in the PHYSICIAN BENEFITS section of this Certi­ ficateCertificate. — Services or supplies that were received prior to the date your coverage be­ gan or after the date that your coverage was terminated, unless otherwise stated in this Certificate. — Services or supplies for which benefits have been paid under any Workers' Compensation Law or other similar laws whether or not you make a claim for such compensation or receive such benefits. However, this exclusion shall not apply if you are a corporate officer of any business or enterprise, defined as a “small business” under paragraph (b), Section 3 or the Illinois Small Business Purchasing Act, as amended, and are employed by the cor­ poration and elect to withdraw yourself from the operation of the Illinois Workers' Compensation Act according to the provisions of the Act. — Services or supplies that are furnished to you by the local, state or federal government and services or supplies to the extent payments or benefits for such services or supplies are provided by or available from the local, state or federal government (for example, Medicare) whether or not those payments or benefits are received, except, however, this exclusion shall not be appli­ cable to medical assistance benefits under Article V, VI, or VII of the Illinois Public Aid Code (Ill. Rev. Stat. ch. 23 § 1‐1 et seq.) or similar legislation of any state, benefits provided in compliance with the Tax Equity and Fiscal Responsibility Act or as otherwise provided by law. — Services or supplies rendered to you as the result of an injury caused by another anoth­ er person to the extent that you have collected damages for such injury and that the Plan has provided benefits for the services or supplies rendered in connection with such injury. — Services or supplies that do not meet accepted standards of medical or dental practice including, but not limited to, services which are Experimental/In­ vestigational in nature. This exclusion however does not apply to a) the cost of routine patient care associated with Experimental/Investigational treatment treat­ ment if you are a qualified individual participating in an Approved Clinical Trial programTrial, if those services or supplies would otherwise be covered under this Certificate if not provided in connection with an Approved Clinical Trial program andand b) applied behavior analysis used for the treatment of Autism Spectrum Disorder(s). — Custodial Care Service. IL‐G‐H‐OF‐2016 89

Concurrent Review. Once you have been admitted to a Hospital as an Inpatient, your length of stay will be reviewed by the Participating IPA/Participating Medical Group. The pur­ pur- pose of that review is to ensure that your length of stay is appropriate given your diagnosis and the treatment that you are receiving. This is known as Concurrent Review. If your Hospital stay is longer than the usual length of stay for your type of condi­ condi- tion, the Participating IPA/Participating Medical Group will contact your Primary Care Physician or Woman's Principal Health Care Provider to determine whether there is a medically necessary reason for you to remain in the Hospital. Should it be determined that your continued stay in the Hospital is not medically necessary, you will be informed of that decision, in writing, and of the date that your benefits for that stay will end. EXCLUSIONS — WHAT IS NOT COVERED Expenses for the following are not covered under your benefit program: — Services or supplies that are not specifically stated in this Certificate. — Services or supplies that were not ordered by your Primary Care Physician or Woman's Principal Health Care Provider except as explained in the EMERGENCY CARE BENEFITS section, SUBSTANCE USE DIS­ DIS- ORDER TREATMENT BENEFITS section, HOSPITAL BENEFITS section and, for Mental Illness (other than Serious Mental Illness) or routine vision examinations, in the PHYSICIAN BENEFITS section of this Certi­ Certi- ficate. — Services or supplies that were received prior to the date your coverage be­ be- gan or after the date that your coverage was terminated. — Services or supplies for which benefits have been paid under any Workers' Compensation Law or other similar laws whether or not you make a claim for such compensation or receive such benefits. However, this exclusion shall not apply if you are a corporate officer of any business or enterprise, defined as a “small business” under paragraph (b), Section 3 or the Illinois Small Business Purchasing Act, as amended, and are employed by the cor­ cor- poration and elect to withdraw yourself from the operation of the Illinois Workers' Compensation Act according to the provisions of the Act. — Services or supplies that are furnished to you by the local, state or federal government and services or supplies to the extent payments or benefits for such services or supplies are provided by or available from the local, state or federal government (for example, Medicare) whether or not those payments or benefits are received, except, however, this exclusion shall not be appli­ appli- cable to medical assistance benefits under Article V, VI, or VII of the Illinois Public Aid Code (Ill. Rev. Stat. ch. 23 § 1‐1 et seq.) or similar legislation of any state, benefits provided in compliance with the Tax Equity and Fiscal Responsibility Act or as otherwise provided by law. — Services or supplies rendered to you as the result of an injury caused by another person to the extent that you have collected damages for such injury and that the Plan has provided benefits for the services or supplies rendered in connection with such injury. — Services or supplies that do not meet accepted standards of medical or dental practice including, but not limited to, services which are Experimental/In­ In- vestigational in nature. This exclusion however does not apply to a) the cost of routine patient care associated with Investigational treatment if you are a qualified individual participating in an Approved Clinical Trial program, if those services or supplies would otherwise be covered under this Certificate if not provided in connection with an Approved Clinical Trial program and