Common use of English Translation Clause in Contracts

English Translation. If you need Spanish-language assistance to understand this document, you may request it at no additional cost by calling Customer Service at (000) 000-0000. VERIFICATION OF BENEFITS‌ Verification of benefits is available for Members or authorized health care Providers on behalf of Members. You may call Customer Service with a medical benefits inquiry or verification of benefits during normal business hours. Please remember that a benefits inquiry or verification of benefits is NOT a verification of coverage of a specific medical procedure. • Verification of benefits is NOT a guarantee of payment. • If the verified service requires Prior Authorization, please call (000) 000-0000. PRIOR AUTHORIZATION (also known as Pre-Certification) Prior Authorization is NOT a guarantee of coverage in the following situations: • The Member is no longer covered under this Contract at the time the services are received. • The benefits under this Contract have been exhausted (examples of this include day limits). • In cases of fraud or misrepresentation. • Services that are not Covered Services under your benefit plan. Prior Authorization approvals apply only to services which have been specified in the request for Prior Authorization and/or Prior Authorization list available on our website, XxxxxxxXxxxx.xxx. A Prior Authorization approval does not apply to any other services; other than the specific service being prior authorized. Payment or authorization of such a service does not require or apply to payment of claims at a later date regardless of whether such later claims have the same, similar or related diagnoses. IN-NETWORK For Prior Authorization your PROVIDER must call (000) 000-0000. • Required of your Provider or facility for ALL in-patient hospital admissions that are in-network, except for maternity admissions. • Your Provider should notify us by the next business day of an emergency or maternity admission. • Your Provider can request Non-Urgent Care Prior Authorizations during normal business hours. • Emergency Medical Services do NOT require Prior Authorization.

English Translation. If you You need Spanish-language assistance to understand this document, you You may request it at no additional cost by calling Customer Service at (000) 000-0000. VERIFICATION OF BENEFITS‌ Verification of benefits is available for Members or authorized health care Providers on behalf of Members. You may call Customer Service with a medical benefits inquiry or verification of benefits during normal business hours. Please remember that a benefits inquiry or verification of benefits is NOT a verification of coverage of a specific medical procedure. • Verification of benefits is NOT a guarantee of payment. • If the verified service requires Prior Authorization, please call (000) 000-0000. PRIOR AUTHORIZATION (also known as Pre-Certification) Prior Authorization is NOT a guarantee of coverage in the following situations: • The Member is no longer covered under this Contract at the time the services are received. • The benefits under this Contract have been exhausted (examples of this include day limits). • In cases of fraud or misrepresentation. • Services that are not Covered Services under your Your benefit plan. Prior Authorization approvals apply only to services which have been specified in the request for Prior Authorization and/or Prior Authorization list available on our Our website, XxxxxxxXxxxx.xxx. A Prior Authorization approval does not apply to any other services; other than the specific service being prior authorized. Payment or authorization of such a service does not require or apply to the payment of claims at a later date regardless of whether such later claims have the same, similar similar, or related diagnoses. IN-NETWORK For Prior Authorization your Authorization, Your PROVIDER must call (000) 000-0000. • Required of your Your Provider or facility for ALL in-patient hospital admissions that are in-network, except for maternity admissions. • Your Provider should notify us Us by the next business day of an emergency or maternity admissionmaternityadmission. • Your Provider can request Non-Urgent Care Prior Authorizations during normal business hours. • Emergency Medical Services do NOT require Prior Authorization.

English Translation. If you need Spanish-Spanish language assistance to understand this document, you may request it at no additional cost by calling the Customer Service at (000) 000-0000. NOTICE: The laws of the state of Georgia prohibit insurers from unfairly discriminating against any person based upon his or her status as a victim of family violence. VERIFICATION OF BENEFITS‌ Verification of benefits is available for Members or authorized health care Providers on behalf of Members. You may call Customer Service with a medical benefits inquiry or verification of benefits during normal business hours. Please remember that a benefits inquiry or verification of benefits is NOT a verification of coverage of a specific medical procedure. • Verification of benefits is NOT a guarantee of payment. • If the verified service requires Prior Authorization, please call (000) 000-0000. PRIOR AUTHORIZATION (also known as Pre-Certification) Prior Authorization is NOT a guarantee of coverage in the following situations: • The Member is no longer covered under this Contract at the time the services are received. • The benefits under this Contract have been exhausted (examples of this include day limits). • In cases of fraud or misrepresentation. • Services that are not Covered Services under your benefit plan. IN-NETWORK For Prior Authorization your PROVIDER must call (000) 000-0000. • Required of your Physician or facility for ALL in-patient hospital admissions that are in-network. • The Provider should notify us by the next business day of an emergency or maternity admission. • Non-Urgent Care Prior Authorizations can be requested during normal business hours. • Emergency Medical Services do NOT require Prior Authorization. OUT-OF-NETWORK For Prior Authorization YOU must call (000) 000-0000. • Required by YOU for ALL in-patient hospital admissions that are out-of-network. • YOU are responsible for notifying us within 1-business day of an emergency or maternity admission, or your claim may be denied. • Non-Urgent Care Prior Authorizations may be requested during normal business hours. • Emergency Medical Services do NOT require Prior Authorization. Prior Authorization approvals apply only to services which have been specified in the request for Prior Authorization and/or Prior Authorization prior authorization list available on our website, XxxxxxxXxxxx.xxx. A Prior Authorization approval does not apply to any other services; other than the specific service being prior authorized. Payment or authorization of such a service does not require or apply to payment of claims at a later date date, regardless of whether such later claims have the same, similar or related diagnoses. INELIGIBILITY‌ If you purchased your coverage through the Health Insurance Marketplace, see “REPORTING LIFE & INCOME CHANGES TO THE MARKETPLACE” at the end of this document for additional information. COVERAGE FOR YOU This Certificate describes the benefits you may receive under your health care plan. You are called the Subscriber or Member. Alliant allows child-NETWORK For Prior Authorization only policies under this type of plan. COVERAGE FOR YOUR DEPENDENTS If you are covered by this plan, you may enroll your PROVIDER must call eligible Dependents. Your Covered Dependents are also called Members. Enrollment of Dependents can be done during Open Enrollment or upon experiencing a Special Enrollment Period qualifying event. Eligibility requirements apply to Dependents as well. YOUR ELIGIBLE DEPENDENTS MAY INCLUDE: • Your Spouse, if you are not legally separated. Domestic partners are not considered eligible Dependents except when State or Federal law supersedes this Contract; • Your Dependent children through the end of the year in which they attain age 26; • Your legally adopted children from the date you assume legal responsibility; • Your children for whom you assume legal guardianship and stepchildren; • Your children (000) 000-0000. • Required or children of your Provider or facility spouse) for ALL in-patient hospital admissions that are in-network, except for maternity admissions. whom you have legal responsibility resulting from a valid court decree; • Your Provider should notify us children who are mentally or physically handicapped and totally dependent on you for support, regardless of age. o To be eligible for coverage as an Incapacitated Dependent, the Dependent must have been covered under this Contract prior to reaching age 26. Certification of the handicap is required within 31 days of attainment of age 26. A certification of the handicap may be required periodically but not more frequently than annually. Please note: For the purpose of this Contract, a spouse is the Subscriber’s legal spouse as recognized by the next business day State in which the Subscriber lives. If the wrong date of birth of a child is entered on an emergency application, the child has no coverage for the period for which he or maternity admissionshe is not legally eligible. • Your Provider can request Non-Urgent Care Prior Authorizations during normal business hours. • Emergency Medical Services do NOT require Prior AuthorizationAny overpayments made for coverage for any child under these conditions will be refunded by either you or Alliant.

English Translation. If you need Spanish-language assistance to understand this document, you may request it at no additional cost by calling Customer Service at (000) 000-0000. VERIFICATION OF BENEFITS‌ Verification of benefits is available for Members or authorized health care Providers on behalf of Members. You may call Customer Service with a medical benefits inquiry or verification of benefits during normal business hours. Please remember that a benefits inquiry or verification of benefits is NOT a verification of coverage of a specific medical procedure. • Verification of benefits is NOT a guarantee of payment. • If the verified service requires Prior Authorization, please call (000) 000-0000. PRIOR AUTHORIZATION (also known as Pre-Certification) Prior Authorization is NOT a guarantee of coverage in the following situations: • The Member is no longer covered under this Contract at the time the services are receivedarereceived. • The benefits under this Contract have been exhausted (examples of this include day limits). • In cases of fraud or misrepresentation. • Services that are not Covered Services under your benefit plan. Prior Authorization approvals apply only to services which have been specified in the request for Prior Authorization and/or Prior Authorization list available on our website, XxxxxxxXxxxx.xxx. A Prior Authorization approval does not apply to any other services; other than the specific service being prior authorized. Payment or authorization of such a service does not require or apply to payment of claims at a later date regardless of whether such later claims have the same, similar or related diagnoses. IN-NETWORK For Prior Authorization your PROVIDER must call (000) 000-0000. • Required of your Provider or facility for ALL in-patient hospital admissions that are in-network, except for maternity admissions. • Your Provider should notify us by the next business day of an emergency or maternity admission. • Your Provider can request Non-Urgent Care Prior Authorizations during normal business hours. • Emergency Medical Services do NOT require Prior Authorization.