Out-of-Network Benefits. The out-of-network benefits portion of this Contract provides coverage when You receive Covered Services from Non-Participating Providers. Your out-of-pocket expenses will be higher when You receive out-of-network benefits. In addition to Cost-Sharing, You will also be responsible for paying any difference between the Allowed Amount and the Non-Participating Provider’s charge.
Out-of-Network Benefits. The out-of-network benefits portion of this Contract provides coverage when You receive Covered Services from Non-Participating Providers. Your out-of-pocket expenses will be higher when You receive out-of-network benefits. In addition to Cost-Sharing, You will also be responsible for paying any difference between the Allowed Amount and the Non-Participating Provider’s charge. READ THIS ENTIRE CONTRACT CAREFULLY. IT IS YOUR RESPONSIBILITY TO UNDERSTAND THE TERMS AND CONDITIONS IN THIS CONTRACT. This Contract is governed by the laws of New York State. The insurance evidenced by this Contract provides DENTAL insurance ONLY. This Contract is a New York State of Health, The Official Health Plan Marketplace, certified stand-alone dental plan offered outside the New York State of Health. If You need foreign language assistance to understand this Contract, You may call Us at 0-000-000-0000 TABLE OF CONTENTS Section I. Definitions 7 Section II. How Your Coverage Works 11 Participating Providers 11 The Role of Primary Care Dentists 11 Services Subject to Preauthorization 11 Medical Necessity 12 Important Telephone Numbers and Addresses 13 Section III. Cost-Sharing Expenses and Allowed Amount 14 Section IV. Who is Covered 16 Section V. Pediatric Dental Care 19 Section VI. Adult Dental Care 21 Section VII. Exclusions and Limitations 23 Section VIII. Claim Determinations 25 Section IX. Grievance Procedures 27 Section X. Utilization Review 29 Section XI. External Appeal 32 Section XII. Termination of Coverage 35 Section XIII. Extension of Benefits 36 Section XIV. Temporary Suspension Rights for Armed Forces’ Members 37 Section XV. General Provisions 38 Section XVI. Schedule of Benefits 42 Riders, Contract Amendments. End of Contract This is Your PREFERRED PROVIDER ORGANIZATION INSURANCE CONTRACT Issued by BlueCross BlueShield of Western New York 000 Xxxx Xxxxxxx Xx. Buffalo, New York 14202 President & CEO This is Your individual Contract for preferred provider organization coverage issued by BlueCross BlueShield of Western New York. This Contract, together with the attached Schedule of Benefits, applications, and any amendment or rider amending the terms of this Contract, constitute the entire agreement between You and Us. You have the right to return this Contract. Examine it carefully. If You are not satisfied, You may return this Contract to Us and ask Us to cancel it. Your request must be made in writing within ten (10) days from the date You receive this Contract....
Out-of-Network Benefits. The out-of-network benefits portion of this Contract provides coverage when You receive Covered Services from Non-Participating Providers. Your out-of-pocket expenses will be higher when You receive out-of-network benefits. In addition to Cost-Sharing, You will also be responsible for paying any difference between the Allowed Amount and the Non-Participating Provider’s charge. READ THIS ENTIRE CONTRACT CAREFULLY. IT IS YOUR RESPONSIBILITY TO UNDERSTAND THE TERMS AND CONDITIONS IN THIS CONTRACT. This Contract is governed by the laws of New York State. The insurance evidenced by this Contract provides DENTAL insurance ONLY. This Contract is a New York State of Health, The Official Health Plan Marketplace, certified stand-alone dental plan offered outside the New York State of Health. If You need foreign language assistance to understand this Contract, You may call Us at 0-000-000-0000 This is Your PREFERRED PROVIDER ORGANIZATION INSURANCE CONTRACT Issued by BlueCross BlueShield of Western New York 000 Xxxx Xxxxxxx Xx. Buffalo, New York 14202 President & CEO This is Your individual Contract for preferred provider organization coverage issued by BlueCross BlueShield of Western New York. This Contract, together with the attached Schedule of Benefits, applications, and any amendment or rider amending the terms of this Contract, constitute the entire agreement between You and Us. You have the right to return this Contract. Examine it carefully. If You are not satisfied, You may return this Contract to Us and ask Us to cancel it. Your request must be made in writing within ten (10) days from the date You receive this Contract. We will refund any Premium paid including any Contract fees or other charges.
Out-of-Network Benefits. The out-of-network benefits portion of this Contract provides coverage when You receive Covered Services from Non-Participating Providers. Your out-of-pocket expenses will be higher when You receive out-of-network benefits. In addition to Cost-Sharing, You will also be responsible for paying any difference between the Allowed Amount and the Non-Participating Provider’s charge. READ THIS ENTIRE CONTRACT CAREFULLY. IT IS YOUR RESPONSIBILITY TO UNDERSTAND THE TERMS AND CONDITIONS IN THIS CONTRACT. This Contract is governed by the laws of New York State. The insurance evidenced by this Contract provides DENTAL insurance ONLY. This Contract is a New York State of Health, The Official Health Plan Marketplace, certified stand-alone dental plan offered outside the New York State of Health. If You need foreign language assistance to understand this Contract, You may call Us at 0-000-000-0000 SECTION I Definitions Defined terms will appear capitalized throughout the Contract Acute: The onset of disease or injury, or a change in the Member's condition that would require prompt medical attention. Allowed Amount: The maximum amount on which Our payment is based for Covered Services. See the Cost-Sharing Expenses and Allowed Amount section of this Contract for a description of how the Allowed Amount is calculated. If Your Non-Participating Provider charges more than the Allowed Amount, You will have to pay the difference between the Allowed Amount and the Provider’s charge, in addition to any Cost-Sharing requirements. Appeal: A request for Us to review a Utilization Review decision or a Grievance again. Balance Billing: When a Non-Participating Provider bills You for the difference between the Non-Participating Provider’s charge and the Allowed Amount. A Participating Provider may not Balance Bill You for Covered Services. Contract: This Contract issued by BlueCross BlueShield of Western New York, including the Schedule of Benefits and any attached riders.
Out-of-Network Benefits. 1. Examination One in any 12 month period
Out-of-Network Benefits. When using Out of Network benefit, prior authorization is required for all inpatient and outpatient hospital admissions, all elective ambulatory surgical procedures, and most diagnostic procedures performed in a non-plan hospital or freestanding surgical center. To obtain prior authorization, please contact the Customer Service Department. A penalty is applied to Out of Network reimbursement when the member does not complete the prior authorization process.
Out-of-Network Benefits. The out-of-network benefits portion of this Contract provides coverage when You receive Covered Services from Non-Participating Providers. Your out-of-pocket expenses will be higher when You receive out-of-network benefits. In addition to Cost-Sharing, You will also be responsible for paying any difference between the Allowed Amount and the Non-Participating Provider’s charge. READ THIS ENTIRE CONTRACT CAREFULLY. IT IS YOUR RESPONSIBILITY TO UNDERSTAND THE TERMS AND CONDITIONS IN THIS CONTRACT. This Contract is governed by the laws of New York State. The insurance evidenced by this Contract provides DENTAL insurance ONLY. This Contract is a New York State of Health, The Official Health Plan Marketplace, certified stand-alone dental plan offered outside the New York State of Health. By: Xxxxxxxxxxx Del Xxxxxxx, Chief Executive Officer MVP Health Services Corp. TABLE OF CONTENTS SECTION I – Definitions 4 SECTION II - How Your Coverage Works 10 C. Participating Providers 10 D. The Role of Primary Care Dentists 10
Out-of-Network Benefits. The plan participant pays full fee to the provider and United Healthcare Vision (UHCV) reimburses the participant for services rendered up to maximum allowance. There are no copays or deductibles. If you visit an out-of-network provider, you will need to send your itemized receipts, with primary-insured’s unique identification number and the patient’s name and date of birth, to: UnitedHealthcare Vision Claims Department X.X. Xxx 00000 Xxxx Xxxx Xxxx, XX 00000 xxx.xxxxxxxxxxxxxxxxxxxxxx.xxx Basic Benefits – Eye Examination Up to $32.00 Single Vision Up to $42.00 Bifocal Up to $48.00 Trifocal Up to $60.00 Lenticular Up to $72.00 Frames Up to $50.00 Elective Contact Lenses Covered-in-full contacts All other elective contacts Up to $100.00 Up to $100.00 Necessary Contact Lenses Up to $100.00 Once Every 12 Months Out-of-Network Reimbursement Receipts for services and materials purchased on different dates must be submitted at the same time to receive reimbursement. Receipts must be submitted within 12 months of the date of service. AppeAnppdeinxdiBx B, D- Deennttaal/lUUpgpragdrea, Pdaeg,ec2ont. Appendix B, Medical - Compensation Group I $S2e5pt0e/m$b5e0r 00 -XXxxxxxxxxxxxxxx x0x0,X0x0x0x0 PPO Versatile Plan 3 with RX Plan 6 Benefits-at-a-Glance WmHIP The information in this document is based on BCBSM’s current interpretation of the Patient Protection and Affordable Care Act (PPACA). Interpretations of PPACA vary and the federal government continues to issue guidance on how PPACA should be interpreted and applied. Efforts will be made to update this document as more information about PPACA becomes available. This BAAG is only an educational tool and should not be relied upon as legal or compliance advice. Additionally, some PPACA requirements may differ for particular members enrolled in certain programs, and those members should consult with their plan administrators for specific details. In-Network Out-of-Network Deductible, Copays/Coinsurance and Dollar Maximums Deductible - per calendar year $250 per member $500 per family $ 500 per member $1,000 per family Copays/Coinsurance • Fixed Dollar Copays $20 copay for: Office visits Urgent Care visits $25 copay for: Non-emergency visits in ER $25 copay for: Non-emergency visits in emergency room • Percent Coinsurance 10% 30% Note: Services without a network are covered at the in-network level. Out-of-Pocket Maximum – per calendar year • Percent Coinsurance Excludes Deductible $1,000 per member $2,000 per family $2,...
Out-of-Network Benefits. The out-of-network benefits portion of this Contract provides coverage when You receive Covered Services from Non-Participating Providers. Your out-of-pocket expenses will be higher when You receive out-of-network benefits. In addition to Cost-Sharing, You will also be responsible for paying any difference between the Allowed Amount and the Non-Participating Provider’s charge. READ THIS ENTIRE CONTRACT CAREFULLY. IT IS YOUR RESPONSIBILITY TO UNDERSTAND THE TERMS AND CONDITIONS IN THIS CONTRACT. This Contract is governed by the laws of New York State. The insurance evidenced by this Contract provides DENTAL insurance ONLY. By: Xxxxxxxxxxx Del Xxxxxxx, Chief Executive Officer MVP Health Services Corp. TABLE OF CONTENTS SECTION I - Definitions 4 SECTION II - How Your Coverage Works 9 C. Participating Providers 9 D. The Role of Primary Care Dentists 9
Out-of-Network Benefits. I understand that I am solely responsible for obtaining information about my ‘Out-of-network’ benefits from my health insurance. I understand that I can request a superscript from my therapist, at time of session, and bill my health insurance ‘Out-of-network’. I understand that I am solely responsible for payment of services at time of service to Insightful Minds Counseling, LLC. I understand that I am responsible for billing my health insurance for ‘out-of- network’ reimbursement, unless otherwise discussed and agreed upon with Insightful Minds Counseling, LLC. I understand that Insightful Minds Counseling, LLC cannot guarantee that my health insurance company will reimburse me for all fee’s incurred while in treatment with Insightful Minds Counseling, LLC. Sliding-Fee Scale Only I have discussed my qualifications for a sliding-fee scale with my provider and have agreed to pay the sliding-fee of $ per session. I agree to notify Insightful Minds Counseling, LLC, in-writing, of a change of income which would require an adjustment to my sliding-fee rate. I understand that this means I will alert Insightful Minds Counseling, LLC that I need a lower rate or that I am able to pay a higher rate per session. I (we) agree to and understand the above agreement. Client Signature: Date: Parent/Guardian Signature*: Date: Provider Signature: Date:
