Common use of Reconstructive Surgery for Cosmetic Purposes Clause in Contracts

Reconstructive Surgery for Cosmetic Purposes. Reconstructive Surgery for Cosmetic purposes is not Covered unless reconstruction is performed after a mastectomy. Cosmetic Surgery is not Covered. Examples of Cosmetic Surgery include breast augmentation, dermabrasion, dermaplaning, excision of acne scarring, acne surgery (including cryotherapy), asymptomatic keloid/scar revision, microphlebectomy, sclerotherapy (except for truncal veins), and nasal rhinoplasty. Rehabilitation and Therapy Rehabilitation and Therapy, as listed below, is not Covered. Short or Long-term Rehabilitation services listed are not Covered: • Athletic trainers or treatments delivered by Athletic trainers are not Covered. • Vocational Rehabilitation Services are not Covered. • Long-term Therapy or Rehabilitation Services are not Covered. These therapies include treatment for chronic or incurable conditions for which rehabilitation produces minimal or temporary change or relief. Therapies are considered Long-term Rehabilitation when: o You have reached maximum rehabilitation potential. o You have reached a point where Significant Improvement is unlikely to occur. o You have had therapy for four consecutive months. o Long-Term Therapy includes treatment for chronic or incurable conditions for which rehabilitation produces minimal or temporary change or relief. Treatment of chronic conditions is not Covered. Chronic conditions include, but are not limited to, Muscular Dystrophy, Down Syndrome, Cerebral Palsy, and Developmental Delays not associated with a defined event of illness or injury. • Treatment of chronic conditions is not Covered. Chronic conditions include, but are not limited to, Muscular Dystrophy, Down Syndrome, and Cerebral Palsy. Speech Therapy services listed below are not Covered: • Therapy for stuttering is not Covered. • Hearing Aids and the evaluation for the fitting of Hearing Aids are not Covered, except for school aged children under 18 years old (or under 21 years of age if still attending high school). • Additional benefits beyond those listed in the Speech Therapy Benefit Section are not Covered. Services for Which You or Your Dependent are Eligible under Any Governmental Program Services for which you or your Dependent are eligible under any governmental program (except Medicaid), to the extent determined by law, are not Covered. Services for which, in the absence of any health service plan or insurance plan, no charge would be made to you or your Dependent, are not Covered. Services Requiring Prior Authorization When Out-of-network If you fail to obtain Prior Authorization for services received Out-of-network that require Prior Authorization, those services are not Covered. However, Members are not liable when an In- network Practitioner/Provider does not obtain Prior Authorization. Refer to Prior Authorization Section for specific information. Sexual Dysfunction Treatment Treatment for sexual dysfunction, including medication, counseling, and clinics, are not Covered, except for penile prosthesis as listed in the Benefits Section. Skilled Nursing Facility Care Custodial or Domiciliary care is not Covered. Smoking Cessation Services Smoking Cessation services listed below are not Covered: • Hypnotherapy for Smoking Cessation Counseling is not Covered, • Over-the-counter (OTC) drugs are not Covered, unless listed as a Covered Over-the- counter (OTC) medication on our Formulary. • Acupuncture for Smoking Cessation Counseling is not Covered. Thermography Thermography Services are not Covered. Transplant Services Transplant Services listed below are not Covered: • Non-human Organ transplants, except for porcine (pig) heart valve, are not Covered. • Transportation costs for deceased Members are not Covered. • The medical and Hospital services of an Organ transplant donor when the recipient of an Organ transplant is not a Member or when the transplant procedure is not a Covered Benefit are not Covered. • Travel and lodging expenses are not Covered except as provided in the Benefits Section. Treatment While Incarcerated Services or supplies a member receives while in the custody of any state or federal law enforcement authorities or while in jail or prison are not Covered. Women’s Health Care Elective abortions after the 24th week of pregnancy are not Covered. Maternity and newborn care, as follows, are not Covered: • Use of an emergency facility for non-emergent services is not Covered. • Elective Home Birth and any prenatal or postpartum services connected with an Elective Home Birth are not Covered. Allowable sites for a delivery of a child are Hospitals and licensed birthing centers. Elective Home Birth means a birth that was planned or intended by the Member or Practitioner/Provider to occur in the home. Work-related Illnesses or Injuries Work-related illnesses or injuries are not Covered, even if: • You fail to file a claim within the filing period allowed by the applicable law. • You obtain care not authorized by Workers’ Compensation Insurance. • Your employer fails to carry the required Worker’s Compensation Insurance. • You fail to comply with any other provisions of the law. Claims Your health care benefits are considered and paid according to the conditions outlined in this Section. If you paid a Provider for services, this Section outlines the process to follow for reimbursement. When services are obtained from an In-network Practitioner/Provider, the Practitioner/Provider will submit the claim to Presbyterian for you. It is important that you provide your current Presbyterian identification card to the Practitioner/Provider so they may obtain the mailing address listed on the back of the card. Services obtained from In-network Practitioners/Providers may require Cost Sharing amounts (Copayments, Deductible and/or Coinsurance) that you pay at the time of service. The amount of your Cost Sharing responsibility for each service can be found in your Summary of Benefits and Coverage.

Reconstructive Surgery for Cosmetic Purposes. Reconstructive Surgery for Cosmetic purposes is not Covered unless reconstruction is performed after a mastectomy. Cosmetic Surgery is not Covered. Examples of Cosmetic Surgery include breast augmentation, dermabrasion, dermaplaning, excision of acne scarring, acne surgery (including cryotherapy), asymptomatic keloid/scar revision, microphlebectomy, sclerotherapy (except for truncal veins), and nasal rhinoplasty. Rehabilitation and Therapy Rehabilitation and Therapy, as listed below, is not Covered. Short or Long-term Rehabilitation services listed are not Covered: • Athletic trainers or treatments delivered by Athletic trainers are not Covered. • Vocational Rehabilitation Services are not Covered. • Long-term Therapy or Rehabilitation Services are not Covered. These therapies include treatment for chronic or incurable conditions for which rehabilitation produces minimal or temporary change or relief. Therapies are considered Long-term Rehabilitation when: o You have reached maximum rehabilitation potential. o You have reached a point where Significant Improvement is unlikely to occur. o You have had therapy for four consecutive months. o Long-Term Therapy includes treatment for chronic or incurable conditions for which rehabilitation produces minimal or temporary change or relief. Treatment of chronic conditions is not Covered. Chronic conditions include, but are not limited to, Muscular Dystrophy, Down Syndrome, Cerebral Palsy, and Developmental Delays not associated with a defined event of illness or injury. • Treatment of chronic conditions is not Covered. Chronic conditions include, but are not limited to, Muscular Dystrophy, Down Syndrome, and Cerebral Palsy. Speech Therapy services listed below are not Covered: • Therapy for stuttering is not Covered. Covered.‌‌‌‌‌ • Hearing Aids and the evaluation for the fitting of Hearing Aids are not Covered, except for school aged children under 18 years old (or under 21 years of age if still attending high school). • Additional benefits beyond those listed in the Speech Therapy Benefit Section are not Covered. Services for Which You or Your Dependent are Eligible under Any Governmental Program Services for which you or your Dependent are eligible under any governmental program (except Medicaid), to the extent determined by law, are not Covered. Services for which, in the absence of any health service plan or insurance plan, no charge would be made to you or your Dependent, are not Covered. Services Requiring Prior Authorization When Out-of-network If you fail to obtain Prior Authorization for services received Out-of-network that require Prior Authorization, those services are not Covered. However, Members are not liable when an In- network Practitioner/Provider does not obtain Prior Authorization. Refer to Prior Authorization Section for specific information. Sexual Dysfunction Treatment Treatment for sexual dysfunction, including medication, counseling, and clinics, are not Covered, except for penile prosthesis as listed in the Benefits Section. Skilled Nursing Facility Care Custodial or Domiciliary care is not Covered. Smoking Cessation Services Smoking Cessation services listed below are not Covered: • Hypnotherapy for Smoking Cessation Counseling is not Covered, • Over-the-counter (OTC) drugs are not Covered, unless listed as a Covered Over-the- counter (OTC) medication on our Formulary. • Acupuncture for Smoking Cessation Counseling is not Covered. Thermography Thermography Services are not Covered. Transplant Services Services‌‌‌ Transplant Services listed below are not Covered: • Non-human Organ transplants, except for porcine (pig) heart valve, are not Covered. • Transportation costs for deceased Members are not Covered. • The medical and Hospital services of an Organ transplant donor when the recipient of an Organ transplant is not a Member or when the transplant procedure is not a Covered Benefit are not Covered. • Travel and lodging expenses are not Covered except as provided in the Benefits Section. Treatment While Incarcerated Services or supplies a member receives while in the custody of any state or federal law enforcement authorities or while in jail or prison are not Covered. Women’s Health Care Elective abortions after the 24th week of pregnancy are not Covered. Maternity and newborn care, as follows, are not Covered: • Use of an emergency facility for non-emergent services is not Covered. • Elective Home Birth and any prenatal or postpartum services connected with an Elective Home Birth are not Covered. Allowable sites for a delivery of a child are Hospitals and licensed birthing centers. Elective Home Birth means a birth that was planned or intended by the Member or Practitioner/Provider to occur in the home. Work-related Illnesses or Injuries Work-related illnesses or injuries are not Covered, even if: • You fail to file a claim within the filing period allowed by the applicable law. • You obtain care not authorized by Workers’ Compensation Insurance. • Your employer fails to carry the required Worker’s Compensation Insurance. • You fail to comply with any other provisions of the law. Claims Claims‌‌‌ Your health care benefits are considered and paid according to the conditions outlined in this Section. If you paid a Provider for services, this Section outlines the process to follow for reimbursement. When services are obtained from an In-network Practitioner/Provider, the Practitioner/Provider will submit the claim to Presbyterian for you. It is important that you provide your current Presbyterian identification card to the Practitioner/Provider so they may obtain the mailing address listed on the back of the card. Services obtained from In-network Practitioners/Providers may require Cost Sharing amounts (Copayments, Deductible and/or Coinsurance) that you pay at the time of service. The amount of your Cost Sharing responsibility for each service can be found in your Summary of Benefits and Coverage.current

Reconstructive Surgery for Cosmetic Purposes. Reconstructive Surgery for Cosmetic purposes is not Covered unless reconstruction is performed after a mastectomy. Cosmetic Surgery is not Covered. Examples of Cosmetic Surgery include breast augmentation, dermabrasion, dermaplaning, excision of acne scarring, acne surgery (including cryotherapy), asymptomatic keloid/scar revision, microphlebectomy, sclerotherapy (except for truncal veins), and nasal rhinoplasty. Rehabilitation and Therapy Rehabilitation and Therapy, as listed below, is not Covered. Short or Long-term Rehabilitation services listed are not Covered: • Athletic trainers or treatments delivered by Athletic trainers are not Covered. • Vocational Rehabilitation Services are not Covered. • Long-term Therapy or Rehabilitation Services are not Covered. These therapies include treatment for chronic or incurable conditions for which rehabilitation produces minimal or temporary change or relief. Therapies are considered Long-term Rehabilitation when: o You have reached maximum rehabilitation potential. o You have reached a point where Significant Improvement is unlikely to occur. o You have had therapy for four consecutive months. o Long-Term Therapy includes treatment for chronic or incurable conditions for which rehabilitation produces minimal or temporary change or relief. Treatment of chronic conditions is not Covered. Chronic conditions include, but are not limited to, Muscular Dystrophy, Down Syndrome, Cerebral Palsy, and Developmental Delays not associated with a defined event of illness or injury. • Treatment of chronic conditions is not Covered. Chronic conditions include, but are not limited to, Muscular Dystrophy, Down Syndrome, and Cerebral Palsy. Speech Therapy services listed below are not Covered: • Therapy for stuttering is not Covered. • Hearing Aids and the evaluation for the fitting of Hearing Aids are not Covered, except for school aged children under 18 years old (or under 21 years of age if still attending high school). • Additional benefits beyond those listed in the Speech Therapy Benefit Section are not Covered. Services for Which You or Your Dependent are Eligible under Any Governmental Program Services for which you or your Dependent are eligible under any governmental program (except Medicaid), to the extent determined by law, are not Covered. Services for which, in the absence of any health service plan or insurance plan, no charge would be made to you or your Dependent, are not Covered. Services Requiring Prior Authorization When Out-of-network (outside of the 5-county area) If you fail to obtain Prior Authorization for services received Out-of-network (outside of the 5- county area) that require Prior Authorization, those services are not Covered. However, Members are not liable when an In- In-network Practitioner/Provider does not obtain Prior Authorization. Refer to Prior Authorization Section for specific information. Sexual Dysfunction Treatment Treatment for sexual dysfunction, including medication, counseling, and clinics, are not Covered, except for penile prosthesis as listed in the Benefits Section. Skilled Nursing Facility Care Custodial or Domiciliary care is not Covered. Smoking Cessation Services Smoking Cessation services listed below are not Covered: • Hypnotherapy for Smoking Cessation Counseling is not Covered, • Over-the-counter (OTC) drugs are not Covered, unless listed as a Covered Over-the- counter (OTC) medication on our Formulary. • Acupuncture for Smoking Cessation Counseling is not Covered. Thermography Thermography Services are not Covered. Transplant Services Transplant Services listed below are not Covered: • Non-human Organ transplants, except for porcine (pig) heart valve, are not Covered. • Transportation costs for deceased Members are not Covered. • The medical and Hospital services of an Organ transplant donor when the recipient of an Organ transplant is not a Member or when the transplant procedure is not a Covered Benefit are not Covered. • Travel and lodging expenses are not Covered except as provided in the Benefits Section. Treatment While Incarcerated Services or supplies a member receives while in the custody of any state or federal law enforcement authorities or while in jail or prison are not Covered. Women’s Health Care Elective abortions after the 24th week of pregnancy are not Covered. Maternity and newborn care, as follows, are not Covered: • Use of an emergency facility for non-emergent services is not Covered. • Elective Home Birth and any prenatal or postpartum services connected with an Elective Home Birth are not Covered. Allowable sites for a delivery of a child are Hospitals and licensed birthing centers. Elective Home Birth means a birth that was planned or intended by the Member or Practitioner/Provider to occur in the home. Work-related Illnesses or Injuries Work-related illnesses or injuries are not Covered, even if: • You fail to file a claim within the filing period allowed by the applicable law. • You obtain care not authorized by Workers’ Compensation Insurance. • Your employer fails to carry the required Worker’s Compensation Insurance. • You fail to comply with any other provisions of the law. Claims Your health care benefits are considered and paid according to the conditions outlined in this Section. If you paid a Provider for services, this Section outlines the process to follow for reimbursement. When services are obtained from an In-network Practitioner/Provider, the Practitioner/Provider will submit the claim to Presbyterian for you. It is important that you provide your current Presbyterian identification card to the Practitioner/Provider so they may obtain the mailing address listed on the back of the card. Services obtained from In-network Practitioners/Providers may require Cost Sharing amounts (Copayments, Deductible and/or Coinsurance) that you pay at the time of service. The amount of your Cost Sharing responsibility for each service can be found in your Summary of Benefits and Coverage.current

Reconstructive Surgery for Cosmetic Purposes. Reconstructive Surgery for Cosmetic purposes is not Covered unless reconstruction is performed after a mastectomy. Cosmetic Surgery is not Covered. Examples of Cosmetic Surgery include breast augmentation, dermabrasion, dermaplaning, excision of acne scarring, acne surgery (including cryotherapy), asymptomatic keloid/scar revision, microphlebectomy, sclerotherapy (except for truncal veins), and nasal rhinoplasty. Rehabilitation and Therapy Rehabilitation and Therapy, as listed below, is not Covered. Short or Long-term Rehabilitation services listed are not Covered: • Athletic trainers or treatments delivered by Athletic trainers are not Covered. • Vocational Rehabilitation Services are not Covered. • Long-term Therapy or Rehabilitation Services are not Covered. These therapies include treatment for chronic or incurable conditions for which rehabilitation produces minimal or temporary change or relief. Therapies are considered Long-term Rehabilitation when: o You have reached maximum rehabilitation potential. o You have reached a point where Significant Improvement is unlikely to occur. o You have had therapy for four consecutive months. o Long-Term Therapy includes treatment for chronic or incurable conditions for which rehabilitation produces minimal or temporary change or relief. Treatment of chronic conditions is not Covered. Chronic conditions include, but are not limited to, Muscular Dystrophy, Down Syndrome, Cerebral Palsy, and Developmental Delays not associated with a defined event of illness or injury. • Treatment of chronic conditions is not Covered. Chronic conditions include, but are not limited to, Muscular Dystrophy, Down Syndrome, and Cerebral Palsy. Speech Therapy services listed below are not Covered: • Therapy for stuttering is not Covered. • Hearing Aids and the evaluation for the fitting of Hearing Aids are not Covered, except for school aged children under 18 years old (or under 21 years of age if still attending high school). • Additional benefits beyond those listed in the Speech Therapy Benefit Section are not Covered. Services for Which You or Your Dependent are Eligible under Any Governmental Program Services for which you or your Dependent are eligible under any governmental program (except Medicaid), to the extent determined by law, are not Covered. Services for which, in the absence of any health service plan or insurance plan, no charge would be made to you or your Dependent, are not Covered. Services Requiring Prior Authorization When Out-of-network If you fail to obtain Prior Authorization for services received Out-of-network that require Prior Authorization, those services are not Covered. However, Members are not liable when an In- In-network Practitioner/Provider does not obtain Prior Authorization. Refer to Prior Authorization Section for specific information. Sexual Dysfunction Treatment Treatment for sexual dysfunction, including medication, counseling, and clinics, are not Covered, except for penile prosthesis as listed in the Benefits Section. Skilled Nursing Facility Care Custodial or Domiciliary care is not Covered. Smoking Cessation Services Smoking Cessation services listed below are not Covered: • Hypnotherapy for Smoking Cessation Counseling is not Covered, • Over-the-counter (OTC) drugs are not Covered, unless listed as a Covered Over-the- counter (OTC) medication on our Formulary. • Acupuncture for Smoking Cessation Counseling is not Covered. Thermography Thermography Services are not Covered. Transplant Services Transplant Services listed below are not Covered: • Non-human Organ transplants, except for porcine (pig) heart valve, are not Covered. • Transportation costs for deceased Members are not Covered. • The medical and Hospital services of an Organ transplant donor when the recipient of an Organ transplant is not a Member or when the transplant procedure is not a Covered Benefit are not Covered. • Travel and lodging expenses are not Covered except as provided in the Benefits Section. Treatment While Incarcerated Services or supplies a member receives while in the custody of any state or federal law enforcement authorities or while in jail or prison are not Covered. Women’s Health Care Elective abortions after the 24th week of pregnancy are not Covered. Maternity and newborn care, as follows, are not Covered: • Use of an emergency facility for non-emergent services is not Covered. • Elective Home Birth and any prenatal or postpartum services connected with an Elective Home Birth are not Covered. Allowable sites for a delivery of a child are Hospitals and licensed birthing centers. Elective Home Birth means a birth that was planned or intended by the Member or Practitioner/Provider to occur in the home. Work-related Illnesses or Injuries Work-related illnesses or injuries are not Covered, even if: • You fail to file a claim within the filing period allowed by the applicable law. • You obtain care not authorized by Workers’ Compensation Insurance. • Your employer fails to carry the required Worker’s Compensation Insurance. • You fail to comply with any other provisions of the law. Claims Your health care benefits are considered and paid according to the conditions outlined in this Section. If you paid a Provider for services, this Section outlines the process to follow for reimbursement. When services are obtained from an In-network Practitioner/Provider, the Practitioner/Provider will submit the claim to Presbyterian for you. It is important that you provide your current Presbyterian identification card to the Practitioner/Provider so they may obtain the mailing address listed on the back of the card. Services obtained from In-network Practitioners/Providers may require Cost Sharing amounts (Copayments, Deductible and/or Coinsurance) that you pay at the time of service. The amount of your Cost Sharing responsibility for each service can be found in your Summary of Benefits and Coverage. Out-of-network Practitioners/Providers may require payment in full at the time of service and may refuse to file a claim. When this happens you must pay the Out-of-network Practitioner/Provider and then file a claim for reimbursement with us. Notice of Claim The timely filing limit for an In-network Practitioner/Provider is ninety (90) days from the date of service, whereas the timely filing limit for an Out-of-network Practitioner/Provider is one year from the date of service. Written notice of claim must be given to us within twenty days after the date of loss or as soon as reasonably possible. Failure to give notice within the time specified will not invalidate or reduce any claim if notice is given as soon as reasonably possible. Claim Forms You may call or write to us to notify us of a claim. Upon receipt of a notice of claim, we will furnish you with the forms needed for filing proof of service. Forms will be furnished within 15 days after we receive such notice. You may access our web site, xxxxx://xxx.xxx.xxx/healthplans/member-information/Pages/forms-and-documents.aspx to obtain a claim form. In-network Practitioners/Providers We reimburse In-network Practitioners/Providers for Covered services provided to you. You should not be required to pay sums to any In-network Practitioner/Provider, except for the required cost sharing amount. You will be responsible for the payment of fees charged for missed appointments or appointments canceled without adequate notice, if any. If you are asked by an In-network Practitioner/Provider to make any payments in addition to the Cost Sharing amount specified in this Agreement, you should consult our Presbyterian Customer Service Center at (000) 000-0000 or 0-000-000-0000, Monday through Friday from 7 a.m. to 6 p.m. Hearing impaired users may call our TTY line at 711 before making any such additional payments. You will not be liable to an In-network Practitioner/Provider for any sums that we owe the Practitioner/Provider. Procedure for Reimbursement When you receive Covered Services from a Practitioner/Provider and the Practitioner/Provider charged for that service, written proof (claim) of such charge must be furnished to us within 90 days from the date of service for In-network Practitioners/Providers and within one year from the date of service for Out-of- network Practitioners/Providers in order for you to receive reimbursement. If you are relying on an Out-of-network Practitioner/Provider to furnish a claim on your behalf, you are responsible for ensuring claims have been submitted within one year from the date of service. Any such charge shall be paid upon our receipt of a Practitioner/Provider billing or completed valid claim for the Health Care Services for which claim is made. If you need a claim form or have questions regarding a charge made by your Practitioner/Provider, please contact our Presbyterian Customer Service Center at (000) 000-0000 or 0-000-000-0000, Monday through Friday from 7 a.m. to 6 p.m. Hearing impaired users may call our TTY 711. Claim forms are also available on our website at xxx.xxx.xxx. Please submit your completed claim form to: Presbyterian Insurance Company, Inc. Attn: Claims P.O. Box 26267 Albuquerque, NM 87125-6267 Services Received Outside the United States Benefits are available for Emergency Health Care Services and Urgent Care services received outside the United States. These services are Covered as explained in the Benefits Section. You are responsible for ensuring that claims sent to us, at the address cited above, are appropriately translated and that the monetary exchange rate effective on the date(s) you received medical care is clearly identified when submitting claims for services received outside the United States. Presbyterian cannot reimburse foreign Practitioners/Providers. You should then submit the claim or a summary of the medical services rendered, in addition to Proof of Payment. Proof of payment includes the check, credit card statement or receipt showing that the services were paid in full. Claim Fraud Anyone who knowingly presents a false or fraudulent claim for payment of a loss, or benefit or knowingly presents false information for services is guilty of a crime and may be subject to civil fines and criminal penalties. We may terminate your Coverage for any type of fraudulent activity. For further information regarding Fraud, refer to the General Provisions Section.

Reconstructive Surgery for Cosmetic Purposes. Reconstructive Surgery for Cosmetic purposes is not Covered unless reconstruction is performed after a mastectomy. Cosmetic Surgery is not Covered. Examples of Cosmetic Surgery include breast augmentation, dermabrasion, dermaplaning, excision of acne scarring, acne surgery (including cryotherapy), asymptomatic keloid/scar revision, microphlebectomy, sclerotherapy (except for truncal veins), and nasal rhinoplasty. Rehabilitation and Therapy Rehabilitation and Therapy, as listed below, is not Covered. Short or Long-term Rehabilitation services listed are not Covered: • Athletic trainers or treatments delivered by Athletic trainers are not Covered. • Vocational Rehabilitation Services are not Covered. • Long-term Therapy or Rehabilitation Services are not Covered. These therapies include treatment for chronic or incurable conditions for which rehabilitation produces minimal or temporary change or relief. Therapies are considered Long-term Rehabilitation when: o You have reached maximum rehabilitation potential. o You have reached a point where Significant Improvement is unlikely to occur. o You have had therapy for four consecutive months. o Long-Term Therapy includes treatment for chronic or incurable conditions for which rehabilitation produces minimal or temporary change or relief. Treatment of chronic conditions is not Covered. Chronic conditions include, but are not limited to, Muscular Dystrophy, Down Syndrome, Cerebral Palsy, and Developmental Delays not associated with a defined event of illness or injury. • Treatment of chronic conditions is not Covered. Chronic conditions include, but are not limited to, Muscular Dystrophy, Down Syndrome, and Cerebral Palsy. Speech Therapy services listed below are not Covered: • Therapy for stuttering is not Covered. • Hearing Aids and the evaluation for the fitting of Hearing Aids are not Covered, except for school aged children under 18 years old (or under 21 years of age if still attending high school). • Additional benefits beyond those listed in the Speech Therapy Benefit Section are not Covered. Services for Which You or Your Dependent are Eligible under Any Governmental Program Services for which you or your Dependent are eligible under any governmental program (except Medicaid), to the extent determined by law, are not Covered. Services for which, in the absence of any health service plan or insurance plan, no charge would be made to you or your Dependent, are not Covered. Services Requiring Prior Authorization When Out-of-network If you fail to obtain Prior Authorization for services received Out-of-network that require Prior Authorization, those services are not Covered. However, Members are not liable when an In- In-network Practitioner/Provider does not obtain Prior Authorization. Refer to Prior Authorization Section for specific information. Sexual Dysfunction Treatment Treatment for sexual dysfunction, including medication, counseling, and clinics, are not Covered, except for penile prosthesis as listed in the Benefits Section. Skilled Nursing Facility Care Custodial or Domiciliary care is not Covered. Smoking Cessation Services Smoking Cessation services listed below are not Covered: • Hypnotherapy for Smoking Cessation Counseling is not Covered, • Over-the-counter (OTC) drugs are not Covered, unless listed as a Covered Over-the- counter (OTC) medication on our Formulary. • Acupuncture for Smoking Cessation Counseling is not Covered. Thermography Thermography Services are not Covered. Transplant Services Transplant Services listed below are not Covered: • Non-human Organ transplants, except for porcine (pig) heart valve, are not Covered. • Transportation costs for deceased Members are not Covered. • The medical and Hospital services of an Organ transplant donor when the recipient of an Organ transplant is not a Member or when the transplant procedure is not a Covered Benefit are not Covered. • Travel and lodging expenses are not Covered except as provided in the Benefits Section. Treatment While Incarcerated Services or supplies a member receives while in the custody of any state or federal law enforcement authorities or while in jail or prison are not Covered. Women’s Health Care Elective abortions after the 24th week of pregnancy are not Covered. Maternity and newborn care, as follows, are not Covered: • Use of an emergency facility for non-emergent services is not Covered. • Elective Home Birth and any prenatal or postpartum services connected with an Elective Home Birth are not Covered. Allowable sites for a delivery of a child are Hospitals and licensed birthing centers. Elective Home Birth means a birth that was planned or intended by the Member or Practitioner/Provider to occur in the home. Work-related Illnesses or Injuries Work-related illnesses or injuries are not Covered, even if: • You fail to file a claim within the filing period allowed by the applicable law. • You obtain care not authorized by Workers’ Compensation Insurance. • Your employer fails to carry the required Worker’s Compensation Insurance. • You fail to comply with any other provisions of the law. Claims Your health care benefits are considered and paid according to the conditions outlined in this Section. If you paid a Provider for services, this Section outlines the process to follow for reimbursement. When services are obtained from an In-network Practitioner/Provider, the Practitioner/Provider will submit the claim to Presbyterian for you. It is important that you provide your current Presbyterian identification card to the Practitioner/Provider so they may obtain the mailing address listed on the back of the card. Services obtained from In-network Practitioners/Providers may require Cost Sharing amounts (Copayments, Deductible and/or Coinsurance) that you pay at the time of service. The amount of your Cost Sharing responsibility for each service can be found in your Summary of Benefits and Coverage. Out-of-network Practitioners/Providers may require payment in full at the time of service and may refuse to file a claim. When this happens you must pay the Out-of-network Practitioner/Provider and then file a claim for reimbursement with us. Notice of Claim The timely filing limit for an In-network Practitioner/Provider is 90 days from the date of service, whereas the timely filing limit for an Out-of-network Practitioner/Provider is one year from the date of service. Written notice of claim must be given to us within 20 days after the date of loss or as soon as reasonably possible. Failure to give notice within the time specified will not invalidate or reduce any claim if notice is given as soon as reasonably possible. Claim Forms You may call or write to us to notify us of a claim. Upon receipt of a notice of claim, we will furnish you with the forms needed for filing proof of service. Forms will be furnished within 15 days after we receive such notice. You may access our web site, xxxxx://xxx.xxx.xxx/healthplans/member-information/Pages/forms-and-documents.aspx to obtain a claim form. In-network Practitioners/Providers We reimburse In-network Practitioners/Providers for Covered services provided to you. You should not be required to pay sums to any In-network Practitioner/Provider, except for the required cost sharing amount. You will be responsible for the payment of fees charged for missed appointments or appointments canceled without adequate notice, if any. If you are asked by an In-network Practitioner/Provider to make any payments in addition to the Cost Sharing amount specified in this Agreement, you should consult our Presbyterian Customer Service Center at (000) 000-0000 or 0-000-000-0000, Monday through Friday from 7 a.m. to 6 p.m. Hearing impaired users may call our TTY line at 711 before making any such additional payments. You will not be liable to an In-network Practitioner/Provider for any sums that we owe the Practitioner/Provider. Procedure for Reimbursement When you receive Covered Services from a Practitioner/Provider and the Practitioner/Provider charged for that service, written proof (claim) of such charge must be furnished to us within 90 days from the date of service for In-network Practitioners/Providers and within one year from the date of service for Out-of- network Practitioners/Providers in order for you to receive reimbursement. If you are relying on an Out-of-network Practitioner/Provider to furnish a claim on your behalf, you are responsible for ensuring claims have been submitted within one year from the date of service. Any such charge shall be paid upon our receipt of a Practitioner/Provider billing or completed valid claim for the Health Care Services for which claim is made. If you need a claim form or have questions regarding a charge made by your Practitioner/Provider, please contact our Presbyterian Customer Service Center at (000) 000-0000 or 0-000-000-0000, Monday through Friday from 7 a.m. to 6 p.m. Hearing impaired users may call our TTY 711. Claim forms are also available on our website at xxx.xxx.xxx. Please submit your completed claim form to: Presbyterian Insurance Company, Inc. Attn: Claims X.X. Xxx 00000 Xxxxxxxxxxx, XX 00000-0000 Services Received Outside the United States Benefits are available for Emergency Health Care Services and Urgent Care services received outside the United States. These services are Covered as explained in the Benefits Section. You are responsible for ensuring that claims sent to us, at the address cited above, are appropriately translated and that the monetary exchange rate effective on the date(s) you received medical care is clearly identified when submitting claims for services received outside the United States. Presbyterian cannot reimburse foreign Practitioners/Providers. You should then submit the claim or a summary of the medical services rendered, in addition to Proof of Payment. Proof of payment includes the check, credit card statement or receipt showing that the services were paid in full. Claim Fraud Anyone who knowingly presents a false or fraudulent claim for payment of a loss, or benefit or knowingly presents false information for services is guilty of a crime and may be subject to civil fines and criminal penalties. We may terminate your Coverage for any type of fraudulent activity. For further information regarding Fraud, refer to the General Provisions Section.

Reconstructive Surgery for Cosmetic Purposes. Reconstructive Surgery for Cosmetic purposes is not Covered unless reconstruction is performed after a mastectomy. Cosmetic Surgery is not Covered. Examples of Cosmetic Surgery include breast augmentation, dermabrasion, dermaplaning, excision of acne scarring, acne surgery (including cryotherapy), asymptomatic keloid/scar revision, microphlebectomy, sclerotherapy (except for truncal veins), and nasal rhinoplasty. Rehabilitation and Therapy Rehabilitation and Therapy, as listed below, is not Covered. Short or Long-term Rehabilitation services listed are not Covered: • Athletic trainers or treatments delivered by Athletic trainers are not Covered. • Vocational Rehabilitation Services are not Covered. • Long-term Therapy or Rehabilitation Services are not Covered. These therapies include treatment for chronic or incurable conditions for which rehabilitation produces minimal or temporary change or relief. Therapies are considered Long-term Rehabilitation when: o You have reached maximum rehabilitation potential. o You have reached a point where Significant Improvement is unlikely to occur. o You have had therapy for four consecutive months. o Long-Term Therapy includes treatment for chronic or incurable conditions for which rehabilitation produces minimal or temporary change or relief. Treatment of chronic conditions is not Covered. Chronic conditions include, but are not limited to, Muscular Dystrophy, Down Syndrome, Cerebral Palsy, and Developmental Delays not associated with a defined event of illness or injury. • Treatment of chronic conditions is not Covered. Chronic conditions include, but are not limited to, Muscular Dystrophy, Down Syndrome, and Cerebral Palsy. Speech Therapy services listed below are not Covered: • Therapy for stuttering is not Covered. • Hearing Aids and the evaluation for the fitting of Hearing Aids are not Covered, except for school aged children under 18 years old (or under 21 years of age if still attending high school). • Additional benefits beyond those listed in the Speech Therapy Benefit Section are not Covered. Services for Which You or Your Dependent are Eligible under Any Governmental Program Services for which you or your Dependent are eligible under any governmental program (except Medicaid), to the extent determined by law, are not Covered. Services for which, in the absence of any health service plan or insurance plan, no charge would be made to you or your Dependent, are not Covered. Services Requiring Prior Authorization When Out-of-network (outside of the 5-county area) If you fail to obtain Prior Authorization for services received Out-of-network (outside of the 5- county area) that require Prior Authorization, those services are not Covered. However, Members are not liable when an In- In-network Practitioner/Provider does not obtain Prior Authorization. Refer to Prior Authorization Section for specific information. Sexual Dysfunction Treatment Treatment for sexual dysfunction, including medication, counseling, and clinics, are not Covered, except for penile prosthesis as listed in the Benefits Section. Skilled Nursing Facility Care Custodial or Domiciliary care is not Covered. Smoking Cessation Services Smoking Cessation services listed below are not Covered: • Hypnotherapy for Smoking Cessation Counseling is not Covered, • Over-the-counter (OTC) drugs are not Covered, unless listed as a Covered Over-the- counter (OTC) medication on our Formulary. • Acupuncture for Smoking Cessation Counseling is not Covered. Thermography Thermography Services are not Covered. Transplant Services Transplant Services listed below are not Covered: • Non-human Organ transplants, except for porcine (pig) heart valve, are not Covered. • Transportation costs for deceased Members are not Covered. • The medical and Hospital services of an Organ transplant donor when the recipient of an Organ transplant is not a Member or when the transplant procedure is not a Covered Benefit are not Covered. • Travel and lodging expenses are not Covered except as provided in the Benefits Section. Treatment While Incarcerated Services or supplies a member receives while in the custody of any state or federal law enforcement authorities or while in jail or prison are not Covered. Women’s Health Care Healthcare Elective abortions after the 24th week of pregnancy are not Covered. Maternity and newborn care, as follows, are not Covered: • Use of an emergency facility for non-emergent services is not Covered. • Elective Home Birth and any prenatal or postpartum services connected with an Elective Home Birth are not Covered. Allowable sites for a delivery of a child are Hospitals and licensed birthing centers. Elective Home Birth means a birth that was planned or intended by the Member or Practitioner/Provider to occur in the home. Work-related Illnesses or Injuries Work-related illnesses or injuries are not Covered, even if: • You fail to file a claim within the filing period allowed by the applicable law. • You obtain care not authorized by Workers’ Compensation Insurance. • Your employer fails to carry the required Worker’s Compensation Insurance. • You fail to comply with any other provisions of the law. Claims Your health care healthcare benefits are considered and paid according to the conditions outlined in this Section. If you paid a Provider for services, this Section outlines the process to follow for reimbursement. When services are obtained from an In-network Practitioner/Provider, the Practitioner/Provider will submit the claim to Presbyterian for you. It is important that you provide your current Presbyterian identification card to the Practitioner/Provider so they may obtain the mailing address listed on the back of the card. Services obtained from In-network Practitioners/Providers may require Cost Sharing amounts (Copayments, Deductible and/or Coinsurance) that you pay at the time of service. The amount of your Cost Sharing responsibility for each service can be found in your Summary of Benefits and Coverage.

Reconstructive Surgery for Cosmetic Purposes. Reconstructive Surgery for Cosmetic purposes is not Covered unless reconstruction is performed after a mastectomy. Cosmetic Surgery is not Covered. Examples of Cosmetic Surgery include breast augmentation, dermabrasion, dermaplaning, excision of acne scarring, acne surgery (including cryotherapy), asymptomatic keloid/scar revision, microphlebectomy, sclerotherapy (except for truncal veins), and nasal rhinoplasty. Rehabilitation and Therapy Rehabilitation and Therapy, as listed below, is not Covered. Short or Long-term Rehabilitation services listed are not Covered: • Athletic trainers or treatments delivered by Athletic trainers are not Covered. • Vocational Rehabilitation Services are not Covered. • Long-term Therapy or Rehabilitation Services are not Covered. These therapies include treatment for chronic or incurable conditions for which rehabilitation produces minimal or temporary change or relief. Therapies are considered Long-term Rehabilitation when: o You have reached maximum rehabilitation potential. o You have reached a point where Significant Improvement is unlikely to occur. o You have had therapy for four consecutive months. o Long-Term Therapy includes treatment for chronic or incurable conditions for which rehabilitation produces minimal or temporary change or relief. Treatment of chronic conditions is not Covered. Chronic conditions include, but are not limited to, Muscular Dystrophy, Down Syndrome, Cerebral Palsy, and Developmental Delays not associated with a defined event of illness or injury. injury.‌‌‌‌ • Treatment of chronic conditions is not Covered. Chronic conditions include, but are not limited to, Muscular Dystrophy, Down Syndrome, and Cerebral Palsy. Speech Therapy services listed below are not Covered: • Therapy for stuttering is not Covered. • Hearing Aids and the evaluation for the fitting of Hearing Aids are not Covered, except for school aged children under 18 years old (or under 21 years of age if still attending high school). • Additional benefits beyond those listed in the Speech Therapy Benefit Section are not Covered. Services for Which You or Your Dependent are Eligible under Any Governmental Program Services for which you or your Dependent are eligible under any governmental program (except Medicaid), to the extent determined by law, are not Covered. Services for which, in the absence of any health service plan or insurance plan, no charge would be made to you or your Dependent, are not Covered. Services Requiring Prior Authorization When Out-of-network If you fail to obtain Prior Authorization for services received Out-of-network that require Prior Authorization, those services are not Covered. However, Members are not liable when an In- In-network Practitioner/Provider does not obtain Prior Authorization. Refer to Prior Authorization Section for specific information. Sexual Dysfunction Treatment Treatment for sexual dysfunction, including medication, counseling, and clinics, are not Covered, except for penile prosthesis as listed in the Benefits Section. Skilled Nursing Facility Care Custodial or Domiciliary care is not Covered. Smoking Cessation Services Smoking Cessation services listed below are not Covered: • Hypnotherapy for Smoking Cessation Counseling is not Covered, Covered,‌‌‌‌ • Over-the-counter (OTC) drugs are not Covered, unless listed as a Covered Over-the- counter (OTC) medication on our Formulary. • Acupuncture for Smoking Cessation Counseling is not Covered. Thermography Thermography Services are not Covered. Transplant Services Transplant Services listed below are not Covered: • Non-human Organ transplants, except for porcine (pig) heart valve, are not Covered. • Transportation costs for deceased Members are not Covered. • The medical and Hospital services of an Organ transplant donor when the recipient of an Organ transplant is not a Member or when the transplant procedure is not a Covered Benefit are not Covered. • Travel and lodging expenses are not Covered except as provided in the Benefits Section. Treatment While Incarcerated Services or supplies a member receives while in the custody of any state or federal law enforcement authorities or while in jail or prison are not Covered. Women’s Health Care Elective abortions after the 24th week of pregnancy are not Covered. Maternity and newborn care, as follows, are not Covered: • Use of an emergency facility for non-emergent services is not Covered. • Elective Home Birth and any prenatal or postpartum services connected with an Elective Home Birth are not Covered. Allowable sites for a delivery of a child are Hospitals and licensed birthing centers. Elective Home Birth means a birth that was planned or intended by the Member or Practitioner/Provider to occur in the home. Work-related Illnesses or Injuries Work-related illnesses or injuries are not Covered, even if: • You fail to file a claim within the filing period allowed by the applicable law. • You obtain care not authorized by Workers’ Compensation Insurance. • Your employer fails to carry the required Worker’s Compensation Insurance. • You fail to comply with any other provisions of the law. Claims Claims‌‌‌ Your health care healthcare benefits are considered and paid according to the conditions outlined in this Section. If you paid a Provider for services, this Section outlines the process to follow for reimbursement. When services are obtained from an In-network Practitioner/Provider, the Practitioner/Provider will submit the claim to Presbyterian for you. It is important that you provide your current Presbyterian identification card to the Practitioner/Provider so they may obtain the mailing address listed on the back of the card. Services obtained from In-network Practitioners/Providers may require Cost Sharing amounts (Copayments, Deductible and/or Coinsurance) that you pay at the time of service. The amount of your Cost Sharing responsibility for each service can be found in your Summary of Benefits and Coverage. Out-of-network Practitioners/Providers may require payment in full at the time of service and may refuse to file a claim. When this happens you must pay the Out-of-network Practitioner/Provider and then file a claim for reimbursement with us. Notice of Claim The timely filing limit for an In-network Practitioner/Provider is 90 days from the date of service, whereas the timely filing limit for an Out-of-network Practitioner/Provider is one year from the date of service. Written notice of claim must be given to us within 20 days after the date of loss or as soon as reasonably possible. Failure to give notice within the time specified will not invalidate or reduce any claim if notice is given as soon as reasonably possible. Claim Forms You may call or write to us to notify us of a claim. Upon receipt of a notice of claim, we will furnish you with the forms needed for filing proof of service. Forms will be furnished within 15 days after we receive such notice. You may access our web site, xxxxx://xxx.xxx.xxx/healthplans/member-information/Pages/forms-and-documents.aspx to obtain a claim form. In-network Practitioners/Providers We reimburse In-network Practitioners/Providers for Covered services provided to you. You should not be required to pay sums to any In-network Practitioner/Provider, except for the required cost sharing amount. You will be responsible for the payment of fees charged for missed appointments or appointments canceled without adequate notice, if any. If you are asked by an In-network Practitioner/Provider to make any payments in addition to the Cost Sharing amount specified in this Agreement, you should consult our Presbyterian Customer Service Center at (000) 000-0000 or 0-000-000-0000, Monday through Friday from 7 a.m. to 6 p.m. Hearing impaired users may call TTY 711 before making any such additional payments. You will not be liable to an In- network Practitioner/Provider for any sums that we owe the Practitioner/Provider.‌ Procedure for Reimbursement When you receive Covered Services from a Practitioner/Provider and the Practitioner/Provider charged for that service, written proof (claim) of such charge must be furnished to us within 90 days from the date of service for In-network Practitioners/Providers and within one year from the date of service for Out-of- network Practitioners/Providers in order for you to receive reimbursement. If you are relying on an Out-of-network Practitioner/Provider to furnish a claim on your behalf, you are responsible for ensuring claims have been submitted within one year from the date of service. Any such charge shall be paid upon our receipt of a Practitioner/Provider billing or completed valid claim for the Health Care Services for which claim is made. If you need a claim form or have questions regarding a charge made by your Practitioner/Provider, please contact our Presbyterian Customer Service Center at (000) 000-0000 or 0-000-000-0000, Monday through Friday from 7 a.m. to 6 p.m. Hearing impaired users may call TTY 711. Claim forms are also available on our website at xxx.xxx.xxx. Please submit your completed claim form to: Presbyterian Insurance Company, Inc. Attn: Claims P.O. Box 26267 Albuquerque, NM 87125-6267 Services Received Outside the United States Benefits are available for Emergency Health Care Services and Urgent Care services received outside the United States. These services are Covered as explained in the Benefits Section. You are responsible for ensuring that claims sent to us, at the address cited above, are appropriately translated and that the monetary exchange rate effective on the date(s) you received medical care is clearly identified when submitting claims for services received outside the United States. Presbyterian cannot reimburse foreign Practitioners/Providers. You should then submit the claim or a summary of the medical services rendered, in addition to Proof of Payment. Proof of payment includes the check, credit card statement or receipt showing that the services were paid in full. Claim Fraud Anyone who knowingly presents a false or fraudulent claim for payment of a loss, or benefit or knowingly presents false information for services is guilty of a crime and may be subject to civil fines and criminal penalties. We may terminate your Coverage for any type of fraudulent activity. For further information regarding Fraud, refer to the General Provisions Section.

Reconstructive Surgery for Cosmetic Purposes. Reconstructive Surgery for Cosmetic purposes is not Covered unless reconstruction is performed after a mastectomy. Cosmetic Surgery is not Covered. Examples of Cosmetic Surgery include breast augmentation, dermabrasion, dermaplaning, excision of acne scarring, acne surgery (including cryotherapy), asymptomatic keloid/scar revision, microphlebectomy, sclerotherapy (except for truncal veins), and nasal rhinoplasty. Rehabilitation and Therapy Rehabilitation and Therapy, as listed below, is not Covered. Short or Long-term Rehabilitation services listed are not Covered: • Athletic trainers or treatments delivered by Athletic trainers are not Covered. • Vocational Rehabilitation Services are not Covered. • Long-term Therapy or Rehabilitation Services are not Covered. These therapies include treatment for chronic or incurable conditions for which rehabilitation produces minimal or temporary change or relief. Therapies are considered Long-term Rehabilitation when: o You have reached maximum rehabilitation potential. o You have reached a point where Significant Improvement is unlikely to occur. o You have had therapy for four consecutive months. o Long-Term Therapy includes treatment for chronic or incurable conditions for which rehabilitation produces minimal or temporary change or relief. Treatment of chronic conditions is not Covered. Chronic conditions include, but are not limited to, Muscular Dystrophy, Down Syndrome, Cerebral Palsy, and Developmental Delays not associated with a defined event of illness or injury. injury.‌‌‌‌ • Treatment of chronic conditions is not Covered. Chronic conditions include, but are not limited to, Muscular Dystrophy, Down Syndrome, and Cerebral Palsy. Speech Therapy services listed below are not Covered: • Therapy for stuttering is not Covered. • Hearing Aids and the evaluation for the fitting of Hearing Aids are not Covered, except for school aged children under 18 years old (or under 21 years of age if still attending high school). • Additional benefits beyond those listed in the Speech Therapy Benefit Section are not Covered. Services for Which You or Your Dependent are Eligible under Any Governmental Program Services for which you or your Dependent are eligible under any governmental program (except Medicaid), to the extent determined by law, are not Covered. Services for which, in the absence of any health service plan or insurance plan, no charge would be made to you or your Dependent, are not Covered. Services Requiring Prior Authorization When Out-of-network If you fail to obtain Prior Authorization for services received Out-of-network that require Prior Authorization, those services are not Covered. However, Members are not liable when an In- In-network Practitioner/Provider does not obtain Prior Authorization. Refer to Prior Authorization Section for specific information. Sexual Dysfunction Treatment Treatment for sexual dysfunction, including medication, counseling, and clinics, are not Covered, except for penile prosthesis as listed in the Benefits Section. Skilled Nursing Facility Care Custodial or Domiciliary care is not Covered. Smoking Cessation Services Smoking Cessation services listed below are not Covered: • Hypnotherapy for Smoking Cessation Counseling is not Covered, • Over-the-counter (OTC) drugs are not Covered, unless listed as a Covered Over-the- counter (OTC) medication on our Formulary. • Acupuncture for Smoking Cessation Counseling is not Covered. Covered.‌‌‌‌ Thermography Thermography Services are not Covered. Transplant Services Transplant Services listed below are not Covered: • Non-human Organ transplants, except for porcine (pig) heart valve, are not Covered. • Transportation costs for deceased Members are not Covered. • The medical and Hospital services of an Organ transplant donor when the recipient of an Organ transplant is not a Member or when the transplant procedure is not a Covered Benefit are not Covered. • Travel and lodging expenses are not Covered except as provided in the Benefits Section. Treatment While Incarcerated Services or supplies a member receives while in the custody of any state or federal law enforcement authorities or while in jail or prison are not Covered. Women’s Health Care Elective abortions after the 24th week of pregnancy are not Covered. Maternity and newborn care, as follows, are not Covered: • Use of an emergency facility for non-emergent services is not Covered. • Elective Home Birth and any prenatal or postpartum services connected with an Elective Home Birth are not Covered. Allowable sites for a delivery of a child are Hospitals and licensed birthing centers. Elective Home Birth means a birth that was planned or intended by the Member or Practitioner/Provider to occur in the home. Work-related Illnesses or Injuries Work-related illnesses or injuries are not Covered, even if: • You fail to file a claim within the filing period allowed by the applicable law. • You obtain care not authorized by Workers’ Compensation Insurance. • Your employer fails to carry the required Worker’s Compensation Insurance. • You fail to comply with any other provisions of the law. Claims Claims‌‌‌ Your health care healthcare benefits are considered and paid according to the conditions outlined in this Section. If you paid a Provider for services, this Section outlines the process to follow for reimbursement. When services are obtained from an In-network Practitioner/Provider, the Practitioner/Provider will submit the claim to Presbyterian for you. It is important that you provide your current Presbyterian identification card to the Practitioner/Provider so they may obtain the mailing address listed on the back of the card. Services obtained from In-network Practitioners/Providers may require Cost Sharing amounts (Copayments, Deductible and/or Coinsurance) that you pay at the time of service. The amount of your Cost Sharing responsibility for each service can be found in your Summary of Benefits and Coverage. Out-of-network Practitioners/Providers may require payment in full at the time of service and may refuse to file a claim. When this happens you must pay the Out-of-network Practitioner/Provider and then file a claim for reimbursement with us. Notice of Claim The timely filing limit for an In-network Practitioner/Provider is 90 days from the date of service, whereas the timely filing limit for an Out-of-network Practitioner/Provider is one year from the date of service. Written notice of claim must be given to us within 20 days after the date of loss or as soon as reasonably possible. Failure to give notice within the time specified will not invalidate or reduce any claim if notice is given as soon as reasonably possible. Claim Forms You may call or write to us to notify us of a claim. Upon receipt of a notice of claim, we will furnish you with the forms needed for filing proof of service. Forms will be furnished within 15 days after we receive such notice. You may access our web site, xxxxx://xxx.xxx.xxx/healthplans/member-information/Pages/forms-and-documents.aspx to obtain a claim form. In-network Practitioners/Providers We reimburse In-network Practitioners/Providers for Covered services provided to you. You should not be required to pay sums to any In-network Practitioner/Provider, except for the required cost-sharing amount. You will be responsible for the payment of fees charged for missed appointments or appointments canceled without adequate notice, if any. If you are asked by an In-network Practitioner/Provider to make any payments in addition to the Cost Sharing amount specified in this Agreement, you should consult our Presbyterian Customer Service Center at (000) 000-0000 or 0-000-000-0000, Monday through Friday from 7 a.m. to 6 p.m. Hearing impaired users may call TTY 711 before making any such additional payments. You will not be liable to an In- network Practitioner/Provider for any sums that we owe the Practitioner/Provider.‌ Procedure for Reimbursement When you receive Covered Services from a Practitioner/Provider and the Practitioner/Provider charged for that service, written proof (claim) of such charge must be furnished to us within 90 days from the date of service for In-network Practitioners/Providers and within one year from the date of service for Out-of- network Practitioners/Providers in order for you to receive reimbursement. If you are relying on an Out-of-network Practitioner/Provider to furnish a claim on your behalf, you are responsible for ensuring claims have been submitted within one year from the date of service. Any such charge shall be paid upon our receipt of a Practitioner/Provider billing or completed valid claim for the Health Care Services for which claim is made. If you need a claim form or have questions regarding a charge made by your Practitioner/Provider, please contact our Presbyterian Customer Service Center at (000) 000-0000 or 0-000-000-0000, Monday through Friday from 7 a.m. to 6 p.m. Hearing impaired users may call TTY 711. Claim forms are also available on our website at xxx.xxx.xxx. Please submit your completed claim form to: Presbyterian Insurance Company, Inc. Attn: Claims X.X. Xxx 00000 Xxxxxxxxxxx, XX 00000-0000 Services Received Outside the United States Benefits are available for Emergency Health Care Services and Urgent Care services received outside the United States. These services are Covered as explained in the Benefits Section. You are responsible for ensuring that claims sent to us, at the address cited above, are appropriately translated and that the monetary exchange rate effective on the date(s) you received medical care is clearly identified when submitting claims for services received outside the United States. Presbyterian cannot reimburse foreign Practitioners/Providers. You should then submit the claim or a summary of the medical services rendered, in addition to Proof of Payment. Proof of payment includes the check, credit card statement or receipt showing that the services were paid in full.