UnitedHealthcare Optimum Choice Optimum Choice, Inc. Certificate Of .
UnitedHealthcare Optimum ChoiceOptimum Choice, Inc.Certificate of CoverageForthe Health Savings Account (HSA) Plan BBQYofAIMS Benefit TrustEnrolling Group Number: 717578Effective Date: January 1, 2021
Optimum Choice, Inc.800 King Farm BoulevardRockville, Maryland 208501-240-683-5376OPTIMUM CHOICE, INC.Christopher J Mullins CEOCCOV.OCI.2018.LG.MD
Table of ContentsSchedule of Benefits . 1How Do You Access Benefits? . 1Selecting a Network Primary Care Physician. 1What are Ref erral Health Services?. 2Utilization Review Determinations . 3What Will You Pay for Covered Health Care Services?. 4Additional Benefits Required By Maryland Law.16Allowed Amounts.18Provider Network .18Designated Providers .19Health Care Services from Out-of -Network Providers .19Centers for Cardiac Surgery and Joint Replacement .20Case Management Program.20Failure to Comply with Recommended Treatment (Second Opinion).20Continuity of Care.20Certificate of Coverage . 1What Is the Certificate of Coverage?. 1Can This Certificate Change?. 1Other Information You Should Have . 1Introduction to Your Certificate. 2What Are Defined Terms?. 2How Do You Use This Document? . 2How Do You Contact Us? . 2Your Responsibilities. 3Enrollment and Required Contributions . 3Be Aware the Policy Does Not Pay for All Health Care Services. 3Decide What Services You Should Receive. 3Choose Your Physician . 3Obtain Precertif ication . 3Pay Your Share. 3Pay the Cost of Excluded Services . 3Show Your ID Card . 4File Claims with Complete and Accurate Information . 4Our Responsibilities. 5Determine Benef its . 5Pay for Our Portion of the Cost of Covered Health Care Services. 5Pay Network Providers . 5Pay for Covered Health Care Services Provided by Out-of -Network Providers . 5Review and Determine Benefits in Accordance with our Reimbursement Policies . 5Off er Health Education Services to You. 6Certificate of Coverage Table of Contents. 7Section 1: Covered Health Care Services . 8When Are Benefits Available for Covered Health Care Services? . 81. Acupuncture Services . 82. Ambulance Services . 93. Cellular and Gene Therapy . 94. Chiropractic Services . 95. Clinical Trials . 96. Congenital Heart Disease (CHD) Surgeries .127. Dental Services - Accident Only .12i
8. Dental Services - Adjunctive .139. Diabetes Services .1410. Durable Medical Equipment (DME), Orthotics and Supplies .1511. Emergency Health Care Services - Outpatient .1612. Gender Dysphoria .1613. Habilitative Services.1614. Hearing Aids .1715. Home Health Care.1716. Hospice Care.1817. Hospital - Inpatient Stay .1918. Inf ertility Services .1919. Lab, X-Ray and Diagnostic - Outpatient .2020. Major Diagnostic and Imaging - Outpatient .2021. Mental Health Care and Substance-Related and Addictive Disorders Services .2022. Ostomy and Urologic Supplies.2223. Pharmaceutical Products - Outpatient.2224. Physician Fees for Surgical and Medical Services .2325. Physician's Office Services - Sickness and Injury .2326. Pregnancy - Maternity Services .2327. Preventive Care Services .2428. Prosthetic Devices .2629. Reconstructive Procedures .2630. Rehabilitation Services - Outpatient Therapy .2731. Scopic Procedures - Outpatient Diagnostic and Therapeutic .2832. Skilled Nursing Facility/Inpatient Rehabilitation Facility Services .2833. Surgery - Outpatient.2834. Temporomandibular Disorder (TMD) Services .2935. Therapeutic Treatments - Outpatient .2936. Transplantation Services .3037. Urgent Care Center Services.3038. Virtual Visits .3039. Wigs.31Additional Benefits Required By Maryland Law.3140. Amino Acid-Based Elemental Formula.3141. Bones of Face, Neck, and Head .3142. Child Wellness Services .3143. Treatment of Cleft Lip or Palate or Both .3244. Hair Prosthesis .3245. In Vitro Fertilization.3246. Lymphedema Services .3347. Medical Foods .3348. Standard Fertility Preservation Procedures .3349. Surgical Morbid Obesity Treatment .3450. Telemedicine Services .34Section 2: Exclusions and Limitations. 35How Do We Use Headings in this Section?.35We Do Not Pay Benefits for Exclusions .35Where Are Benef it Limitations Shown? .35A. Alternative Treatments.35B. Dental .36C. Devices, Appliances and Prosthetics .36D. Drugs.37E. Experimental or Investigational or Unproven Services .39F. Foot Care .40G. Gender Dysphoria .40ii
H. Medical Supplies .41I. Mental Health Care and Substance-Related and Addictive Disorders .42J. Nutrition.42K. Personal Care, Comfort or Convenience .42L. Physical Appearance .44M. Procedures and Treatments .44N. Providers.45O. Reproduction .46P. Services Provided under another Plan .47Q. Transplants .47R. Travel .47S. Types of Care .48T. Vision and Hearing .48U. All Other Exclusions .48Section 3: When Coverage Begins. 51How Do You Enroll?.51What If You Are Hospitalized When Your Coverage Begins?.51Who Is Eligible for Coverage?.52Eligible Person .52Dependent.52When Do You Enroll and When Does Coverage Begin? .52Initial Enrollment Period .52Open Enrollment Period.52New Eligible Persons .53Adding New Dependents .53Special Enrollment Period .54Section 4: When Coverage Ends . 56General Information about When Coverage Ends .56What Events End Your Coverage? .56Fraud or Intentional Misrepresentation of a Material Fact .57Coverage for a Disabled Dependent Child .57Extension of Coverage .57Continuation of Coverage .58Continuation of Coverage under State Law for Surviving Spouses and Children .58Continuation of Coverage under State Law for Divorced Spouses and Children .59Continuation of Coverage under State Law Due to the Subscriber's Voluntary or InvoluntaryTermination .60Section 5: How to File a Claim. 61How Are Covered Health Care Services from Network Providers Paid? .61How Are Covered Health Care Services from an Out-of-Network Provider Paid?.61Required Information.61Payment of Benefits .62Section 6: Questions, Complaints and Appeals . 63What if You Have a Question?.63What if You Have a Complaint? .63Adverse Decisions, Adverse Decision Grievances and Adverse Decision Complaints.63Defined Terms .63Notice Requirements.64Complaints .64Internal Adverse Decision Grievance Process .64Adverse Decisions .64Adverse Decision Grievances .65Expedited Review in Emergency Cases .66Assistance From the Health Education and Advocacy Unit .67iii
Medical Directors.67Adverse Decision Complaints to the Insurance Commissioner .68Assistance f rom State Agencies .68Coverage and Appeal Decisions .69Section 7: Coordination of Benefits . 73Benefits When You Have Coverage under More than One Plan .73When Does Coordination of Benefits Apply?.73Definitions .73What Are the Rules for Determining the Order of Benefit Payments? .75Effect on the Benefits of This Plan.77Right to Receive and Release Needed Information .77Payments Made .77Does This Plan Have the Right of Recovery?.77Section 8: General Legal Provisions. 78What Is Your Relationship with Us?.78What Is Our Relationship with Providers and Groups?.78What Is Your Relationship with Providers and Groups? .79Notice .79Statements by Group or Subscriber.79Do We Pay Incentives to Providers?.79Who Interprets Benefits and Other Provisions under the Policy? .80Who Provides Administrative Services? .80Amendments to the Policy.80How Do We Use Information and Records?.81Do We Require Examination of Covered Persons? .81Is Workers' Compensation Affected? .81Subrogation and Reimbursement .81When Do We Receive Ref unds of Overpayments? .82Is There a Limitation of Action?.83Is There a Liability for Reimbursement? .83What Is the Entire Policy? .83Section 9: Defined Terms. 84Amendments, Riders and Notices (As Applicable)Outpatient Prescription Drug RiderReal Appeal RiderLanguage Assistance ServicesNotice of Non-DiscriminationImportant Notices under the Patient Protection and Affordable CareAct (PPACA)Statement of Employee Retirement Income Security Act of 1974(ERISA) RightsERISA Statementiv
Optimum ChoiceOptimum Choice, Inc.Schedule of BenefitsHow Do You Access Benefits?Selecting a Network Primary Care PhysicianYou must select a Network Primary Care Physician, who is located in the Service Area, in order to obtainBenef its. In general health care terminology, a Primary Care Physician may also be referred to as a PCP.A Network Primary Care Physician will be able to coordinate all Covered Health Care Services andsubmit referrals to UnitedHealthcare for services from Network Physicians. If you are the custodial parentof an Enrolled Dependent child, you must select a Network Primary Care Physician who is located in theService Area for that child.You may select any Network Primary Care Physician who is located in the Service Area and is acceptingnew patients. You may designate a Network Physician who specializes in pediatrics (including pediatricsubspecialties, based on the scope of that provider's license under applicable state law) as the NetworkPrimary Care Physician for an Enrolled Dependent child. For obstetrical or gynecological care, includingthe ordering of related obstetrical and gynecological items and services, you do not need a referral from aNetwork Primary Care Physician and may seek care directly from any Network professional whospecializes in obstetrics or gynecology or is a nurse midwife.You can get a list of Network Primary Care Physicians, Network obstetricians and gynecologists andother Network providers by going through www.myuhc.com or by calling the telephone number shown onyour ID card.You may change your Primary Care Physician through the telephone number shown on your ID card orwww.myuhc.com. Changes submitted on or before the 15th of the month will be effective on the first dayof the following month in which the change request was received. Changes submitted on or after the 16thof the month will be effective on the first day of the second following month in which the change requestwas received. And remember that if you have a referral from your current Primary Care Physician to aSpecialist, you will need a new ref erral from your new Primary Care Physician.You must see a Network Physician in order to obtain Benefits. Except as specifically described in thisSchedule of Benefits, Benefits are not available for services provided by out-of-Network providers. ThisBenef it plan does not provide an out-of-Network level of Benefits. However, Benefits are provided whenCovered Health Care Services are received from an Out-of-Network provider as a result of anEmergency, at an Urgent Care Center outside your geographic area, or if a Covered Health Care Servicereceived by an Out-of-Network provider was preauthorized or otherwise approved by us or a Networkprovider, or obtained pursuant to a verbal or written ref erral by us or a Network provider.Benefits apply to Covered Health Care Services that are provided by or referred by your Primary CarePhysician. If care from another Network Physician is needed, your Primary Care Physician will provideyou with a ref erral. (See Referral Health Services below.) You do not need a referral from your PrimaryCare Physician for any of the following: Emergency Health Care services. Urgent Care Center services.SBN19.OCI.NET.2018.LG.MD.NETONLY1
Covered Health Care Services from an obstetrician/gynecologist or nurse midwife. Ref ractive eye exams.For f acility charges, Benefits apply to Covered Health Care Services that are billed by a Network facilityand provided under the direction of either a Network or out-of-Network Physician or other provider.Benef its include Physician services provided in a Network facility by a Network or an out-of-NetworkEmergency room Physician, radiologist, anesthesiologist or pathologist.What are Referral Health Services?If your Primary Care Physician is not able to provide a Covered Health Care Service, he or she will referyou to a Network specialist or other Network provider.If specific Covered Health Care Services are not available from a Network provider or our Network cannotprovide reasonable access to a specialist or non-physician specialist with the training and expertise toprovide healthcare services for a condition or disease without unreasonable delay or travel, you may beeligible for Benefits when Covered Health Care Services are received from out-of-Network providers. Inthis situation, your Primary Care Physician will notify us and, if we confirm that care is not available from aNetwork provider, we will work with you and your Primary Care Physician to coordinate care through anout-of-Network provider.Standing Referrals to a Network Specialist PhysicianYou may obtain a standing referral to a Network Specialist Physician under the following circumstances. You have a condition or disease that is life threatening, degenerative, chronic, or disabling andrequires specialized medical care; and The Specialist Physician is a Network Physician and has expertise in treating the life-threatening,degenerative, chronic, or disabling disease or condition.The standing referral will be made in accordance with a written treatment plan for Covered Health CareServices by the Primary Care Physician, the Specialist Physician and the Covered Person. Suchtreatment plan may limit the number of visits to the Specialist Physician, limit the period of time in whichvisits to the Specialist Physician are authorized, and require the Specialist Physician to communicateregularly with the Primary Care Physician regarding the Covered Person's treatment and health status.Referral to an Out-of-Network PhysicianYou may obtain a referral to an out-of-Network Physician for certain services when all of the followingconditio
CCOV.OCI.2018.LG.MD Optimum Choice, Inc. 800 King Farm Boulevard Rockville, Maryland 20850 1-240-683-5376 OPTIMUM CHOICE, INC. Christopher J Mullins CEO
UnitedHealthcare network. Even if a hospital, ambulatory surgery center or other facility contracts with UnitedHealthcare and belongs to the UnitedHealthcare network,the facility may employ or contract with physicians and other health care professionals who . do not . participate in the network.
2014. CTPF will offer five health insurance plans for members under age 65: n Blue Cross and Blue Shield PPO n Blue Cross and Blue Shield HMO Illinois n UnitedHealthcare Choice Plus PPO n UnitedHealthcare Choice HMO n UnitedHealthcare High Deductible Plan with HSA Members currently enrolled
Getting started with the Optimum Business Account Center. An Optimum ID is your key to our services. To take full advantage of your Optimum services, you and your employees will need an Optimum ID or unique username. Creating Optimum IDs to access the Optimum Business Account Center is easy. The first ID created is the Account Manager ID .
COL-17-VA (PY21) CERT 3 Provider Directories Provider Directories for the UnitedHealthcare Choice Plus Network may be obtained: by calling UnitedHealthcare StudentResources at 1-800- 767-0700;
If you lose your card, call Member Services to get a new card. do not need to show your UnitedHealthcare Personal Assist ID card before you receive emergency care. Call 911 or go to the nearest emergency room. Below is a sample indicating what your UnitedHealthcare Personal Assist identifcation card
UnitedHealthcare Community Plan Louisiana State Telemedicine Code List UnitedHealthcare Community Plan requires one of the following modifiers to be reported when performing a service via Telehealth to indicate the type of technology used and to identify the service as Telehealth. UnitedHealthcare
Feb 10, 2016 · UnitedHealthcare Plan of the River Valley, Inc. Wellmont Cardiology Services WHS0065 Amendment to Medical Group Participation Agreement UnitedHealthcare Insurance Company on behalf of itself, UnitedHealthcare of the River Valley, Inc., and United's Affiliates Wellmont Medical Associates WHS0066 Tennessee Program Network Practitioner
Siklus Akuntansi Jasa BAGIAN PROYEK PENGEMBANGAN KURIKULUM DIREKTORAT PENDIDIKAN MENENGAH KEJURUAN DIREKTORAT JENDERAL PENDIDIKAN DASAR DAN MENENGAH DEPARTEMEN PENDIDIKAN NASIONAL 2003 Kode Modul: AK.26.D.2,3. BAGIAN PROYEK PENGEMBANGAN KURIKULUM DIREKTORAT PENDIDIKAN MENENGAH KEJURUAN DIREKTORAT JENDERAL PENDIDIKAN DASAR DAN MENENGAH DEPARTEMEN PENDIDIKAN NASIONAL 2003 Kode Modul: AK.26.D.2,3 .
