Medical Insurance 2012-2013
Preferred Provider Organization “PPO”
Please read the following information so you will know from whom or what group of providers health care may be obtained.
This plan has incorporated several cost containment features that are designed to provide the best care available by providing access to a panel of medical professionals, including Doctors and Hospitals, known as the Preferred Provider Organization (PPO). Network access provides benefits nationwide for Eligible Expenses incurred at 100% of Allowable Charges (except as specifically stated on the Schedule of Benefits) when treated by network providers. Covered Persons utilizing the Preferred Provider Organization will only be responsible for any Deductibles, Copays or coinsurance as shown in the Schedule of Benefits. A Covered Person utilizing medical providers that are not members of the PPO will be responsible for 30% of the Eligible Expenses. However, if such treatment is received in a non-PPO facility due to an Emergency Medical Condition, benefits for Eligible Expense are payable at the PPO level.
When a Covered Person has incurred $5,000 of out-of-pocket Eligible Expenses for all conditions per policy year, the Company payment will increase to 100% of R&C.
If a Covered Person is being treated by a Preferred Provider for an acute, serious chronic condition, pregnancy, newborn, or a terminal illness, and the Provider’s contract terminates with the PPO, the Covered Person may be eligible under certain conditions to continue treatment with the Provider at the PPO rate. Contact the claims administrator for details.
The names and locations of the medical providers that are members of this PPO network are available by contacting Student Health Services. For a complete listing of the PPO Hospital and Doctor facilities, visit www.myfirsthealth.com or call 1-800-226-5116.
Continued Stay Review
The Utilization Review Organization will contact the Covered Person’s Doctor periodically for a review of the medical information to determine the need for continued inpatient Hospital care. Additional days will be certified if they are determined to be necessary. If the Covered Person incurs additional inpatient charges that are not certified, these charges will not be covered.
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