Centers of Expertise
The Plan has identified Centers of Expertise for certain designated procedures:
| Designated Procedure | Plan-Approved Centers of Expertise |
|---|---|
| Certain cardiothoracic procedures for example, heart-valve replacement or heart bypass surgery (40% penalty if not performed at a Center of Expertise) | Deaconess Health System |
| Certain spinal procedures for example, surgery for neck pain or back pain (40% penalty if not performed at a Center of Expertise) | Deaconess Health System Oklahoma Heart Hospital University of Kentucky WVU Health System |
| Cochlear (ear) implants (covered only at a Center of Expertise) | Surgery Center of Oklahoma |
When you or your provider call regarding preauthorization for a service listed in the Preauthorization Requirement section of "Highlights of the Plan," you will be advised if the service is a designated procedure and which Centers of Expertise are available.
The specific designated procedures are listed in "Appendix B: Designated Procedures for Centers of Expertise." The list of designated procedures and approved Centers of Expertise will be updated and expanded periodically.
When you use a Plan-approved Center of Expertise for a designated procedure, the Plan pays 100% of Allowable Charges. In addition, the Plan will reimburse you for pre-approved travel expenses (see "Travel Benefit").
Benefit Penalty for Using Other Providers for Designated Procedures
If you choose a provider other than a Plan-approved Center of Expertise for a designated procedure, a 40% benefit penalty will apply unless that provider is specifically preauthorized by the Plan for your procedure. This means 40% of the amount the Plan would normally pay will be applied to your share of the expenses related to the condition. This benefit penalty does not apply toward any deductibles or out-of-pocket limits.
The terms of the Health Care Program govern the extent to which expenses are eligible for benefit payment. You and your doctor are responsible for decisions about how to treat your medical condition and which providers to choose. The Health Care Program and the participating employers are not health care providers, nor do they guarantee positive health outcomes, avoidance of complications, or avoidance of gaps in care.
