Benefits Handbook (SPD)
Health Care
Participation
Medical
Highlights of the Plan
Benefit Summary
Medical Necessity
Allowable Charge
Alliance Direct and Non-Direct Providers
Annual Deductible
Annual Out-of-Pocket Limits
Care Coordination
Centers of Expertise
Travel Benefit
Bundled Surgery Services
Eligible Expenses
Expenses That Are Not Eligible
Preauthorization, Concurrent Review, and Retrospective Review
Benefit Penalties
How to File a Claim
Definitions
Appendix A: Human Organ, Tissue, and Bone Marrow Transplant Services
Appendix B: Designated Procedures for Centers of Expertise
Appendix C: Services and Products That Require Preauthorization
Prescription Drug
Dental
Vision
Flexible Spending Accounts
Income Security
Retirement
Special Benefits
Policies

Benefit Penalties 

The Plan will apply the following benefit penalties in these specified situations:

  • 25% benefit penalty for failure to obtain preauthorization. If your provider does not obtain preauthorization when it is required, a 25% benefit penalty (100% benefit penalty for transplants) per event will be applied, reducing the amount the Plan will pay. In addition, if these services are later found not to be medically necessary (i.e., during retrospective review), claims for reimbursement will be denied.
  • 40% benefit penalty for using a provider that is not a Plan-approved Center of Expertise for a designated procedure, unless that provider is specifically preauthorized by the Plan for your procedure.
  • 40% benefit penalty for failure to utilize or cooperate with Care Coordination when required by the Plan. 
  • 100% benefit penalty for failure to obtain preauthorization for a transplant at the time you are referred for a transplant and/or evaluation. In other words, the Plan will not cover any of the transplant expenses.

 

Any benefit penalty will reduce the amounts the Plan would normally pay for applicable expenses, including both medical expenses and prescription drug expenses. For example, if the Plan would normally pay $10,000, a 25% benefit penalty means the Plan would instead pay $7,500 and you may be responsible for the remaining $2,500 (in addition to any cost-sharing you would normally pay, such as deductibles and coinsurance). Benefit penalties do not apply toward any deductibles or out-of-pocket limits.