Benefit Plan Provisions
The
Plan has a network that includes both facility and professional providers. The
following explains the Plan's provisions for determination of covered charges
for facilities that it may utilize in lieu of the network
discount and the rights granted to providers of service for appealing adverse
benefit determinations.
ELAP Claim Review and Audit Program
The
Plan has arranged with ELAP Services, LLC (“ELAP”) for a program of claim
review and auditing in order to identify charges
billed in error, charges for excessive or unreasonable fees and charges for
services which are not medically appropriate.
Benefits for claims which are selected for review and auditing may be
reduced for any charges that are determined to be in excess
of Allowable Claim Limits (as defined below). The determination of Allowable Claim Limits
under this Program will supersede any other Plan provisions related to
application of a usual, customary or reasonable fee
determination.
Facilities
will be given a fully detailed explanation of any
charges that are found to be in excess of Allowable Claim Limits, and allowed
the rights and privileges to file an appeal of the determination which are the
same rights and privileges accorded to Plan Participants; and, in return, the facility
must agree not to bill the Plan Participant for charges which were not covered
as a result of the claim review and audit.
This will in no way affect the rights of the Plan Participant to file an
appeal under the Plan. Please refer to
the section in the Summary Plan Description regarding procedures for claims and
appeals for additional information regarding Participant and provider appeals.
Any Plan Participant who receives a
balance-due billing from a medical care provider for these charges should
contact ELAP or the Plan Administrator right away for assistance.
The
Plan Administrator is identified in the General Information section of the
Summary Plan Description, which is available upon request. ELAP may be contacted at:
ELAP
Services, LLC
1550
Liberty Ridge
Suite
330
Wayne,
PA 19087
Phone: 610-321-1030; Fax 610-321-1031
The
Plan Participant must pay for any normal cost-sharing features of the Plan,
such as Deductibles, Coinsurance and Copayments, and any amounts otherwise
excluded or limited according to the terms of the Plan.
The
success of this program will be achieved through a comprehensive review of
detailed records including, for example, itemized charges and descriptions of
the services and supplies provided.
Without this detailed information, the Plan will be unable to make a determination of the amount of Covered Medical
Expense that may be eligible for reimbursement.
Any additional information required for the audit will be requested
directly from the provider of service and the Plan Participant. In the event that
the Plan Administrator does not receive information adequate for the claim
review and audit within the time limits required under applicable regulations,
it will be necessary to deny the claim.
Should such a denial be necessary, the Plan Participant and/or the
provider of service may appeal the denial in accordance with the provisions
which may be found in the section.
Please refer to the section regarding procedures for claims and appeals in
the Summary Plan Description.
In
the following provisions of the Claim Review and Audit Program, the term
"Plan Administrator" shall be deemed to mean ELAP:
“Allowable Claim Limits”
means the charges for services and supplies, listed and included as Covered
Medical Expenses under the Plan, which are Medically Necessary for the care and
treatment of Illness or Injury, but only to the extent that such fees are
within the Allowable Claim Limits. Examples of the determination that a charge
is within the Allowable Claim Limit include, but are not limited to, the
following guidelines:
1. Errors, Unbundled and/or Unsubstantiated Charges. Allowable Claim Limits will not include the
following amounts:
2. Guidelines. The following guidelines will be used when
determining Allowable Claim Limits:
a. Facilities. The
Allowable Claim Limit for claims by a facility, including but not limited to,
hospitals, emergency and urgent care centers, rehabilitation and skilled
nursing centers, and any other health care facility, shall be the greater of (I) 112% of the facility’s
most recent departmental cost ratio, reported to the Centers for Medicare and
Medicaid Services (“
b. Ambulatory Health Care Centers. The Allowable Claim Limit for ambulatory
health care centers, including ambulatory surgery centers, which are
independent facilities shall be the Medicare allowed amount for the services in
the geographic area plus an additional 20%.
In the event that insufficient information is
available to identify the Medicare allowed amount, the Allowable Claim Limit
for such services shall be to the extent available either the outpatient or
inpatient Medicare allowed amount for the service, plus an additional 20%.
c. Ambulance Providers. The
Allowable Claim Limit for emergent and non-emergent ambulance services,
including air and ground transport, shall be the Medicare allowed amount for
the services in the geographic area plus an additional 20%.
d. Directly Contracted Providers. The Allowable Claim Limits for Directly
Contracted Providers shall be the negotiated rate as agreed under the Direct
Agreement.
e. Insufficient Information to Determine Allowable Claim
Limit. In the event that
insufficient information is available to determine Allowable Claim Limits for
specific services or supplies using the guidelines listed in Section 2 above as
may be applicable, ELAP may apply the following guidelines:
i. General Medical
and/or Surgical Services. The Allowable Claim
Limit for any covered services may be calculated based upon industry-standard
resources including, but not limited to, published and publicly available fee
and cost lists and comparisons, or any combination of such resources that in
the opinion of the Plan Administrator results in the determination of a
reasonable expense under the Plan.
ii.
Medical and Surgical
Supplies, Implants, Devices. The
Allowable Claim Limit for charges for medical and surgical supplies made by a
provider may be based upon the invoice price (cost) to the provider, plus an
additional 12%. The documentation used
as the resource for this determination will include, but not be limited to,
invoices, receipts, cost lists or other documentation as deemed appropriate by
the Plan Administrator.
iii. Facility-Billed Physician, Medical and
Surgical Care, Laboratory, X-ray, and Therapy. The Allowable Claim Limit for these services
may be determined based upon the 60th percentile of Fair Health (FH®)
Allowed Benchmarks.
Comparable Services or Supplies. In the event that insufficient information is
available to determine Allowable Claim Limits for specific services or supplies
using the guidelines listed in Section 2 above, Allowable Claim Limits will be determined
considering the most comparable services or supplies based upon comparative
severity and/or geographic area to determine the Allowable Claim Limit. The Plan Administrator reserves the right, in
its sole discretion, to determine any Allowable Claim Limit amount for certain
conditions, services and supplies using accepted industry-standard
documentation, applied without discrimination to any Covered Person.
Notwithstanding any
conflicting contracts or agreements, the Plan may consider the Allowable Claim
Limits as the maximum amount of covered Medical Expense that may be considered
for reimbursement under the Plan, and may apply this determination in lieu of
any PPO network provider hospitals’ per diem, DRG rates or PPO discounted rates
as the amount considered for reimbursement under the Plan. Additionally in the
event that a determination of Allowable Claim Limit for a Claim exceeds the
actual Charges billed for the services and/or supplies, the actual Charges billed
for the Claim shall be the Allowable Claim
Limit.
Provider
of Service Appeal Rights
A Claimant may appoint the provider of service
as the Authorized Representative with full authority to act on his or her
behalf in the appeal of a denied claim.
An assignment of benefits by a Claimant to a provider of service will
not constitute appointment of that provider as an Authorized
Representative. However, in an effort to
ensure a full and fair review of the denied claim, and as a courtesy to a
provider of service that is not an Authorized Representative, the Plan will
consider an appeal received from the provider in the same manner as a
Claimant’s appeal, and will respond to the provider and the Claimant with the
results of the review accordingly. Any
such appeal from a provider of service must be made within the time limits and
under the conditions for filing an appeal specified under the section, “Appeal
Process,” above. Providers requesting such appeal rights under the Plan must agree to
pursue reimbursement for Covered Medical Expenses directly from the Plan,
waiving any right to recover such expenses from the Claimant, and comply with
the conditions of the section, “Requirements for First Appeal,” above.
For purposes of this section, the provider’s
waiver to pursue Covered Medical Expenses does not include the following
amounts, which are the responsibility of the Claimant:
Ø Deductibles;
Ø Copayments;
Ø Coinsurance;
Ø Penalties for failure
to comply with the terms of the Plan;
Ø Charges for services
and supplies which are not included for coverage under the Plan; and
Ø Amounts which are in excess of any stated Plan maximums or limits. Note: This does not apply to amounts found
to be in excess of Allowable
Claim Limits, as defined in the section, “Claim Review and Audit Program.” The provider must agree to waive the right to
balance bill for these amounts.
Also, for purposes
of this section, if a provider indicates on a Form UB92 or on a CMS – 1500 Form
(or similar claim form) that the provider has an assignment of benefits, then
the Plan will require no further evidence that benefits are
legally assigned to that provider.
Contact the Claims
Administrator or the Plan Administrator for additional information regarding
provider of service appeals.
Plan ISI Facility Grandfathered