Benefit Plan Provisions
This
Plan does not have a PPO agreement that includes charges from hospitals and
other facilities. The following explains the Plan's provisions for
determination of covered charges for facilities and the rights granted to
providers of service for appealing adverse benefit determinations.
ELAP Claim Review and Audit Program
The
Plan has arranged with the “Designated Decision Maker” (“DDM”) 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.
Medical
care providers 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 provider 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, “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 the DDM or the Plan Administrator right away for assistance.
The
Plan Administrator is identified in the General Information section of the
Summary Plan Description. The DDM 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, “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 the "Designated
Decision Maker" (“DDM”):
“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:
a.
Charges
identified as improperly coded, duplicated, unbundled and/or for services not
performed;
b.
Charges
for treating injuries sustained or illnesses contracted, including infections
and complications, which, in the opinion of the Plan Administrator can be
attributed to medical errors by the provider;
c.
Charges
that cannot be identified or understood; and
d.
Charges
that cannot be verified from audits of medical records.
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, the DDM 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.
Pharmaceuticals.
The Allowable Claim
Limit for pharmacy charges by a provider may be determined by
applying the Average Wholesale Price (AWP) as defined by REDBOOK at the rate of
112% of AWP.
iii.
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.
iv. 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.
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 A Facility Only