Accident and Health Filing: Model Language

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Accident and Health Product Filing

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Model Language

SubjectModel Language

Cover Page

04/02/2018

Individual- Table of Contents

04/02/2018

Group- Table Of Contents

04/02/2018

Definitions

04/02/2018

How This Coverage Works (Introduction, Selecting a Primary Care Provider, Preauthorization, Medically Necessary)

04/02/2018

Access to Care and Transitional Care (Referrals, Specialty Care Provider as PCP)

04/02/2018

Cost-Sharing Expenses and Allowed Amount

04/02/2018

Individual-Who is Covered (Eligibility)

05/03/2018

Group-Who is Covered (Eligibility)

04/02/2018

Primary and Preventive Care (Well-Baby and Well-Child Care, Adult Annual Physical Examinations, Adult Immunizations, Well-Woman Examinations, Mammograms, Family Planning & Reproductive Health Services, Bone Mineral Density Measurements or Testing, Screening for Prostate Cancer)

04/02/2018

Pre-Hospital Emergency Medical Services

04/02/2018

Emergency and Urgent Care

04/02/2018

Outpatient and Professional Services (Acupuncture, Advanced Imaging Services, Allergy Testing and Treatment, Ambulatory Surgery Center, Chemotherapy, Chiropractic Services, Clinical Trials, Dialysis, Habilitation Services, Home Health Care, Infertility Treatment, Infusion Therapy, Interruption of Pregnancy, Laboratory Procedures, Diagnostic testing and Radiology Services, Maternity and Newborn Care, Office Visits, Outpatient Hospital Services, Preadmission Testing, Prescription Drugs for Use in the Office, Rehabilitation Services, Second Opinions, Surgical Services, Oral Surgery, Reconstructive Breast Surgery, Other Reconstructive and Corrective Surgery, Telemedicine, Transplants)

04/02/2018

Additional Benefits (Autism Spectrum Disorder, Diabetic Equipment, Supplies and Self-Management Education, Durable Medical Equipment and Braces, Hearing Aids, Hospice, Prosthetics, Orthotics)

04/02/2018

Inpatient Services (Hospital Services, Observation Services, Inpatient Medical Services, Inpatient Stay for Maternity Care, Inpatient Stay for Mastectomy Care, Autologous Blood Banking Services, Rehabilitation Services, Skilled Nursing Facility, End of Life Care)

05/01/2018

Mental Health and Substance Use

04/02/2018

Prescription Drugs

04/02/2018

Wellness

04/02/2018

Pediatric Vision

04/02/2018

Pediatric Dental

04/02/2018

Exclusions

04/02/2018

Claims Determinations

04/02/2018

Grievance

04/02/2018

Utilization Review

04/02/2018

External Appeal

04/02/2018

Coordination of Benefits (Group Only)

04/02/2018

Termination

05/03/2018

Extension of Benefits

04/02/2018

Continuation (Group Only - includes Temporary Suspension Rights for Members of Armed Forces)

04/02/2018

Conversion

04/02/2018

Temporary Suspension Rights for Members of the Armed Forces (Individual Only)

04/02/2018

General Provisions (Incontestability, Legal Actions, Subrogation, Unilateral Modification)

04/02/2018

Schedule of Benefits

05/01/2018

Age 29 Rider

04/02/2018

Out-of-Network Rider

04/02/2018

Family Planning Rider

04/02/2018

Domestic Partner Rider

04/02/2018

Medically Necessary Abortion Rider

04/02/2018

Updated 05/03/2018

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