Frequently Asked Questions:
Health Savings Account (HSA)
Arkansas Blue Cross and Blue Shield Self-Funded Open Access Point of Service plan

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Health Savings Account (HSA) Information

  1. What is a Health Savings Account (HSA) plan?
  2. How does the HSA work in conjunction with a high deductible health plan?
  3. Who owns my HSA account?
  4. Who is eligible to open an HSA?
  5. How do I make deposits to my HSA?
  6. How much can I contribute to my HSA?
  7. Can I ever contribute more than the annual limit?
  8. Who may contribute?
  9. When can I make HSA contributions?
  10. What if my spouse has an HSA, too?
  11. How do I access my HSA account?
  12. What are the tax benefits of an HSA?
  13. Is there a time restriction on when I may use the funds in the account?
  14. If I change employers, what happens to my HSA?
  15. Can I pay out of pocket for my medical expenses instead of using my HSA?
  16. What if I receive covered services and I do not have funds available in my HSA account?
  17. What should I do with my receipts?
  18. Do I need a referral for any service?
  19. If I meet the individual deductible and I'm on a family plan, do I have to meet the family deductible?
  20. How are pharmacy expenses handled under the HSA plan?

Eligibility and Enrollment

  1. Who is eligible for health-care coverage with Health Advantage?
  2. When can I apply for coverage?
  3. Can my dependents be added to my plan after it is in effect?
  4. What if my application for coverage is completed after the enrollment period has expired?
  5. What if I receive a court order to cover my child?
  6. How will my coverage be affected if I am called to active military duty?
  7. What is a Certificate of Credible Coverage (COC)?
  8. If I change jobs, how can I get a COC as evidence of my coverage with Health Advantage?

Health Plan Information

  1. Do I need to take my member ID card each time I go to the doctor or have a prescription filled?
  2. What if I lose my ID card?
  3. What is an open-access plan?
  4. What is a point-of-service plan?
  5. What is the difference between in-network and out-of-network services?
  6. Does Health Advantage provide online services for members?
  7. What does my health plan cover and what will I need to pay?
  8. What is a deductible?
  9. What services are subject to the deductible?
  10. What is a copayment?
  11. What is coinsurance?
  12. What is applied to the annual coinsurance maximum?
  13. How can I make sure I receive covered services from in-plan physicians or plan providers?
  14. What is a coverage policy?
  15. What can I do to reduce my out-of-pocket expenses?
  16. Why would a health plan ask for additional information such as medical records?
  17. What are my wellness benefits?
  18. Are weight-loss programs covered?
  19. I am pregnant; what should I do concerning my health-care benefits?
  20. What is case management?
  21. Are FluMist and flu shots covered?
  22. Are diabetic supplies covered??
  23. What services are limited on the open-access POS plan?

PCP Selection

  1. Am I required to select a primary care physician (PCP)?
  2. If I decide to select a PCP, must I select the same PCP for all family members?
  3. What is the proper procedure for seeing my PCP?
  4. If I select a PCP, may I change my PCP?
  5. What if I become ill or am injured and my PCP office is not open?

Authorizations

  1. Do I need a referral to receive medical care from a plan specialist?
  2. What if the medical care recommended by a PCP is not available through a plan specialist or plan provider?

Emergency Care and Urgent Care

  1. If I am out of the Health Advantage service area and have an unexpected illness or injury, what should I do?
  2. What medical conditions are considered an emergency?
  3. What is the BlueCard program?

Claims Processing

  1. What is the time limit for filing a claim for benefits?
  2. When will I receive an EOB and how will I know what amount I need to pay?
  3. How long should it take for me to receive an EOB from the date of my service?
  4. How can I find out if Health Advantage has processed a claim?
  5. How can I find out my financial responsibility for a claim?
  6. Why does my provider send me a billing statement?
  7. What do I need to look at closest when I receive an EOB?
  8. What if I receive an Explanation of Benefits (EOB) and the claim has not been paid?
  9. What should I do if any of my services were denied?
  10. What if I do not agree with the Explanation of Benefits (EOB) determination?
  11. How do I appeal a claim or benefit determination?
  12. What if I disagree with a determination but am not able to file the appeal of a claim or benefit determination myself?
  13. What if I have to pay for covered medical services or medical supplies?

Other Insurance and Coordination of Benefits

  1. Does Health Advantage coordinate benefits?
  2. If I have secondary coverage, how can I get a copy of my Explanation of Benefits from Health Advantage?
  3. How do I update other insurance information?

If your plan includes a Health Advantage prescription drug benefit

  1. Do I have a choice between brand-name and generic medications?
  2. I am taking a medication on a continuing basis; can I get a refill for more than one month?
  3. Should prescriptions written by a non-plan physician before I became a Health Advantage member be rewritten?
  4. Are contraceptives covered by Health Advantage?

Other Helpful Information

  1. Contact information
  2. Important Information about your plan
For additional information on the following subjects, refer to your Health Advantage Evidence of Coverage and Schedule of Benefits for the terms, conditions, limitations and exclusions of your benefit plan, or call Health Advantage Customer Service. Information and forms on the website may use the term "member" instead of "participant."

Health Plan Information

1. What is a Health Savings Account (HSA) plan?
A Health Savings Account is a bank account held by a bank or custodian that can be used to pay for medical care. Money may be deposited into the account by individuals and/or employers on a tax-free basis and used to pay for qualified medical services. In order to open and contribute to a Health Savings Account, an individual must be covered by a high-deductible health plan that meets certain government-mandated requirements.

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2. How does the HSA work in conjunction with a high deductible health plan?
Here's how it works:

Preventive services: The high-deductible health plan covers 100 percent of covered preventive services, with no out-of-pocket cost to you when using participating providers. A copy of the Health Advantage preventive health guidelines is included in all new member packets and can be found at www.HealthAdvantage-hmo.com.

Routine care: You and/or your employer can deposit funds tax free into an HSA t to cover the cost of medical services received before you reach your health Plan deductible. For each covered service you receive, the Health Advantage allowed amount is applied towards your deductible, even though you may be paying for the service from your HSA. There are no copayments as there are with traditional HMO coverage. Unused dollars are saved from year to year to reduce the amount you may have to pay out-of-pocket in future years.

Specialty care or major expenses: Once your deductible has been met, major medical expenses are covered by the open-access point-of-service plan. A referral is not required. Remember, more of your bill will be paid by the health plan if you receive care from in-plan providers.

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3. Who owns my HSA account?
You do. Just like any other checking account, this account is held by a bank in your name. If your employer makes a contribution or allows payroll deduction, they may require you to use the custodian of the account that they use. You can withdraw funds from that account and transfer to an account with another custodian of your choice. Regardless of where the funds are held, once deposited they belong to you and can only be accessed by you.

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4. Who is eligible to open an HSA?
To be eligible, you must meet these criteria:

  • You must be covered by an HSA-qualified plan, and you cannot be covered by any other medical plan that is not an HSA-qualified health plan.
  • You must not be claimed as a dependent on another individual's tax return.
  • You must be a U.S. resident, and not a resident of Puerto Rico or American Samoa.
  • You may not be active military, or have received veterans' benefits within the last 3 months.
  • You must not be enrolled in Medicare.

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5. How do I make deposits to my HSA?
Your employer may allow you to contribute through payroll deductions, or you may make deposits directly to your account.

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6. How much can I contribute to my HSA?
The total contribution for the year cannot exceed the statutory limits. For 2009, the individual plan contribution maximum is $3,000 and $5,950 for a family plan.

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7. Can I ever contribute more than the annual limit?
Yes, if you are 55 or older and not enrolled in Medicare, you are eligible to contribute an additional amount above the regular limits (referred to as a catch-up contribution). In 2009, this amount is $1,000.

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8. Who may contribute?
Anyone may contribute to your HSA. Your employer, family members or other persons may contribute to your HSA on your behalf, provided combined contributions to your account do not exceed the contribution limits.

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9. When can I make HSA contributions?
You can make contributions at any time. Remember, deposits from any source cannot exceed the maximums allowed by law. You can make contributions any time up to April 15 of the following year and count those deposits toward your contributions for this year. No deposits can be made until you have a qualified high-deductible health plan in place.

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10. What if my spouse has an HSA, too?
If your spouse has an HSA family plan and you have an HSA family plan, and both of you are covered under the other's plan, both of your HSA contributions are limited to the total statutory limit for one family plan. For 2009, the maximum is $5,950. If the policy holder and spouse are eligible and each has an HSA plan, they may divide the maximum contribution among the two as they agree.

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11. How do I access my HSA account?
You make withdrawals using a check or debit card, like you do from any other checking account.

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12. What are the tax benefits of an HSA?
There are several benefits:

  • Contributions to the account are tax-free.
  • Withdrawals from the account for qualified medical expenses are tax-free.
  • Any investment and interest earnings in your account are tax deferred.
  • Depending on the state where you live, you may save on your state tax as well.

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13. Is there a time restriction on when I may use the funds in the account?
No, you may reimburse yourself for an eligible medical expense any time. The only restriction is that the service must have occurred after the HSA was opened.

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14. If I change employers, what happens to my HSA?
You own your HSA. So, if you change employers, you can take the account with you. You can even use it after you retire, for example, to pay for medical expenses.

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15. Can I pay out of pocket for my medical expenses instead of using my HSA?
Yes. You may pay out-of-pocket expenses with after-tax dollars and let your HSA balance grow tax-free.

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16. What if I receive covered services and I do not have funds available in my HSA account?
You will be responsible for any remaining out-of-pocket amount needed to satisfy your deductible before the Plan begins paying benefits. Then, if your plan has coinsurance, you will pay only the appropriate coinsurance for covered services, up to your coinsurance maximum.

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17. What should I do with my receipts?
You should retain all of your receipts for any medical services paid for through your HSA. You may need this documentation to support those payments to the IRS.

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18. Do I need a referral for any service?
Your HSA plan is an open-access, point-of-service plan so no referrals are required. However, a participating provider must be used in order for in-plan benefits to apply.

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19. If I meet the individual deductible and I'm on a family plan, do I have to meet the family deductible?
Yes. If anyone else is on your policy, you must meet the family deductible instead of the individual deductible. The individual deductible only applies to people that are on an individual plan.

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20. How are pharmacy expenses handled under the HSA plan?
Pharmacy expenses are handled just like any medical expense, except you use your drug card for most medications. The Health Advantage allowed amount is applied to your deductible and can be paid for using your HSA funds. Once your deductible has been satisfied, the Plan pays pharmacy costs at 80 percent of the allowed amount until the out-of-pocket coinsurance maximum is met.

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Notice: Establishing a personal health account has important tax and legal consequences for both employers and employees. Arkansas Blue Cross and Blue Shield, a mutual insurance company, does not provide legal or tax advice, nor does Arkansas Blue Cross recommend particular financial institutions as trustees or custodians of Health Savings Accounts. You should consult with your tax and/or legal advisor if you have any questions about tax or legal issues concerning your HSA.

Eligibility and Enrollment     See above section "Who is eligible to open an HSA?"

1. Who is eligible for health-care coverage with Health Advantage?
Full-time employees of enrolled groups that live or work in the state of Arkansas and their eligible dependents. Eligible dependents include a legal spouse, an unmarried child under the age of 19 (or your group's maximum dependent age), a full-time student under the limiting age specified in the group contract, or a child of any age that is certified disabled due to mental or physical incapacity and chiefly dependent on the employee for financial support. Proof of Incapacity Questionnaire (PDF) must be submitted.

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2. When can I apply for coverage?
Employees may apply for coverage for themselves and their eligible dependents according to the following guidelines. Refer to your Evidence of Coverage for more information.

Initial Enrollment Period: New employees may apply for coverage during the initial enrollment period, which is 31 days within date of full-time employment. Coverage is effective at the expiration of the waiting period required by the employer. For newly acquired dependents, the employee must apply for coverage when acquiring a new dependent according to the following guidelines.

  • Newborns: Within 90 days from date of birth to be effective on the date of birth. (Your employer may have a different enrollment timeframe)
  • Spouse: Within 31 days of date of marriage to be effective on the first day of the month following the marriage.
  • Adopted children: Within 60 days of placement for adoption or petition for adoption to be effective on date of placement for adoption or petition for adoption or date of birth if the newborn application is made within 60 days of date of birth.

Open Enrollment Period: A one-month period annually for employees to make changes to health-plan coverage. The period is the one-month period prior to the group renewal date, or the one-month period specified by the employer. The effective date of coverage is the group renewal date.

Special Enrollment Period: The 31-day period that an employee has to apply for coverage after the initial enrollment period. The two instances in which a special enrollment period occurs are: 1) after loss of coverage as a result of loss of eligibility, and 2) addition of a new dependent.

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3. Can my dependents be added to my plan after it is in effect?
Eligible dependents can be added during your group's open enrollment period or during a special enrollment period.

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4. What if my application for coverage is completed after the enrollment period has expired?
You are considered a late enrollee and are not eligible for coverage. You may apply for coverage during your group's next period or a special enrollment period.

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5. What if I receive a court order to cover my child?
If a court has ordered the employee to provide coverage for a child, coverage will be effective on the first day of the month following the date written notification and satisfactory proof of the court order is received by Health Advantage. If an employee is not covered when application is made, the employee must be enrolled at the same time as the child. This does not apply to a child for whom the spouse of the employee is court-ordered to cover his/her child.

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6. How will my coverage be affected if I am called to active military duty?
If you are ordered to active duty in the armed services of the United States of America for more than 30 days, your (and any covered dependents') coverage may be continued under the Uniformed Services Employment and Reemployment Rights Act (USERRA) or on COBRA for a period of 18 months with your group health plan. When you are called to active duty for more than 30 days, your dependents will be eligible for Tricare Standard benefits, effective immediately, with no premium payment required.

Upon returning from active military service, you (and any previously covered dependents) may enroll in the plan within 90 days of your return. The effective date of coverage will be the date of reemployment. Health Advantage may require a copy of the military orders or other proof of the active duty or termination date thereof.

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7. What is a Certificate of Credible Coverage (COC)?
A Certificate of Credible Coverage (COC) lists your coverage with Health Advantage from the initial effective date to your termination date. This certificate is generated after your policy is terminated. Insurance companies use this certificate to reduce pre-existing time clauses and to verify insurance coverage with other carriers. (If a COC is generated prior to a termination date, the end date will appear as 12/31/9999.)

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8. If I change jobs, how can I get a COC as evidence of my coverage with Health Advantage?
A COC is mailed to the member's home for every family member when your coverage is terminated. You may request a copy by contacting Customer Service or you can print a copy of the Certificate of Creditable Coverage at anytime from My Blueprint under "Order Certificate of Coverage Letter."

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Health Plan Information

1. Do I need to take my member ID card each time I go to the doctor or have a prescription filled?
We strongly recommend that you carry your ID card with you at all times, and that your family members carry their ID cards with them as well. To ensure prompt payment of claims, please make sure that the information on your ID card is correct and that all providers have the correct date of birth and the spelling of your name.

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2. What if I lose my ID card?
Contact Health Advantage Customer Service and request one or order one through My Blueprint. You will receive your new card within five to seven days.

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3. What is an open-access plan?
An open-access plan allows a member to receive in-network covered services at the in-network benefit level from plan physicians and plan providers without first having these services authorized or arranged by a primary care physician. Although selection of a primary care physician is encouraged, it is optional and not required. Plan physicians and providers are referred to as in-network providers. Non-plan physicians and providers are also referred to as out-of-network providers.

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4. What is a point-of-service plan?
A point-of-service (POS) plan allows a member the option to receive covered services in addition to emergency care and urgent care services without first receiving authorization from the member's PCP or Health Advantage. Benefits elected through the point of service option are sometimes referred to as "out-of-network" benefits. Health Advantage does not pay as great a part of the cost of services through a point of service as are paid for in-network services. On a POS plan, the member is responsible for a copayment and/or coinsurance, and a deductible for services received. The copayment, coinsurance, and deductible amounts for specific services are listed on the benefit summary for your plan.

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5. What is the difference between in-network and out-of-network services?
In-network services are covered services or supplies a member receives from plan physicians or plan providers. Out-of-network services are services or supplies a member receives from non-plan physician or other non-plan provider that is not in the Health Advantage provider network. Emergency care and urgent care services that meet the emergency care guidelines, are covered at the in-network benefit level up to the allowable charge. (See definition for "emergency care" and "urgent care" in your Evidence of Coverage). The member may be billed the difference between billed charges and allowable charges for services received from non-plan providers.

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6. Does Health Advantage provide online services for members?
Yes. You may access www.HealthAdvantage-hmo.com for the following:

  • Health Plan information: General information about the health plan, referral information, coverage policy guidelines, preventive health and drug information, BlueCard Program, FAQs, and health education programs. A "Forms for members" section is also available.
  • Provider Directory: A listing of all network PCPs, specialists, hospitals, pharmacies and other providers contracted by Health Advantage.
  • Eligibility/Claim information: By registering for My Blueprint, you may check membership eligibility and claims status, print an Explanation of Benefits, review primary care physician information, order a COC letter, and order a replacement member ID card.
  • HealthConnect Blue: A complimentary health information service for members who have everyday health concerns and questions, or who have ongoing (chronic) health conditions such as diabetes, lung or breathing problems or heart conditions. Health coaches are available 24/7 by calling 1-800-318-2384. Specially trained health professionals, such as nurses, respiratory therapists, and dietitians provide health information and support so you can work more effectively with your doctor. Other benefits of the program include an audio library on more than 470 health-care topics, personalized follow-up calls, healthy reminders throughout the year to help you better control your health, educational materials mailed to your home at no charge and Internet access to an encyclopedia of valuable health information provided by HealthConnect Blue. HealthConnect Blue can be accessed through My Blueprint. A log-in ID and password are required.
  • Health-care Cost & Quality-Health Information Guide: Allows you to search for information on a wide range of health topics.
  • Select Quality Care: A hospital quality guide that provides information on health-care procedures, mortality rates and complications.
  • Cost-of-Care Estimator: Access information that helps you to know how much treatment for a condition may cost based on your location.

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7. What does my health plan cover and what will I need to pay?
Your health plan covers preventive and medical services as defined in your Evidence of Coverage/Summary Plan Description. You may be responsible for any applicable copayments, deductibles and/or coinsurance. Usually, you will be responsible for any applicable copayments and/or deductibles at the time of service and may receive a bill at a later date for your coinsurance responsibility. Depending on the type of benefit plan chosen by your employer, a referral or prior approval may be required for certain specialty services.

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8. What is a deductible?
The deductible is the amount of allowable charges for out-of-network covered services for which the member is responsible before the member pays the copayment/coinsurance and Health Advantage makes payment for a service received. Specific in-network and all out-of-network covered services are subject to a deductible. Coinsurance and copayments are not applied to the member's deductible.

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9. What services are subject to the deductible?
All covered services received from non-plan providers except for emergency care are subject to the out-of-network deductible. If your plan has an in-network deductible, certain specialty services that have a coinsurance responsibility are subject to the in-network deductible. Copayments and coinsurance do not count toward the deductible. Refer to your benefit summary.

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10. What is a copayment?
A copayment is the predetermined fixed dollar amount a member must pay to receive a specific service. Copayment may mean a defined percentage of charges a member must pay to receive specific services.

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11. What is coinsurance?
Coinsurance is a defined percentage of the allowable that a member pays for a service after the copayment is paid. Once the annual coinsurance maximum is met for each member or for the family, no further coinsurance will be charged for the current contract year. Copayments do not count toward the annual coinsurance maximum.

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12. What is applied to the annual coinsurance maximum?
The annual coinsurance maximum is the maximum amount of coinsurance payments a member is required to make in connection with covered services or supplies in a contract year. The deductible, copayments, and amounts a member may have to pay in excess of contract benefit limits and benefit exclusions do not contribute to the annual coinsurance limit. Out-of-network deductible, copayments and coinsurance are not applied to in-network annual coinsurance limit.

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13. How can I make sure I receive covered services from in-plan physicians or plan providers?
Members may find a physician or provider by accessing the Health Advantage provider directory at www.HealthAdvantage-hmo.com or contact Customer Service to verify whether a specific provider is in-network. Remember, if your plan is self-funded, you should access the provider directory specific to your self-funded plan.

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14. What is a coverage policy?
The Health Advantage coverage policy is a database of policies and/or coverage criteria that is developed by the medical director(s) and used by Health Advantage to make benefit determinations. The coverage policy is available to members and health-care providers at www.HealthAdvantage-hmo.com. Members may request a copy of specific coverage policies for certain conditions or procedures by calling Customer Service toll free at 1-800-843-1329 or emailing Customer Service.

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15. What can I do to reduce my out-of-pocket expenses?
If you are on a specific plan that requires referrals, using participating providers and obtaining the required referrals prior to the service will reduce your out-of-pocket expenses. If you are on a point-of-service or open-access plan, using participating providers will result in fewer out-of-pocket expenses to you since there are no (or lower) deductibles and lower coinsurance responsibilities.

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16. Why would a health plan ask for additional information such as medical records?
Additional information may be requested when a claim is pended for review. Some examples of this would be:

  1. To ensure the specific medical criteria are met. There are specific procedures that are only covered when specific criteria are met for coverage. The Health Advantage coverage policies are located on the website under the link "Coverage Policy".
  2. When a policy has a pre-existing clause, the medical records are requested during the look-back period (This is the six-month timeframe prior to your effective date with Health Advantage or from the first date of your waiting period, whichever is earlier) to determine if the claims that have been submitted are related to a pre-existing condition.

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17. What are my wellness benefits?
Health Advantage provides services recommended for the prevention and early detection of disease. Promotion of these services is accomplished through direct communication with your physician. The preventive health guidelines reflect recommendations from leading authorities and local practitioners and are meant to be a guide. Treatment is at the clinical discretion of your physician.

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18. Are weight-loss programs covered?
We suggest that you work with your physician to develop a healthy lifestyle for you and your family. Weight-loss programs and treatments designed to assist weight loss, such as health club memberships, dietary supplements, surgical procedures or complications resulting from surgical procedures, are not covered.

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19. I am pregnant; what should I do concerning my health-care benefits?
You should schedule an appointment with a participating obstetrician as soon as possible (no referral required). Health Advantage offers a free Special Delivery prenatal care program as an additional benefit for pregnant mothers regardless of their pregnancy-risk status. Once registered, an assessment will be done, and each expectant mom will receive educational materials and coupons by mail to encourage good health practices during pregnancy. You can register by accessing www.HealthAdvantage-hmo.com or by calling Customer Service.

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20. What is case management? The Health Advantage case management program is a personalized, multidisciplinary process to assist patients and family members of patients who face catastrophic illnesses and long-term recoveries in meeting health needs. Case management promotes individual health-care management while facilitating appropriate health-care measures within the most cost-effective environment. Your physician will direct all care if you become part of the case management program. Registered nurses who are case managers will follow your care and cost of benefits, and be available to answer questions. Examples of situations in which case management may assist in conservation of limited benefits include, but are not limited to, emergency hospital admissions; rehabilitation services; home-health care, including home IV; pain management; hospice; and transplant-related services.

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21. Are FluMist and flu shots covered?
Yes. When in-plan providers are used, the member may not be billed the difference in the billed and allowed.

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22. Are diabetic supplies covered?
Yes. You have the option for specific services to be covered out-of-network. Out-of-plan providers for specific services may be used, and because of an exception by Health Advantage, the claims will be processed on your in-network Benefit level. Please read this carefully since it may help you to save money.

Health Advantage has in-plan providers that carry diabetic supplies and equipment. There are also participating mail order companies that can ship your items to you. If you need strips, lancets, and glucometers, a participating DME supplier or mail order company can be utilized. You will not be responsible to pay the difference in the billed and allowed amounts. If the provider is in-plan, they are required to write off that amount. When using a participating provider they will file the claim for you. Health Advantage processes these claims as medical claims and you will receive an Explanation of Benefits.

Syringes are only covered at the time the insulin is purchased. The insulin and syringes are processed through your prescription card at a participating pharmacy. There is no additional copay for the syringes. Only the amount of syringes to be used for that fill of insulin will be covered.

A participating pharmacy is not considered a participating DME supplier. If you wish to obtain strips, lancets and glucometers from ANY out-of-plan provider, you may do so. As an exception, if the ordering physician is an in-plan provider, you may pay for the items and submit an itemized receipt to Health Advantage. The claim will be processed as a medical claim and processed on the in-network benefit level. The claim will be processed with the Health Advantage allowed amount, your copay will be applied, and the payment will be made directly to you. Health Advantage WILL NOT REIMBURSE you for the difference in the billed and allowed amount. Therefore, it may save you money if you use in-plan providers for your diabetic supplies. You may access the online provider directory at www.HealthAdvantage-hmo.com or call 1-800-843-1329 for a copy of the provider directory. Keep in mind that the online directory is more current.

Payment for diabetic supplies does not apply towards the DME contract maximum. There is no contract maximum amount or limit for diabetic supplies.

Diabetic Shoes/Inserts

Diabetic shoes/inserts are covered based on Medicare guidelines. The claim will be processed as a medical claim and the Diabetic Supplies Benefit will apply. In-plan providers must be utilized and the ordering physician must be in-plan in order for the claim to be paid. If you live in a region that does not have participating providers and the region allows you to go out-of-network, the claim will be paid on the in-network benefit level. Keep in mind, when out-of-plan providers are utilized, you may be billed the difference in the billed and allowed amounts. Also, diabetic shoes/inserts are only covered when they are billed with a diabetic diagnosis.

Diabetes Management Services

Education/management training programs or services for diabetes can be obtained by participating providers. Health Advantage will pay one global fee per member per lifetime no matter how many times they go for education unless a significant medical event happens where the member would need additional education. An example of this would be if you are being taken off of oral medication and changed to insulin. The Health Advantage allowed amount is $210.00 per member per lifetime. When in-plan providers are used, you cannot be billed the difference in the billed and allowed amount, however; your applicable copayment will apply.

Other supplies or durable medical equipment (DME) items
Except for the diabetic supplies listed above, DME must be obtained from an in-plan provider and ordered by an in-plan physician. If an out-of-plan provider is used, the claim will be denied. DME examples are crutches, wheel chairs, walkers, etc.

Aero chambers: Some DME supply companies do not carry these. You may purchase this at a pharmacy or from any out-of-network provider and submit an itemized receipt to Health Advantage. Coverage will be provided based on benefit guidelines, the Health Advantage allowed amount, and the claim will be processed on the in-plan DME benefit level (applicable copayment will apply). The claim will be processed as a medical/DME claim and payment will be made directly to you. If an out-of-plan provider is used, you may be billed the difference in the billed and allowed amounts.

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23. What services are limited on the open-access POS plan?
The following information is a listing of general limitations for your health plan and is provided in response to the most frequently asked questions by members. Many covered services are covered according to the Health Advantage coverage policy, and some services may require a prior authorization. Refer to your Evidence of Coverage and Benefit Summary for specific information on the terms, conditions, limitations and exclusions for your health plan.

  • Vision Examinations: Coverage is provided for one routine eye examination per member every two years by an in-plan specialist. Routine vision examinations are not covered out-of-network. Eyeglasses and contact lenses are not covered except for initial acquisition when purchased within six months following cataract surgery and are subject to a maximum allowable charge of $50.
  • Mammograms: Members may self-refer to a participating provider for one breast-cancer screening test (mammogram) per contract year. Additional mammograms that are medically necessary are covered.
  • Annual GYN Visits: Annual gynecological visits with a participating provider for cervical cancer screenings do not require a referral. Additional pap smear tests that are medically necessary are covered.
Inpatient Hospital Services: Inpatient hospital services are covered at the semiprivate room rate. The member is responsible for the difference between a private room and semiprivate room rate except when a private room is medically necessary or when a hospital has only private rooms. Emergency transportation by ambulance is covered up to a $1,000 benefit maximum per member per contract year. In addition to the member's copayment/coinsurance (if applicable), the member is responsible for the difference in the billed and allowed charge when a non-participating provider is utilized.

Inpatient Rehabilitation: Inpatient rehabilitation is limited to 60 inpatient days per member per contract year.

Outpatient Rehabilitation Therapy: Physical therapy, occupational therapy, speech therapy and chiropractic services are limited to 30 aggregate visits per member per contract year.

Cardiac Rehabilitation: Cardiac rehabilitation is limited to 36 outpatient visits per member per contract year.

Mental Health and Substance Abuse Services: Mental health and substance abuse services are a combined benefit and are limited to seven inpatient or partial hospitalization days and 30 outpatient visits, unless the group has purchased an additional rider for additional visits/days.

Durable Medical Equipment (DME): Except for services covered under diabetic benefits and services, DME, orthotics and prosthetics are limited to $2,000 per member per contract year.

Skilled Nursing Facility Services: Skilled nursing facility services have a day limit per contract year. Refer to your Benefit Summary.

Home-Health Services: Home-health visits are limited to 50 visits per member per contract year.

Organ Transplant Services: Coverage is for no more than two transplants per member per lifetime or a lifetime maximum amount. Refer to your Benefit Summary for the specific lifetime maximum.

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PCP Selection

1. Am I required to select a primary care physician (PCP)?
Members are not required to select a PCP; however, Health Advantage does encourage selection of a PCP to provide routine medical care and preventive health services and to coordinate health care. The PCP must be listed as a PCP in the Health Advantage provider directory. Members may call Customer Service to select or change a PCP. All PCP changes are effective on the first day of the next month.

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2. If I decide to select a PCP, must I select the same PCP for all family members?
You may select the same PCP for all family members, or you may select a different PCP for each family member.

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3. What is the proper procedure for seeing my PCP?
If you are a new Member, we recommend that you contact your PCP office to schedule an appointment. You should also have your medical records transferred to your new PCP.

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4. If I select a PCP, may I change my PCP?
You may change your PCP by contacting Health Advantage Customer Service toll free at 1-800-843-1329. All requests are effective on the first day of the following month. NOTE: If your group is enrolled electronically, you may be required to make the change online or contact your group administrator to make the change.

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5. What if I become ill or am injured and my PCP office is not open?
Contact your PCP or the physician on call. He or she will instruct you on what to do. Since you are on an open-access plan, you may see any PCP you want to see. However, if your problem is so severe that immediate medical care is needed, get help first at the nearest medical facility. Your PCP should be notified of any emergency care within 24 hours.

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Authorizations

1. Do I need a referral to receive medical care from a plan specialist?
No. Members may receive in-network covered services at the in-network benefit level from plan physicians and plan providers without a referral.

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2. What if the medical care recommended by a PCP is not available through a plan specialist or plan provider?
If medically necessary covered services are not available through plan physicians or plan providers, Health Advantage, on the request of a plan physician or plan provider or the member, made within a reasonable period prior to receiving the service, may authorize covered services by a non-plan physician or provider at the allowable charge or an agreed rate. Even though services are covered at the in-network benefit level, a non-plan physician or provider may bill the member for the charges in excess of the allowable charges. The member may have information or medical records submitted from the physician with their out-of-network request.

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Emergency Care and Urgent Care

1. If I am out of the Health Advantage service area and have an unexpected illness or injury, what should I do?
If it is an emergency, go to the nearest medical facility. Health Advantage will cover emergency care and urgent care outside the service area (state of Arkansas). Urgent care is an unexpected illness or injury that cannot wait until the member returns to the service area. The member may limit expenses to copayment/coinsurance for emergency care and urgent care by using the BlueCard program. The member may be billed the difference between the billed charges and allowable charges for services received from out-of-network providers that do not participate in the BlueCard program. NOTE: Health Advantage should be notified within 24 hours for emergency admissions to an out-of-plan hospital.

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2. What medical conditions are considered an emergency?
Conditions that are so severe as to cause serious disability if not treated are considered emergencies. Some examples of emergencies that require immediate attention include:

*Heart attack or severe chest pain *Serious burns *Acute abdominal pain
*Uncontrollable bleeding *Poisoning *High fever
*Broken bones *Unconsciousness *Severe shortness of breath
*Convulsions or choking

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3. What is the BlueCard program?
The BlueCard program enables a member to receive medical services outside the service area (state of Arkansas) from a Blue Cross or Blue Shield (BlueCard) traditional network provider and limit expenses to the member’s in-network deductible (if applicable), copayment and coinsurance. Claims are filed with the local Blue Cross and/or Blue Shield plan with the XCH prefix and the member's ID number and routed electronically to Health Advantage for payment. To locate the nearest participating BlueCard traditional network provider, members may go to bcbs.com or bluecares.com or call 1-800-810-2583 (BLUE). Services are covered according to the member’s out-of-area status.

Members traveling outside the service area. Health Advantage members on short-term travel outside the service area have access to the BlueCard Program for emergency and urgent care at the travel location. Medical Services other than emergency care or urgent care through the BlueCard program must first be approved by Health Advantage to be covered at the in-network benefit level.

Subscribers and dependents that work, live, or attend school outside the service area for more than 90 days may be eligible for a temporary out-of-area classification. If approved by Health Advantage, the member uses his/her Health Advantage ID card to access services covered by Health Advantage on the member's group health plan. Services are covered at the in-network benefit level when provided by a Blue Cross and/or Blue Shield provider listed in the BlueCard traditional network. The subscriber must submit a signed application. Applications for out-of-area classification are available online. Renewal is required annually for dependents. Active employees must have application approved by their group administrator.

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Claims Processing

1. What is the time limit for filing a claim for benefits?
A notice of claim must be made to Health Advantage by the member or the provider within 180 days of the date on which Covered Services were first incurred.

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2. When will I receive an EOB and how will I know what amount I need to pay?
You will receive an EOB when you have a member responsibility of a deductible, copayment or coinsurance, or when a service is denied. You should keep your EOB to compare it with the bill that you receive from the provider. Your minimum responsibility should match the amount requested from the provider. This may differ if the service is denied as a non-covered service or as a benefit limitation. If the amount indicated on your EOB does not match the amount billed by the provider, you may call the provider or Customer Service at Health Advantage.

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3. How long should it take for me to receive an EOB from the date of my service?
Once the provider submits a claim, it should be processed within 30 days. This may be delayed if additional information is requested.

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4. How can I find out if Health Advantage has processed a claim?
An EOB is mailed to your home each time a claim is processed. You may check the status of a claim online by going to My Blueprint and selecting "Check Claims Status." If the status shows "complete," the claim has been processed. If the status shows "in process," the claim has been received by Health Advantage, but final action has not been taken. You also may call MyBlueLine, an interactive voice response system, toll free, 24/7, at 1-800-843-1329.

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5. How can I find out my financial responsibility for a claim?
An EOB is mailed to your home each time a claim is processed. Your copayment and coinsurance responsibility (if you have one) will be shown on the EOB. You may print a copy of the EOB for any claim that shows "complete" from My Blueprint under "Check Claims Status." You also may call MyBlueLine, an interactive voice response system, toll free, 24/7, at 1-800-843-1329.

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6. Why does my provider send me a billing statement?
If the statement date is less than 30 days old from the date of service, it is possible that the billing statement may cross with the payment of the claim. If adequate time has been allowed for the processing of the claim, you should research the bill. If the claim has been processed and you received an EOB, the amount that the provider is billing you should be matched with the amount on the EOB that is listed as the member's responsibility. If the amount the provider is billing you is higher, or Health Advantage has not processed the claim, a call should be made to the provider's office. Explain the amounts shown on your EOB, ask them to research your bill, and ask them to verify the information filed on the claim. If the information filed doesn't match your ID card, the provider will need to file a corrected claim to Health Advantage. If you no longer have the EOB, you may view your claim information by using our online tools at www.HealthAdvantage-hmo.com. If the issue cannot be resolved, you or the provider can call the Customer Service Department at Health Advantage.

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7. What do I need to look at closest when I receive an EOB?
The provider name and date of service should match a service that you received. If you did not receive this service, please call the provider. They may have filed an incorrect claim. If the date of service and provider information are correct, you should review the amount shown as your responsibility such as a copayment, coinsurance, deductible or denied charge. If you have questions or feel the amount is incorrect, you should call the Customer Service Department.

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8. What if I receive an Explanation of Benefits (EOB) and the claim has not been paid?
If your claim has not been paid and has been put in a "hold" status awaiting additional information or payment, your EOB will have a description of any additional information necessary for the claim to be processed and an explanation of why such information is necessary. If your claim has been denied, your EOB will have a reference to a specific plan provision on which the determination is based and a description of your plan's appeal process.

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9. What should I do if any of my services were denied?
Review the service that was denied and reference the Exclusions or Benefit Limitations in your Evidence of Coverage/Summary Plan Description. If the service was denied correctly, you are responsible to pay the billed charge to the provider. If you feel the claim was denied in error, you may call Customer Service. If you wish to appeal the denial of the claim, please follow the appeal guidelines listed in your Evidence of Coverage/Summary Plan Description.

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10. What if I do not agree with the Explanation of Benefits (EOB) determination?
If you have questions about an EOB determination, you may contact Customer Service toll free at 1-800-843-1329 or write to: Health Advantage Customer Service, P.O. Box 8069, Little Rock, Arkansas 72203. This is an informal request and is not considered a formal appeal.

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11. How do I appeal a claim or benefit determination?
If a claim for benefits is denied either in whole or in part, you may request a review of a denial of benefits for any claim or portion of a claim by sending a request marked "Appeal Request" to Health Advantage, Attention: Member Response Coordinator, P.O. Box 8069, Little Rock, AR 72203. This request can also be sent by fax to 501-212-8518 or by email to appeals@HealthAdvantage-hmo.com. The request must be made within 180 days after the member has been notified of the initial denial of benefits. You may contact the Health Advantage member response coordinator toll free at 1-800-843-1329 for assistance in making an appeal. For more information, refer to your Evidence of Coverage.

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12. What if I disagree with a determination but am not able to file the appeal of a claim or benefit determination myself?
You may designate an authorized representative to represent you in filing an appeal of a claim or benefit determination. For information on designation of an authorized representative, please call Customer Service at 1-800-843-1329.

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13. What if I have to pay for covered medical services or medical supplies?
If you make payment other than required copayments or coinsurance for services covered by Health Advantage, a claim for reimbursement may be made by submitting a copy of your receipt for payment for services received and a copy of the bill to Health Advantage. The request must include the member's ID number and be made within 180 days from the date on which expenses were first incurred. The request for reimbursement may be sent postage paid to: Claims, Health Advantage, P.O. Box 8069, Little Rock, AR 72203-8069.

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Other Insurance and Coordination of Benefits

1. Does Health Advantage coordinate benefits?
Yes. If you or any of your dependents have other insurance coverage that provides benefits for hospital, medical, or other expenses, your benefit payments may be subject to coordination of benefits. Even if Health Advantage is not the primary carrier, you must still follow the plan in order for Health Advantage to coordinate benefits. It is the member’s responsibility to ensure Health Advantage has a copy of the primary carrier’s Explanation of Benefits and all itemized bills, and to inform Health Advantage of all changes in other insurance. If you need to update other insurance information, you may submit the information in writing, contact your employer benefits administrator or call Customer Service.

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2. If I have secondary coverage, how can I get a copy of my Explanation of Benefits from Health Advantage?
An Explanation of Benefits (EOB) is mailed to your home each time a claim is processed. You may print a copy of the EOB for any claim that has been processed from My Blueprint under "Check Claims Status."

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3. How do I update other insurance information?
To update your Medicare information or other insurance information, you may complete the Coordination of Benefits Questionnaire and mail it to: Health Advantage, Attn: Claims COB, P.O. Box 8069, Little Rock, AR 72203-8069. You also may call toll free 1-800-969-3983.

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IF YOUR PLAN INCLUDES A HEALTH ADVANTAGE PRESCRIPTION DRUG BENEFIT

1. Do I have a choice between brand-name and generic medications?
You may request the brand-name medication; however, you will be required to pay an additional charge if a generic medication is available. Please refer to your managed pharmacy benefit rider. You may access the prescription formulary and preferred drug list under pharmacy benefits at www.HealthAdvantage-hmo.com.

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2. I am taking a medication on a continuing basis; can I get a refill for more than one month?
As a service to you, certain prescriptions for maintenance medications can be refilled for a 100-day supply. You will be charged three copayments/coinsurance. Any new or rewritten prescription will be limited to a one-month supply the first time it is filled. You may access a list of maintenance medications under Pharmacy Benefits at www.HealthAdvantage-hmo.com.

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3. Should prescriptions written by a non-plan physician before I became a Health Advantage member be rewritten?
It is best to have any prescriptions that you are currently using rewritten by a Health Advantage physician as soon as possible.

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4. Are contraceptives covered by Health Advantage?
Selected oral contraceptives are covered on your pharmacy benefit plan. The self-injectable drug Depo-SubQ Provera is also covered under your prescription benefits. Please note: Under your medical coverage, the injectable contraceptive Depo Provera is covered. The intrauterine device (IUD) is also covered, including insertion and removal.

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Medications from non-participating pharmacies are not covered except for emergencies

Other Helpful Information

1. Contact Information

Mailing address P.O. Box 8069, Little Rock, AR 72203-8069

Customer Service 1-800-843-1329

Interactive Voice Response (available 24/7) 1-800-843-1329


My Blueprint Select "technical support" for system issues, ID, password, and registration issues. Call 1-800-843-1329 if you have other questions.

Trover (HealthCare Recoveries) 1-800-685-4013 (to report a motor vehicle accident or injury that includes third party liability)

COB information line 1-800-969-3983 to report other medical or pharmacy insurance coverage or changes related to the other insurance information we have on file.

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2. IMPORTANT INFORMATION ABOUT YOUR PLAN:

Advanced Diagnostic Imaging Services. Computed tomography scanning (CT scan), magnetic resonance angiography or imaging (MRI/MRA), nuclear cardiology and positron emission tomography scans (PET scan), collectively referred to as advanced diagnostic imaging.

These services require prior approval from Health Advantage. Please note that prior approval does not guarantee payment or assure coverage; it means only that the information furnished to us at the time indicates that the CT scan, MRI/MRA, nuclear cardiology or PET scan is medically necessary. All services, including any advanced diagnostic imaging receiving prior approval, must still meet all other coverage terms, conditions, and limitations, and coverage for any advanced diagnostic imaging receiving prior approval may still be limited or denied if, when the claims for the advanced diagnostic imaging are received by us, investigation shows that a benefit exclusion or limitation applies, that the member ceased to be eligible for benefits on the date services were provided, that coverage lapsed for non-payment of premium, that out-of-network limitations apply, or any other basis specified in this Evidence of Coverage.

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