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WHAT IS COVERED

If You Do Not Get Approval

If your procedure, treatment or service requires approval and you do not contact a care coordinator before treatment begins, your benefits may be reduced.

The Plan will reduce your normal reimbursement by 20% of the amount of the eligible charge if:

  • You do not call for approval at least four business days before being hospitalized (or for a valid emergency, within 48 hours following admission) or for any extension of the originally approved length of stay before such extension begins; and
  • You do not call for approval before receiving one of the procedures where approval is required.

If you call for approval, but the care you request is reviewed by the care coordinator and found not to be medically necessary, the care will not be covered.

Any additional expenses you have to pay because you did not get proper approval do not count toward your deductible, annual out-of-pocket maximum or the Plan’s coordination of benefits provision.

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