O-2004-2779 - Laserfiche WebLink

Browse Search

Payments - Plan benefits are paid based on reasonable charges, as defined in your r:ertificate. Participating providers agree to :cept reasonable charges, as listed in negotiated payment schedules, as payment in full. For services rendered by nonparticipating physicians. the member is responsible for charges exceeding a fee schedule selected by your employer and defined in your Certificate. For services from other nonparticipating providers, the member is responsible for amounts exceeding reasonable charges, as defined in your Certificate. Participating primary care and specialist physicians and other providers in Humana's networks are not the agents, employees or partners of Humana or any of its affiliates or subsidiaries. They are independent e contractors. Humana is not a provider of medical services. Humana does not endorse or control the clinical judgement or treatment recommendations made by the physicians or other providers listed in network directories or otherwise selected by you. Emergency services received while out of the service area are covered at participating provider level. To be covered, expenses must be medically necessary and specified as covered. Please see your Certificate for more information on medical necessity and other specific plan benefits. (1) Emergency care provided by a nonparticipating provider will be covered at the participating provider level. e (2) Prior authorization required in order to receive these benefits. (3) Transplant services do not apply toward the maximum out-of-pocket expense limit. (4) Any out-of-pocket expense for the treatment of mental health services does not apply towards any out-of-pocket expense limits except for serious mental illness. (5) Subject to certain limitations and exclusions. Refer to the Certificate for additional information. TI,e amount of benefits provided depends upon the plan selecfed. Premiums will var}' according to the selecrion made. For .general qllesriorls about rlll! plan, c"//tact )'OIlT benljirs admillistrator. limitations and This is a partial and sununarized list of lim.itations and exclusions. Your group may have specific limitations and exclusions not included on this list. Please check your Certificate for ."'tis complete listing. The Certificate is .e document upon which benefit payment will be determined. Unless stated otherwise, no coverage will be provided tor the following siruations. I. A sickness 01" injury which is covered under any Workers' Compensation or similar law. 2. Sickness 01' mjury for which the insured person is in any way paid or entitled co payment or care and treatmenC by or through a government program, other than Medicaid or as othen.vise provided by Texas law. J. Education or training; medical services provided by the insured person's parent, spouse, brother, siscer or child. 4. Investigational or experimental drugs or subst:lI1ces not approved by Humana or by the Food and Drug Administration. 5. Treannem, services. supplies or surgery .that is not medically necessary. 6. Purchase or fitting of hearing aids, implantable hearing devices or advice on dleir care. unless provided by rider. 7. Weekend nonemergency hospital admissions. TX-10410-HH 1/04 Exclusions 8. In-vitro fertilization, unless our In-Vitro Fertilization Rider is included in the Group Policy; any medical or surgical treatment of intertility; infertility evaluations; se.x change services or reversal of elective sterilization. 9. Plastic, cosmetic or reconstructive surgery, unless a functional impairment is present or if required to correct a congenital defect, birth abnormality of 3 newborn or for breast reconstruction or as othelwise stated in the certificate. 10. Services and supplies for dental care, treatment of teeth or periodontium or orJI surgery. unless the expenses :t. are medically necessm:y diagnostic and/or surgical treatment of the temporomandibular Gaw or craniomandibular) joint; b. are for the surgical removal of a nmlor or lesions in the mouth: or c. are incun'cd in connection with an injury to sound natural teeth or jaw. except injUl.ies resulting from biting or chewing, sustained while the person is covered by the Group Policy. For an injury. the care and treatment must be provided within the 12 month period beginning on the date of the injury. !.~~- Insured by Humana Insurance Company @2004 Humana Ine. Also, the insured person must remain covered under the Group Policy during the 12 month period while the care and treatment is being received. We will not cover any tl-ea011ent related co the preparation or the fitting of dentures, including dental implants. 11. Any service, supply or treatment connected ,"vith custodial care. 12. Sickness or injury caused by the insUl-ed person's: a. engaging in an illegal occupation: or b. commission of or an attempt to conunit a criminal act. 13. Any treatment to reduce obesity, including, but not limited co, surgical procedures. 14. Elective abortion unless: a. the physician certifies in writing that the pregnancy would endanger the life of the mother; or b. the pregnancy is a result of rape or incest: or c. the services are received to treat medical complications due to the abortion. 15. Vision analysis. testing or orthoptic training or the purchase of eyeglasses or contact lenses. 16. Care and tl-eaonenc of complications of noncovered procedures. unless required by state law.