CurrentAlliant HealthPolicy N/A

Certificate of Coverage — 2026 SoloCare HMO (Individual & Family Plans) — Georgia

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This Certificate governs benefits, eligibility, member rights/responsibilities, prior authorization, and coverage rules for Subscribers and eligible Dependents enrolled in the 2026 SoloCare HMO Individual and Family Plans offered by Alliant Health Plans in Georgia.

Policy Summary

PayerAlliant Health

PolicyCertificate of Coverage — SoloCare HMO (Individual & Family Plans)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionProviders must call Alliant Medical Management at (800) 865-5922 to obtain Prior Authorization for in‑network inpatient admissions and other services that require authorization.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Georgiajurisdiction

SoloCare HMOplan type

(800) 865-5922prior auth

26dependent age limit

No annual/lifetime limitessential benefits

Coverage, Benefits, and Exclusions

inv-01: Coverage criteria and prior authorization rules

Covered when the following verification and prior authorization rules are met:

Verification of benefits by Member or authorized provider does not guarantee payment or coverage for a specific procedure; verification is not a guarantee of payment.

See verification guidance.

Emergency Medical Services do not require Prior Authorization and Out-of-Network benefits are limited to emergency services only.

Emergency services are covered without prior authorization.

Prior Authorization is required for all in-network inpatient hospital admissions except maternity; for emergency or maternity admissions the provider should notify next business day.

Providers must call Alliant Medical Management at (800) 865-5922 for prior authorization.

Prior Authorization approvals apply only to the services specified in the authorization request and do not guarantee coverage if the member is not covered at time of service, benefits are exhausted, there is fraud/misrepresentation, or the service is excluded under the plan.

Authorizations are limited in scope and subject to contractual coverage rules.

inv-02: Enrollment and Special Enrollment

Enrollment timing and qualifying events:

If You or Your Dependents do not enroll when first eligible, enrollment must wait until the next Open Enrollment Period unless a Special Enrollment Period (SEP) applies.

Late enrollees referenced.

Open Enrollment Period is defined by the federal government and applies whether purchasing through Georgia Access or directly from Alliant Health Plans.

Open Enrollment source.

Special Enrollment Periods include: loss of qualifying health coverage; change in household size; change in primary residence; newly gaining eligibility for an ICHRA or QSEHRA; and enrollment or plan error. SEPs do not include voluntary termination or failure to pay premiums (including COBRA premiums) and exclude situations allowing rescission as specified by regulation.

SEP categories listed.

inv-03: Dependent special cases

Temporary dependent coverage and required timelines:

Newborns are covered automatically for the first 31 days from date of birth. To continue coverage beyond 31 days, an application to add the child as a Dependent and payment of any applicable premium (including the first 31 days) must be received within 31 days; if received after 31 days but within 60 days, coverage will be reinstated retroactively with no break.

Newborn provision and waiver option described.

Adopted children are eligible from the date of legal assumption; an application and premium must be received within 31 days to begin coverage (premium includes first 31 days); if received after 31 days but within 60 days, coverage will be reinstated retroactively with no break.

Adopted child enrollment timing.

Foster children require confirmation of a valid foster parent relationship furnished to Alliant at the Member's expense; an application and premium must be received within 31 days from date of legal assumption to begin coverage; if received after 31 days but within 60 days, coverage will be reinstated retroactively with no break.

Foster child proof and timing requirements.

inv-04: Dependent enrollment changes

Rules for adding or removing dependents:

A Member may add a spouse and eligible stepchildren within 31 days of the date of marriage; the Effective Date will be the date of marriage; notify Georgia Access if purchased through Georgia Access or Alliant if purchased outside Georgia Access.

Timeframe to add spouse/stepchildren.

Dependent removal triggers

Divorce triggers removal of a spouse dependent and requires notification to Georgia Access or Client Services.
Death of an enrolled family member triggers removal and may require different coverage arrangements.
Dependent child reaching age 26 results in termination of dependent coverage at end of calendar year in which they turn 26.
Enrolled dependent child becoming totally or permanently disabled may affect coverage continuation per contract rules.

inv-05: Benefit mechanics and financial responsibility

Network, cost-sharing, and benefit application rules:

All Covered Services must be Medically Necessary to be paid under the Contract; Members have direct access to primary and specialty care without PCP referral.

Medical necessity and direct access.

As an HMO, the plan requires use of In-Network providers to use benefits; Members should confirm provider network status prior to visits via AlliantPlans.com or Client Services.

In-Network requirement and verification.

Members outside the service area should contact Client Services to locate an In-Network provider; Alliant may assist with out-of-service area provider location.

Out-of-area assistance.

In-Network care may require copayments or coinsurance per the Summary of Benefits and Coverage; ER copayment may be waived if admitted; member cost share responsibilities are based on plan design and MAC calculations.

Cost-sharing mechanics and MAC reference.

Deductible is applied on a calendar year basis; certain preventive services are covered prior to meeting the deductible per preventive guidelines and Summary of Benefits and Coverage.

Deductible application and preventive exceptions.

inv-06: Allergy conditions

Allergy testing and treatment coverage stance:

Standard medically necessary testing and treatment for allergy conditions are covered.

Standard allergy testing and treatment covered.

Non-standard allergy tests are considered Non-Covered Services and are excluded (see 'What is Not Covered').

Non-standard tests excluded; reference exclusions section.

inv-07: Ambulance services

Ambulance coverage requires medical necessity and provider/licensure criteria:

Emergency ambulance services are covered when Medically Necessary and when transported by a state licensed vehicle staffed by EMTs, paramedics, or other certified professionals; includes ground, fixed wing, rotary wing, and water transport.

Emergency ambulance staffing and vehicle requirements.

Covered transport contexts include: from home/scene to hospital; between hospitals (including transfers from out-of-network to in-network when required); and between hospital and skilled nursing facility (ground transport only); transport must be to the nearest facility able to give care for the condition.

Permitted transport contexts.

Scheduled ground ambulance services for non-emergency transports are subject to Medical Necessity review and must be medically necessary (except acute facility-to-acute facility transports); benefits may include treatment during transport.

Non-emergency ground ambulance requires review.

Air and water ambulance services are subject to Medical Necessity review; Alliant may select the air ambulance provider; hospital-to-hospital air ambulance is covered only if ground transport would endanger health or transferring hospital lacks appropriate facilities, and transfer must be to the nearest hospital with appropriate facilities.

Air/water ambulance medical necessity and selection rights.

inv-08: Authorized services and member liability

Authorized out-of-network services and member financial responsibility when authorized:

Alliant may authorize application of In-Network cost share amounts (Deductible, Copayment, Coinsurance) to services obtained from an Out-of-Network provider when no In-Network provider is available, but the Member must contact Alliant in advance to request authorization.

Advance authorization required to apply in-network cost share to out-of-network care.

If authorized, Member is responsible for the In-Network cost share; Alliant pays the remaining MAC, but the Out-of-Network provider may bill the Member for any difference between the provider charge and the MAC (example provided illustrating potential balance owed by Member).

Member may still be billed for difference between provider charge and MAC.

Alliant will not reimburse Non-Covered Services; Member is responsible for total billed amount for Non-Covered Services or when benefits are exhausted.

Non-Covered Services remain Member liability.

inv-09: Air ambulance coverage rules

Air/water ambulance coverage criteria and billing rules:

Hospital-to-hospital air ambulance transport is covered only if Medically Necessary (e.g., ground transport would endanger health or transferring hospital lacks adequate facilities) and transfer is to the nearest hospital with appropriate facilities.

Hospital-to-hospital air ambulance criteria.

Fixed or rotary wing air ambulance may be Medically Necessary only if emergency ambulance criteria are met AND one of specified conditions applies (immediate rapid transport required, pick-up inaccessible by land, great distance/time constraints, land transport threatens patient's health, or patient pronounced dead after call but before/during transport).

Exceptional circumstances required for fixed/rotary wing necessity.

Members may be billed for applicable cost-sharing; for Out-of-Network emergent air ambulance services Member pays In-Network cost-sharing and MAC is calculated as the lesser of billed charges or the QPA (Alliant's median contracted rate for similar services).

Billing and MAC/QPA calculation for emergent air ambulance.

inv-10: Anesthesia coverage

Anesthesia coverage requirements:

General anesthesia and associated facility charges are covered for certain dental patients (patients age seven or younger; developmentally disabled; neurological disorder preventing successful local anesthesia; or extensive facial/dental trauma).

Dental patient anesthesia coverage criteria.

Anesthesia services must be Medically Necessary, ordered by the attending Physician, administered by a Physician or Certified Registered Nurse Anesthetist (CRNA) who customarily bills for such services, and must be connected to a procedure that is a Covered Service.

Provider and ordering requirements for anesthesia services.

inv-11: Breast cancer services

Breast cancer treatment and reconstructive care coverage:

Inpatient care following mastectomy or lymph node dissection is covered for an appropriate length of stay as determined by the attending Physician; follow-up visits are included and mastectomy bras are covered up to three per calendar year.

Inpatient post-mastectomy care and prosthesis limits.

Breast reconstructive surgery following mastectomy and related preventive screening are covered; preventive screening per guidelines is provided at no cost when completed according to recommendations.

Reconstructive care and preventive screening no-cost provision.

inv-12: Cancer screening

Cancer screening coverage rules:

Annual breast imaging (digital mammography, tomosynthesis, breast x-ray, breast MRI) is covered for women aged 40 and over, or age 35 and over if recommended by a physician; diagnostic and supplemental breast screening are also covered.

Breast screening frequency and age thresholds.

Colorectal cancer screening follows USPSTF Grade A/B recommendations and American Cancer Society guidelines; such preventive screening is provided at no cost when completed per recommended guidelines.

Colorectal screening preventive coverage and no-cost condition.

inv-13: Clinical trials

Clinical trial coverage and qualification requirements:

Routine patient care costs for Dependent children in approved clinical trials for treatment of children's cancer are covered as Medically Necessary per Georgia law; routine costs for qualifying Members in approved clinical trials for cancer or life-threatening conditions are covered, but the cost of the investigational medication or treatment itself is excluded.

Clinical trial routine cost coverage and medication exclusion.

To qualify for clinical trial coverage Members must be: a Member; diagnosed with cancer or other life-threatening disease/condition; accepted into an approved clinical trial; referred by an In-Network Provider; and receive Prior Authorization from Alliant.

Qualification and prior authorization requirement for clinical trials.

inv-14: Diabetes management

Diabetes management coverage:

Coverage includes diabetes-related equipment and supplies (blood glucose monitors, test strips, lancets, syringes, insulin pumps), pharmacologic agents including insulin, outpatient diabetes self-management training and education, and nutritional therapy, when prescribed by a physician and provided by certified/registered/licensed professionals.

Diabetes services must be prescribed and education provided by qualified personnel.

inv-15: Dialysis treatment

Dialysis coverage:

Dialysis treatment is a Covered Service when Medically Necessary.

Dialysis explicitly listed as covered.

inv-16: DME coverage and limits

DME coverage and payment limits:

Durable Medical Equipment must be Medically Necessary, ordered/prescribed by a Physician, appropriate for in-home use, and meet criteria (repeated use, medical purpose, not for comfort only, not useful to someone not ill); Provider must certify Medical Necessity and expected length of need.

DME medical necessity and ordering requirements.

Plan pays rental charges up to the lesser of the purchase price or twelve (12) months of rental charges.

DME rental payment cap.

inv-17: Emergency room services

Emergency room and emergency medical services coverage rules:

Emergency Medical Services are defined by the prudent layperson standard (acute symptoms that could place health in serious jeopardy, cause serious impairment of bodily functions, or serious dysfunction of any organ) and are covered when Medically Necessary.

Prudent layperson definition of emergency.

A Copayment may apply for ER services; any applicable copayment is waived if the Member is admitted through the ER. Copayment/percentage payable is the same for In-Network and Out-of-Network care and Members cannot be balance-billed for Out-of-Network emergency services per state and federal surprise billing laws.

ER cost-sharing and surprise billing protections.

inv-18: Eye care coverage

Eye care coverage scope:

Covered eye care is limited to medical conditions (not routine vision care) except for children under age 19; Members may obtain services directly from participating ophthalmologists or optometrists.

Pediatric exception and provider access.

inv-19: Fertility preservation coverage

Fertility preservation coverage rules:

Standard fertility preservation services are covered when infertility is the result of medically necessary treatment for cancer, sickle cell disease, or lupus; covered items may include evaluations, labs, medications, procedures, cryopreservation of eggs/sperm/ovarian tissue, and storage of gametes for up to one year.

Coverage subject to limits such as age restrictions, lifetime caps, and exclusion of experimental treatments or long-term storage.

inv-20: Additional covered services

Additional covered assistive and habilitative services:

Contract provides benefits for diagnosis and habilitative/rehabilitative services and other therapy services necessary to develop, maintain, and restore functioning for individuals with Autism Spectrum Disorder, subject to contract conditions, limitations, and cost-sharing.

Autism-related habilitative benefit.

Assistant surgeon services are covered when Medically Necessary and rendered in conjunction with a surgery coordinated by the Member's surgeon.

Assistant surgeon coverage condition.

inv-21: Fertility preservation coverage

Fertility preservation (duplicate):

Standard fertility preservation services covered when infertility results from medically necessary cancer, sickle cell disease, or lupus treatment; may include gamete cryopreservation and up to one year storage, subject to limits and exclusions.

Duplicate fertility preservation block; mirrors earlier criteria.

inv-22: Anesthesia coverage

General anesthesia coverage (duplicate):

Anesthesia services must be Medically Necessary, ordered by the attending Physician, administered by a Physician or CRNA, and connected to a procedure that is a Covered Service; includes spinal/regional anesthesia and injection or inhalation agents (local infiltration excluded).

General anesthesia scope and provider requirements.

inv-23: Habilitative and speech therapy coverage

Habilitative and speech therapy coverage rules:

Medically necessary habilitative services (physical, occupational, speech therapy) are covered to help individuals learn, keep, or improve skills needed for daily living; services must be ordered and supervised by a Physician where required and have calendar-year visit limits as detailed in the Summary of Benefits and Coverage.

Visit limits referenced in Summary of Benefits.

inv-24: Hearing aids coverage

Hearing aid coverage criteria and limits:

Hearing Aids are covered as nonexperimental wearable devices (parts and replacement parts included); personal sound amplification products excluded.

Definition and exclusions for hearing aids.

For plans purchased outside Georgia Access, benefits for children 18 and under include one hearing aid per impaired ear not to exceed $3,000 per aid every 48 months and medically necessary services and supplies during each 48-month coverage period, subject to Summary of Benefits conditions and cost-sharing.

Monetary limit and frequency for hearing aids (applies to outside Georgia Access plans).

inv-25: Home health coverage

Home health care coverage and conditions:

Home Health Care provides intermittent skilled care in the home; coverage requires Physician certification and an approved written plan of care; Member must be essentially confined at home; services have calendar-year visit limits per Summary of Benefits.

Certification, plan of care, confinement and visit limits.

Covered home health services include RN/LPN visits, qualified therapist visits, supervised home health aide, administration of prescribed drugs, and oxygen; services provided by household members or family are excluded.

Included and excluded home health services.

inv-26: Hospice coverage

Hospice coverage criteria:

Hospice care is covered for patients certified by a Physician as terminally ill (expected survival six months or less) and enrolled in an Alliant-recognized hospice program directed by a Physician and coordinated by an RN with an organized treatment plan and hospice team providing around-the-clock care.

Certification, program recognition, and plan of care requirements.

Hospice benefits include inpatient and outpatient hospice services and family support services as specified in the Summary of Benefits and Coverage.

Scope of hospice benefits.

inv-27: Hospital services coverage

Hospital services (inpatient and outpatient) coverage criteria:

Inpatient hospital services are Covered Services when Medically Necessary; for In-Network care the Physician must arrange admission; Covered items include semiprivate room and board, nursing care, ICU, operating/recovery/delivery rooms, labs, diagnostics and therapies; length of stay determined by medical necessity.

Inpatient coverage scope and admission requirement.

Outpatient services are covered when Medically Necessary, including pre-admission tests, outpatient surgery, diagnostic x-rays and labs; Alliant may establish Preferred/In-Network providers for certain services and Members must verify network status.

Outpatient scope and preferred provider program.

inv-28: Maternity coverage

Maternity care coverage and federal protections:

Maternity care and newborn nursery services are covered on the same basis as other care subject to copayment, deductible and coinsurance; federal law prohibits restricting length of stay to less than 48 hours (vaginal) or 96 hours (cesarean) and prohibits requiring prior authorization for those minimum lengths of stay; post-discharge follow-up visits provided if discharged earlier.

Federal minimum stay protections and follow-up visits.

For In-Network physician prenatal, delivery and postpartum care, only one copayment (if applicable) will be charged for these services combined as specified.

Single copayment for maternity physician care.

inv-29: Medical, surgical, mental health and other outpatient coverage

Medical, surgical, mental health and other outpatient coverage rules:

Medical and surgical care includes general treatment of illness or injury and usual pre- and post-operative care as outlined in the Summary of Benefits and Coverage.

Medical and surgical coverage summary.

Hospital inpatient mental health and substance abuse treatment, acute detoxification, and outpatient professional mental health/substance abuse benefits are covered as outlined in the Summary of Benefits and Coverage; reimbursable care must be provided by authorized mental health professionals per contract.

Mental health provider scope and settings.

inv-30: Extracted coverage criteria (partial)

Partial extracted coverage criteria and notable limits:

Medical and surgical care, outpatient services and outpatient surgery are Covered Services when Medically Necessary and as detailed in the Summary of Benefits and Coverage.

General extracted coverage position.

Preventive services meeting USPSTF, ACIP, HRSA and applicable law are covered at no cost In-Network; new government recommendations become covered for plan years beginning one year after issuance or as required by ACA.

Preventive service inclusion and timing of new guidelines.

Physical, occupational and speech therapy services are limited to combined total maximum visits per calendar year as outlined in the Summary of Benefits and Coverage and must be within the lawful scope of practice and rendered personally by the provider.

Therapy visit limits and provider requirements.

Skilled Nursing Facility services have calendar year visit limits and claims are reviewed to verify Skilled Convalescent Care characteristics (favorable prognosis, predictable recovery time, intensity between acute hospital and residence); exclusions apply when care is custodial or benefit limits reached.

SNF review criteria and limits.

Second medical opinions by an In-Network Provider for proposed surgical interventions or any Covered Service are covered.

Second opinion entitlement.

inv-31: Service coverage criteria

Service coverage criteria, limits and member obligations across multiple areas:

Second medical opinion by an In-Network Provider for proposed surgical interventions or any Covered Service is included as a Covered Service.

Second opinion coverage.

Transplant coverage is limited to specified human organ/tissue transplants and certain bone marrow/hematopoietic stem cell transplants per listed conditions; donor costs, facility and professional transplant services included when not excluded, and all transplants must be performed at Alliant-approved Transplant Centers with Prior Authorization.

Transplant scope and prior authorization requirement.

Pre-approved transplant travel expenses for recipient and a support person are reimbursable up to a combined maximum of $10,000 per covered transplant; travel benefits are not subject to deductible or out-of-pocket maximum and have specified allowable items and exclusions.

Transplant travel reimbursement limit and rules.

The outpatient prescription drug program is administered by Prime Therapeutics with a tiered formulary (Generic, Preferred Brand, Non-Preferred Brand, Specialty, Zero-Cost Share); copay/coinsurance determined by Summary of Benefits and prior authorization may be required for select drugs and specialty medications.

Prescription drug program overview and PBM contact.

Tier assignment and formulary management are overseen by a P&T Committee considering clinical appropriateness and cost; member protections exist for formulary changes (30-day notice if member had a prescription within prior 12 months) and a Non-Formulary Drug Exception and appeals process is available.

Formulary governance and member protections.

inv-32: Outpatient Prescription and Pediatric Vision Coverage Criteria

Outpatient prescription drug and pediatric vision coverage criteria:

Drug tiers defined: Generic (lowest cost-share), Preferred Brand, Non-Preferred Brand, Specialty (highest cost-share), and Zero-Cost Share (preventive drugs under ACA); copayment/coinsurance amounts determined by Summary of Benefits and Coverage.

Tier definitions.

Formulary may be modified for reasons including new drugs, FDA/manufacturer actions, reclassification, loss of patent/generics, OTC availability, or therapeutic equivalence; member notice required at least 30 days before non-formulary change if member had prescription in previous 12 months.

Formulary change triggers and member notice protection.

Off-label drugs prescribed for life-threatening or chronic disabling conditions may be covered when pre-approved by Alliant; medical pharmacy benefit drugs (infusion, chemotherapy, provider-administered injectables) are paid under the medical benefit and typically require Prior Authorization.

Off-label pre-approval and medical pharmacy distinction.

Outpatient prescription drug exclusions include many items (e.g., OTC items, non-legend vitamins, certain syringes, newly approved FDA drugs not yet in US market for 180 days, delivery charges, drugs for inpatient use, and other listed exclusions); Pediatric vision may be covered for persons under 19 subject to limits.

Enumerated exclusions and pediatric vision age limit.

inv-33: What Is Not Covered (exclusions)

Services and items expressly excluded from coverage unless otherwise specified:

Exclusions (representative, not exhaustive)

Disposable supplies and personal convenience items (e.g., combs, lotions, bandages) unless Medically Necessary are excluded.
Durable Medical Equipment items specifically excluded (air conditioners, humidifiers, TENS units, certain shoe inserts/orthotics, deluxe equipment, residential structural modifications, duplicate equipment) are not covered.
Infertility services such as artificial insemination, IVF, ZIFT, GIFT, ICSI and related services are excluded.
Vision services and supplies (eyeglasses, contact lenses, routine vision exams) are excluded except where pediatric vision benefits apply.
Various other exclusions include experimental/investigational services, non-medically necessary care, custodial care, certain transplant-related items not listed as covered, routine physicals for employment/travel, and many other enumerated items in the 'What is Not Covered' section.

inv-34: Administrative provisions

Administrative and operational provisions affecting claims and coordination:

Force majeure events may delay or excuse performance obligations, with reasonable efforts expected to perform obligations when possible.

Force majeure provision.

Care received outside the U.S. is covered only for emergency care; non-emergency care outside the U.S. is not covered and Members must pay at point of service and submit documentation for reimbursement based on MAC.

International emergency care rules and reimbursement basis.

Coordination of Benefits rules determine primary/secondary payers and use standard rules (longer plan rule, birthday rule, custody rules, longer policy rule) as detailed in the Certificate.

COB rules summary.

Claims filing and payment: Members/providers must submit correct policy information; Members have 180 days from date of service to submit claims; Alliant will notify within specified timeframes if more info is needed and will complete processing within stated timelines; interest payable at 12% per year if timelines not met.

Claims timing and notice obligations.

Clean Claim requirement: Providers must submit clean claims in a nationally accepted format; Alliant will audit claims and may deny services not ordered by a physician, not documented, unbundled, upcoded, or otherwise noncompliant with coding/billing guidelines.

Medical bill review and audit authority.

inv-35: General coverage stance

General coverage stance:

Benefits are provided only to eligible Members as described in the Certificate and are subject to limitations, exclusions, copayments, deductibles, coinsurance and plan-specific Summary of Benefits and Coverage.

Coverage limited to eligible Members and subject to contract terms.

inv-36: Audit-based denial criteria

Audit-based denial criteria and documentation requirements:

Services may be denied if not ordered by a physician, not documented in the medical record, not requiring a physician order, routine/unbundled charges, improper coding, upcoding, or if considered Non-Covered Services under the Contract.

Grounds for audit-based denials and coding requirements.

Alliant will evaluate Clean Claims for accuracy using CPT/ICD/HCPCS and revenue coding and apply AMA/CMS/NCCI and other federal guidelines in adjudication; Alliant retains discretion to determine coverage following audits and medical bill review.

Coding standards and review process.

inv-37: Termination and post-exhaustion assistance criteria

Termination and post-exhaustion assistance actions:

When a Member exhausts benefits, Alliant notifies the Member and provides education about other available resources and lists resources on its website.

Transition actions following exhaustion of benefits.

If coverage terminates, Member must pay amounts owed for the period prior to termination, including premiums; except for fraud, Alliant will return within 30 days premiums for any unexpired paid period less amounts due to Alliant.

Financial obligations and refund timeline on termination.

Termination triggers

No longer meet eligibility (age or residence) or Dependent reaching age 26 (coverage ends at end of calendar year).
Request for disenrollment: membership ends at midnight on the 14th day following the request (or earlier if accommodated).
Fraud or misrepresentation: Alliant may rescind coverage with 30-calendar day advance written notice; Member has right to appeal and rescission may be retroactive to date of fraud or original enrollment as applicable.

Alliant complies with CMS and NCQA continuity and coordination standards and federal civil rights laws (language assistance and grievance channels available via Client Services and Compliance Officer contact information).

Administrative standards and contact channels.

inv-38: Termination, Premiums, Reinstatement & Appeals Criteria

Termination, premiums, reinstatement and appeals rules:

Membership terminates for ineligibility (age, residence), disenrollment requests (effective 14 days after request unless otherwise requested), change to another plan (ends day before new plan effective date), fraud/misrepresentation (rescission with 30-day notice), discontinuation or withdrawal of product with specified notice periods, and nonpayment of premiums per grace period rules.

Comprehensive termination triggers and notice periods.

Premium nonpayment: premiums due by first day of coverage month; late notices and specified grace periods apply (detailed in Certificate); reinstatement after termination for nonpayment only during Open Enrollment or via a qualifying SEP.

Premium nonpayment and reinstatement pathways.

Internal appeals: Level I must be filed within 180 days; optional Level II within 60 days of Level I denial; expedited appeals available with 72-hour decision timeframe; external review may be requested within 123 calendar days of appeal decision notice.

Appeals timelines and expedited process.

inv-39: Appeals and External Review Procedural Criteria

Appeals and external review procedural criteria and timelines:

Pre-service Level I appeals will be completed within 15 calendar days; optional Level II pre-service appeals within 15 calendar days. Post-service Level I appeals will be completed within 30 calendar days; optional Level II post-service appeals within 30 calendar days.

Internal appeal level timelines.

Expedited (urgent) pre-service appeals are decided within 72 hours when waiting could seriously harm life/health or ability to regain function; providers may request expedited external review simultaneously.

Expedited appeal criteria and 72-hour decision timeframe.

After completing internal appeals, Members may request an External review at no cost within 123 calendar days from the date of the appeal decision notice; external reviews for medical and pharmacy prior authorization include Maximus processes and filing channels.

External review filing deadline and contact methods.

inv-40: Coverage-related definitions

Definitions that affect coverage determination and provider billing:

Covered Services must be Medically Necessary, defined in the Contract, not excluded, not Experimental/Investigational, and provided in accordance with the Contract; when multiple options equal, the least costly non-inferior option is Covered; MAC and exclusions apply to determine coverage.

Definition and determination of Covered Services.

Providers must submit Clean Claims in a nationally accepted format that require no further information, adjustment, or alteration for adjudication; Alliant may request additional information and perform audits per claims processing rules.

Clean Claim requirement and provider responsibilities.

inv-41: Key coverage-informing definitions

Key definitions that inform coverage interpretation:

Dependent: spouse and all children until attaining age 26 (includes natural, adopted, stepchildren, certain foster children and court-ordered dependents); dependent coverage ends at end of calendar year when reaching age 26.

Dependent age limit and scope.

Essential Health Benefits: the plan includes the federally required categories (ambulatory, emergency, hospitalization, maternity/newborn, mental health/substance use, prescription drugs, rehabilitative/habilitative services and devices, laboratory services, preventive/wellness and chronic disease management, pediatric services including oral and vision where applicable).

Essential health benefits inclusion.

Hospital: defined as a state-licensed institution providing inpatient diagnostic and therapeutic services under licensed physicians with continuous 24-hour-a-day nursing services by registered graduate nurses physically present and on duty; excludes extended care, nursing homes, custodial institutions, and certain specialized institutions.

Hospital facility definition and 24-hour nursing requirement.

Billing, Coding, and Code-Level Rules

Cost sharing and deductible notesmixed

No codes listed

Claim coding and MAC determinationmixed

Claims may be reprocessed based on claim coding rules; bundled single procedure code may be used rather than multiple billed codes when procedure codes are inclusive.

Air ambulance payment calculationmixed

MAC for Out-of-Network emergent air ambulance services is calculated as the lesser of the provider's billed charges or the QPA (Alliant's median contracted rate for similar services in a geographic region).

Anesthesia and inpatient hospital billing guidancemixed

Anesthesia services must be medically necessary, ordered by the attending Physician, administered by a physician or CRNA, connected to a covered procedure; inpatient hospital services billed by the Hospital include room/board and facility supplies billed as inpatient services.

Billing guidancemixed

Outpatient prescription drug benefits are administered via PBM (Prime Therapeutics); drugs, supplies and administration billed per the PBM/network rules and plan formulary; contact Prime Member Services for program details.

Medical-pharmacy billing distinctionmixed

Provider-administered drugs (infusion, chemotherapy, blood products, injectable medications requiring provider administration) are covered under the medical pharmacy benefit and billed to the medical benefit rather than the retail pharmacy formulary; most require Prior Authorization.

Excluded services and items (non-covered)mixedNot Covered

Multiple specific services, supplies and items are excluded (e.g., disposable supplies, certain DME items such as TENS units, hearing aids, infertility services including IVF, cosmetic procedures, routine vision services, transplants not specifically listed as covered, non-prescription drugs, and other items listed in the 'What Is Not Covered' section).

Coding requirementsmixedCovered

CPT/ICD-10/HCPCS/Revenue

Charges must be billed using accurate and appropriate CPT, ICD, HCPCS and Revenue codes per AMA and CMS guidelines.

Appeal forms / referencesmixed

Medical prior authorization appeals: appeal form available at https://AlliantPlans.com/wp-content/uploads/Member-Appeal-Form.pdf; include name, member ID, denial date, and reason; submit to Alliant Appeals Department as instructed.

Appeals documentationmixed

Claim appeal form available at https://AlliantPlans.com/wp-content/uploads/Member-Appeal-Form.pdf; include name, member ID, denial notification date, and supporting evidence; mail to Alliant Health Plans Appeals Department PO Box 1247 Dalton, GA 30722 or fax (866) 634-8917.

Drug classificationmixed

Brand Name Drugs are defined as Single Source Brand (no generic equivalent) or Multi-Source Brand (has generic equivalent).

DME definitionmixed

Durable Medical Equipment: equipment determined by Alliant that is durable, primarily used to treat disease or injury, suitable for use outside inpatient settings, not normally useful to persons without disease/injury, and not for exercise or training.

Calendar year deductible application

Application periodDeductible is applied on a calendar year basis (Jan 1–Dec 31); member responsibility resets each calendar year.

Preventive services exceptionCertain preventive services are covered and reimbursable prior to meeting the Deductible.

Reference for amountsSpecific deductible amounts and how they apply are shown in the Summary of Benefits and Coverage.

Out-of-Network emergency QPA/MAC calculation

QPA/MAC rule (out-of-state emergencies)QPA is calculated using the lesser of billed charges or: the 2019 median contracted rate adjusted for inflation; or an APCD/Fair Health amount; or a derived amount per 45 CFR 153.710(c).

Georgia emergency MAC (in-state)For Out-of-Network emergency services in Georgia, MAC is the greater of: verifiable contracted amounts paid by eligible insurers; most recent verifiable amount agreed by Alliant with the provider when previously In-Network; or a higher amount Alliant deems appropriate given service complexity.

Member cost-sharing noteMember pays applicable coinsurance, copayment, or deductible as specified in the policy; Out-of-Network emergency providers may bill the Member for those amounts.

DME rental/payment threshold

Rental payment capPlan pays DME rental charges up to the lesser of the equipment's purchase price or twelve (12) months of rental charges.

Medical necessity and orderingEquipment must be medically necessary, ordered/prescribed by a Physician, appropriate for in‑home use, and related to the patient's physical disorder.

Ongoing proofAlliant may require proof of continuing medical necessity and a Provider statement of expected duration of use.

Preventive screening classification

Preventive screening coverageCertain cancer screening services (e.g., mammography, breast MRI, colorectal screening) are classified as preventive and provided at no cost when completed according to recommended guidelines.

Age-based mammographyAnnual imaging (digital mammography, tomosynthesis, breast x-ray, breast MRI) covered for women aged 40+, or age 35+ if recommended by a physician.

Colorectal screening guidanceColorectal cancer screening follows USPSTF grades A/B and American Cancer Society guidelines and is covered at no cost when completed per guidelines.

Hearing aid benefit limit

Benefit limitOne hearing aid per hearing‑impaired ear not to exceed $3,000 per hearing aid every 48 months (applies to plans purchased outside Georgia Access).

Included itemsIncludes parts, ear molds, repair and replacement parts, nonimplanted bone‑anchored/conduction devices; personal sound amplification products excluded.

Applicable cost-sharing and conditionsBenefits subject to conditions, limitations, exclusions and cost‑sharing as outlined in the Summary of Benefits and Coverage.

Copayment calculation for multi-month fills

Per‑month copay rule for multi‑month fillsWhen multiple‑month fills are provided (e.g., 90‑day supply), a copayment is required for each month: e.g., 3 copayments for a 90‑day retail fill (or 2.5 copayments for a 90‑day mail‑order fill).

Basis for copay calculationCopayment is expressed as a single fill or for a 31‑day supply, whichever is less; multi‑month fills prorate copayments accordingly.

Pharmacy claim submissionPresent Identification Card at in‑network pharmacy; out‑of‑network pharmacy claims require itemized bill submission.

New FDA drug market availability threshold

Market availability thresholdNewly approved FDA drugs must have been available in the U.S. market for at least 180 days to be covered under the outpatient prescription drug benefit.

Exclusions list referenceSee Outpatient Prescription Drug Benefits exclusions for other non‑covered drug categories and conditions.

Formulary change protectionsMembers with prior use may receive 30 days' written notice before a drug is moved to non‑formulary if they had a prescription within the prior 12 months.

Transplant coverage limits

Covered transplant scopeOnly transplants specifically listed as covered (medically appropriate human organ/tissue and certain bone marrow/hematopoietic stem cell transplants) are included; coverage limited to listed transplants and subject to Alliant criteria.

Prior Authorization requirementAll transplant procedures must be Prior Authorized and meet medical necessity and non‑experimental/ investigational criteria; call (800) 865‑5922 to Prior Authorize.

Related benefits and limitsCoverage includes donor costs, facility and professional transplant services as defined; travel reimbursements and antirejection drug benefits subject to specified limits and conditions.

Documentation requirement

Documentation requirementServices that are not ordered by a physician or not documented in the patient's medical record(s) may be excluded from benefits and are subject to denial on audit or medical bill review.

Coding and order complianceClaims must use accurate CPT/ICD‑10/HCPCS/Revenue codes per AMA and CMS guidelines; improper coding or unbundling may affect payment or trigger denial.

Alliant discretionAlliant retains discretion to determine coverage based on claim audit and medical bill review; lack of documentation can lead to repayment recovery or rescission in fraud cases.

External review filing deadline

External review filing deadlineYou must file a request for External review within 123 calendar days from the date of the appeal decision notice.

How to request (medical/pharmacy)For medical and pharmacy prior authorization external appeals, request with Maximus by phone, online, fax, or mail as provided in the External Appeals instructions.

Expedited external review criteriaAn expedited External review may be requested when the expedited internal appeal timeframe (72 hours) would place life, health, or ability to regain maximum function in danger, or other specified urgent conditions.

Contract Year period

Contract Year periodContract Year (Benefit Period) is a calendar year commencing Jan 1 at 12:01 am and ending Dec 31 at 11:59 pm Eastern Time.

Deductible application timeframeDeductible and other annual limits apply on a calendar year basis; see Summary of Benefits and Coverage for year‑specific amounts.

Benefit period noteBenefit Period does not begin before a Member's Effective Date and does not continue after coverage ends.

Provider Requirements, Prior Authorization, and Appeals

Prior Authorization

Call Alliant Medical Management for inpatient prior authorization

Providers must call Alliant Medical Management at (800) 865-5922 for Prior Authorization for all in‑network inpatient hospital admissions (maternity admissions excepted). Non-urgent prior authorization requests should be made during normal business hours; emergency medical services do not require Prior Authorization. Prior Authorization is not a guarantee of coverage and approvals apply only to the services listed in the authorization request.

Prior Authorization phone: (800) 865-5922
Notify Alliant by the next business day for emergency or maternity admissions
Approvals apply only to services outlined in the Prior Authorization request

Documentation Required

Verify provider network status before care

Confirm provider network status before scheduling services. Refer members to AlliantPlans.com or Client Services at (866) 403-2785 to locate In‑Network providers and verify network participation.

Use AlliantPlans.com Find-A-Provider tool to confirm In‑Network status
Client Services phone: (866) 403-2785

Documentation Required

Contact Client Services for out-of-area in-network locators

When a member needs care outside Alliant's service area, contact Alliant Client Services at (866) 403-2785 to attempt to locate an In‑Network provider in the area.

Client Services phone: (866) 403-2785

Prior Authorization

Follow Alliant authorization procedures and timeframes

Some benefits require authorization. To authorize a benefit or service, providers must call the Medical Management Department at (800) 865-5922; authorizations are based on Medical Necessity and follow defined timeframes for urgent, pre‑service, concurrent, and post‑service reviews.

Urgent Care decisions: as soon as possible but no more than 72 hours
Pre‑service decisions: within 7 calendar days (may extend another 7 days)
Concurrent: within 24 hours for urgent requests, otherwise within 7 days
Post‑service review: decision within 30 calendar days

Prior Authorization

Urgent Care definition and expedited prior authorization handling

Urgent Care Services are those where applying non‑urgent timeframes could seriously jeopardize life/health, ability to regain function, or cause severe unmanaged pain per the attending provider; such requests are eligible for expedited handling and decisions within 72 hours. A current list of benefits requiring Prior Authorization is available at AlliantPlans.com or via Client Services.

Urgent Care definition: serious jeopardy to life/health, function, or severe unmanaged pain
Prior Authorization list: AlliantPlans.com or Client Services (866) 403-2785
Expedited decision timeframe for urgent requests: 72 hours

Prior Authorization

Air/water ambulance require medical necessity review

Air and water ambulance transports are subject to Alliant's Medical Necessity review; Alliant reserves the right to select the air ambulance provider. Hospital‑to‑hospital air ambulance is covered only when medically necessary.

Air/water ambulance require Medical Necessity review by Alliant
Alliant retains the right to select the air ambulance provider
Non‑emergency hospital‑to‑hospital air transport must be Medically Necessary

Prior Authorization

Obtain Prior Authorization for clinical trial routine care

Members participating in approved clinical trials must receive Prior Authorization from Alliant for coverage of routine patient care costs; providers should secure prior authorization before enrolling or providing routine trial‑related care.

Routine patient care costs for qualifying clinical trials covered with Prior Authorization
Eligibility requires Member status, qualifying diagnosis, referral by an In‑Network provider, acceptance into an approved trial, and Alliant Prior Authorization

Documentation Required

Ensure physician orders and certifications for specific services

Certain services require an order and physician certification. Home health care requires an attending Physician’s certification and a written plan of care; services must be ordered by the attending Physician and meet the stated clinical criteria.

Home Health Care: physician certification statement and plan of care required; member must be essentially confined at home
Anesthesia and other services must be ordered by the attending Physician

Documentation Required

Member responsibility to verify in‑network/preferred provider status

Members are responsible for verifying In‑Network status of providers; Alliant reserves the right to designate Preferred/In‑Network providers for certain services—providers and members should confirm status via AlliantPlans.com or Client Services.

Members should verify provider status using the Find‑A‑Provider tool or call Client Services at (866) 403-2785
Alliant may establish Preferred/In‑Network Providers for certain services

Prior Authorization

Prior Authorize all transplant procedures

All transplant procedures require Prior Authorization and must be Medically Necessary and not Experimental or Investigational per Alliant criteria; to prior authorize a transplant call (800) 865-5922 and provide a complete medical history and surgeon name.

Prior Authorization phone for transplants: (800) 865-5922
Physician must submit complete medical history, current diagnosis, and surgeon name
Surgery must be performed at an Alliant‑approved Transplant Center

Prior Authorization

Prior Authorization required for select prescription and specialty drugs

A limited number of prescription drugs and most Specialty Drugs require Prior Authorization for Medical Necessity; contact Prime Member Services at (844) 451-8288 for the list of select medications and authorization processes.

Prime Member Services: (844) 451-8288 for prior authorization lists and processes
Most Specialty Drugs typically require Prior Authorization

Prior Authorization

Obtain prior approval for off‑label and many medical pharmacy drugs

Off‑label drug use and many medications under the medical pharmacy benefit require prior approval from Alliant Health Plans; All off‑label drugs must be pre‑approved.

All off‑label drugs must be pre‑approved by Alliant Health Plans
Provider‑administered medical pharmacy medications (infusion, chemotherapy, injectables) commonly require Prior Authorization

Billing Rule

Use correct member identifiers and follow claim submission timelines

Submit claims using the member's correct name, Group and Member numbers. Members have 180 days from the date of service to submit a claim; Alliant will notify providers within 15 working days (electronic) or 30 calendar days (paper) if additional information is needed and will complete processing within the subsequent 15 working days or 30 calendar days respectively.

Providers must ensure accurate Member name, Group and Member numbers on claims
Member claim submission deadline: 180 days from date of service
Notification timeframe for missing info: 15 working days (electronic) / 30 calendar days (paper)

Billing Rule

Submit claims to Alliant with correct policy information

Providers must submit claims to Alliant using the member's correct policy information; providers may receive payment directly when they submit properly completed claims. Members have 180 days to submit their own claims if self‑filing.

Submit claims to Alliant with accurate policy/Member information
Members have 180 days from date of service to submit claims for reimbursement

Denial Risk

Be prepared for medical bill review and audits — proper documentation required

Alliant may request medical records, require Clean Claims and prior authorizations, and audit claims; claims may be denied if services are not properly documented, ordered by a physician, or correctly coded.

All providers must submit Clean Claims as defined by Georgia Department of Community Health
Claims lacking physician orders, adequate documentation, or correct CPT/ICD/HCPCS coding may be denied
Alliant reserves the right to audit claims and perform medical bill review

Documentation Required

Follow procedures for member notifications at benefit exhaustion and termination

When a member exhausts benefits, Alliant will notify the member and provide education about other available resources; follow Alliant procedures for termination and premium reconciliation, and be aware rescission may occur for fraud with required notice and appeal rights.

Alliant notifies Members who have exhausted benefits and lists other resources on its website
If coverage terminates, member must pay amounts owed for the period prior to termination
Rescission for fraud requires 30‑calendar day advance written notice and is appealable

Prior Authorization

Use designated contacts and addresses for prior authorization appeals

For Medical and Pharmacy prior authorization appeals, follow the specified instructions and contact details: submit required information and use the listed mailing/fax addresses and phone numbers for appeals processing.

Medical prior authorization appeals: Alliant Health Plans Appeals Department, PO Box 1247 Dalton, GA 30722; Phone: (800) 865-5922; Fax: (866) 634-8917
Pharmacy/Prime appeals: Prime Therapeutics, Phone: (844) 451-8288; Medical Pharmacy appeals: Prime Therapeutics Management, Phone: (800) 424-1799 Option 3

Denial Risk

Request expedited (urgent) pre‑service appeals when clinically necessary

Providers, members, or authorized representatives may request expedited (urgent) pre‑service appeals when waiting could seriously harm the individual's health or function; Alliant will notify of the decision no later than 72 hours after receipt.

Expedited appeal decision timeframe: 72 hours
Expedited requests may be made by phone or in writing using the same contacts as standard appeals

Documentation Required

Follow required content and submission channels for medical pharmacy PA appeals

Medical Pharmacy prior authorization appeals must include the member's name, member ID, date of the denial letter, and the reason for review; mail or fax appeals to the Prime Therapeutics Medical Pharmacy Appeals Department at the addresses and numbers provided.

Include: member name, member ID number, denial letter date, and reason for review
Mail appeals to: Prime Therapeutics Management, Attn: MP‑3002, P.O. Box 64811, St. Paul, MN 55164‑0811; Fax: (888) 656‑6671; Phone: (800) 424‑1799 Option 3

Documentation Required

Submit claim appeals with required information and use Alliant appeal form

Claim appeals must be submitted in writing and include the member name, member ID number, date of denial notice, and the reason for review; providers and members can use the appeal form available on AlliantPlans.com and mail or fax to the Appeals Department contact provided.

Appeal form available at AlliantPlans.com (Member Appeal Form)
Mail to: Alliant Health Plans Appeals Department, PO Box 1247, Dalton, GA 30722; Fax: (866) 634‑8917

Documentation Required

Submit Clean Claims in accepted national format

Providers must submit Clean Claims—claims received in a nationally accepted format that require no further information, adjustment, or alteration—to ensure timely adjudication and avoid denials or delays.

Clean Claim definition per Georgia Department of Community Health: nationally accepted format requiring no further information
Failure to submit Clean Claims may delay processing or lead to denials

Note

Direct access to primary and specialty physicians (no Alliant referral required)

Members have direct access to primary and specialty care physicians without needing an Alliant‑approved referral; providers can see members without obtaining a referral from Alliant.

No Alliant referral required for primary or specialty physician access
Members may self‑refer to specialists in‑network

Defined Terms

Member / Subscriber

Subscriber / MemberSubscriber (Member) is the person who applied for coverage; references to 'You/Your' apply to the Subscriber and any covered Dependents.

Alliant namingAlliant Health Plans is referred to as 'We/Us/Our' in the Contract.

Plan identifierThis Certificate governs benefits for the 2026 SoloCare HMO Individual and Family Plans (Georgia).

Coverage / Dependents

Coverage for Subscriber and DependentsCoverage describes benefits available to the Subscriber and eligible Dependents; Dependents may be enrolled during Open Enrollment or qualifying Special Enrollment Periods.

Dependent eligibility examplesEligible Dependents include spouse (if not legally separated), dependent children through end of the year they attain age 26, adopted children from date of legal responsibility, stepchildren and certain foster children subject to conditions.

Enrollment process referenceEnrollment and Special Enrollment Periods details are provided in the Enrollment and Special Enrollment sections and Summary of Benefits and Coverage.

Member / Subscriber

DefinitionSubscriber or Member is the person covered under the health care plan; child‑only policies are allowed under this plan type.

ScopeReferences to 'You/Your' apply to the Subscriber and any covered Dependents unless otherwise specified.

Contract relationshipThe Certificate is the Contract between the Subscriber and Alliant and replaces prior Certificates.

Dependent / Covered Dependent

Dependent definitionDependent means eligible family members including spouse and all children until attaining age 26 (end of calendar year), as well as adopted, stepchildren, certain foster children and children under court decree, subject to eligibility rules.

Incapacity exceptionMentally or physically disabled Dependents who are totally dependent may remain covered beyond age 26 if certified and previously covered.

Enrollment timingDependents must be enrolled during Open Enrollment or within Special Enrollment Periods; newborns and adopted/foster children have initial 31‑day coverage windows for continuation.

HMO

HMO definitionHealth Maintenance Organization (HMO) requires Members to choose In‑Network physicians, hospitals or other providers to use benefits.

Network verificationMembers should verify provider network status before visits via AlliantPlans.com or Client Services (866‑403‑2785).

Effect on costUsing In‑Network Providers generally results in lower out‑of‑pocket costs due to contracted rates accepted as payment in full.

In-Network Provider

In‑Network ProviderAn In‑Network Provider is a provider who is part of Alliant's network or has a contract with Alliant; In‑Network rates apply and providers should not balance bill Members beyond allowed amounts.

Member actionMembers can locate In‑Network Providers at AlliantPlans.com or by calling Client Services (866‑403‑2785).

Cost implicationChoosing In‑Network care typically reduces copays, coinsurance and other out‑of‑pocket costs compared with Out‑of‑Network care.

MAC

MAC definitionMaximum Allowed Cost (MAC) is the plan's determined reimbursement amount for Covered Services; member pays applicable cost‑share until deductible/copayment/coinsurance met.

Determination factorsMAC may be adjusted based on claim processing rules, coding accuracy, bundled procedure rules, and applicable statutes (e.g., surprise billing laws).

Effect on provider paymentMAC determines plan payment; In‑Network providers accept MAC as payment in full; Out‑of‑Network provider billing may exceed MAC subject to member responsibility rules.

Cost share / Out-of-Pocket Maximum

Cost share componentsCost share includes copayments, deductible and coinsurance amounts that a Member may owe for In‑Network care; specific amounts are in the Summary of Benefits and Coverage.

Out‑of‑pocket maximumOnce the Member reaches the Out‑of‑Pocket Maximum (including Deductible), the plan covers 100% of allowed costs for the rest of the year.

Application timingDeductible and Out‑of‑Pocket Maximum are applied on a calendar year basis (Contract Year).

In-Network / Out-of-Network

Network status impactIn‑Network providers accept the allowed amount as payment in full and are prohibited from balance billing Members; Out‑of‑Network providers may bill Members for amounts above the allowed amount.

Surprise billing protectionsMembers cannot be balance‑billed for Out‑of‑Network emergency services per state and federal surprise billing laws; special MAC/QPA calculations apply.

Member verificationMembers are responsible for verifying In‑Network status prior to care to avoid unexpected billing.

approved clinical trial

Approved clinical trial definitionAn approved clinical trial is a Phase I–IV trial that is approved or funded by NIH, CDC, AHRQ, CMS, DoD, VA, DOE, conducted under an FDA IND, or otherwise meets specified criteria; participation requires Member acceptance, referral by an In‑Network Provider and Prior Authorization.

Coverage scopeRoutine patient care costs for qualifying Members in approved clinical trials are covered; cost of the investigational treatment itself is excluded.

RequirementsMember must be diagnosed with qualifying condition, be a Member, be accepted into an approved trial, be referred by an In‑Network Provider, and receive Prior Authorization.

medical emergency

Medical emergency definitionA medical emergency is an acute condition with symptoms so severe that a prudent layperson could expect lack of immediate attention to result in serious jeopardy, serious impairment of bodily functions, or serious dysfunction of an organ.

Implication for careEmergency Medical Services covered in ERs and freestanding emergency rooms; copay waived if admitted; Members cannot be balance‑billed for Out‑of‑Network emergency services.

Relation to urgent careUrgent Care differs from emergency care and is defined by conditions that jeopardize health or function or cause severe unmanaged pain but are not life‑threatening.

Hearing Aid

Hearing Aid definitionHearing Aid is any non‑experimental wearable instrument or device to aid hearing (worn in or on the body), including parts, ear molds, repair and replacement parts; personal sound amplification products excluded.

Examples includedIncludes non‑implanted bone‑anchored/conduction hearing aids and frequency modulation systems.

Benefit limitationsBenefit limits (e.g., $3,000 per aid every 48 months) and applicability depend on plan purchase channel and Summary of Benefits and Coverage.

Habilitative services

Habilitative services definitionHabilitative services are health care services that help individuals learn, keep, or improve skills needed for daily living (e.g., physical, occupational, speech therapy and certain DME).

Coverage noteServices must be medically necessary and are subject to calendar‑year visit limits as detailed in the Summary of Benefits and Coverage.

Provider requirementServices must be ordered and supervised by an appropriate Provider (Physician) when required.

Urgent Care

Urgent Care definitionUrgent Care is medical care for conditions that could jeopardize life/health or ability to regain maximum function, or cause severe unmanaged pain; not life‑threatening and not ER care.

Access after hoursMembers needing Urgent or Emergency care after normal business hours can contact Client Services (866‑403‑2785) or visit AlliantPlans.com to locate In‑Network facilities.

Appeals relevanceUrgent Care determinations may qualify for expedited internal appeals with a 72‑hour decision timeframe.

In-Network / Preferred Provider

Preferred/In‑Network ProvidersPreferred or In‑Network Providers are providers designated by Alliant; Members should verify provider status via Find‑A‑Provider or Client Services (866‑403‑2785).

Member responsibilityMembers are responsible for confirming In‑Network status prior to receiving services to understand cost sharing and network applicability.

Alliant discretionAlliant may establish Preferred or In‑Network Providers for certain services to manage quality and cost.

Preventive care

Preventive care definitionPreventive care includes outpatient and office visits designed to prevent illness or detect health issues early in asymptomatic Members; covered at no cost when in‑network and meeting federal/state requirements.

When not preventiveIf a Member has symptoms or a diagnosed condition, related services are considered diagnostic and not covered under preventive‑only rules.

Reference for guidelinesFor details and covered preventive services, see Alliant's preventive guidelines on the provider website.

Telemedicine

Telemedicine definitionTelemedicine is the provision of clinical services by a duly licensed Provider via secure real‑time audio, video or data communications, with the patient present and participating.

Payment basisPayment for telemedicine services is based on the negotiated rate or current MAC for the service provided.

Use casesTelemedicine may replace in‑person consultations when real‑time communication is possible and clinically appropriate.

Donor Costs

Donor costs definitionDonor Costs are all direct and indirect costs incurred in connection with removing, preserving and transporting an organ or tissue from a donor or self‑donor.

Coverage relationDonor Costs are defined separately from Facility Transplant and Professional Provider transplant services; coverage subject to Contract terms.

Exclusions noteCertain transplant‑related items (e.g., donor travel) may have specific limits or exclusions; see the Transplant section for details.

Facility Transplant

Facility TransplantFacility Transplant means all Medically Necessary facility services and supplies in connection with a covered transplant except donor costs and antirejection drugs.

ScopeIncludes inpatient facility charges, operating room, nursing and related facility services required for the transplant.

Prior AuthorizationTransplant services require Prior Authorization and must be performed at Alliant‑approved Transplant Centers per policy.

Medically appropriate

Medically appropriate'Medically appropriate' for transplant means the recipient or self‑donor meets Alliant's established criteria for the transplant.

Selection criteriaTransplant candidates and procedures are reviewed against Alliant's selection and medical necessity criteria during Prior Authorization.

Effect on coverageOnly medically appropriate transplants that meet criteria and are authorized will be covered under the Contract.

Zero-Cost Share

Zero‑Cost Share (AC)Zero‑Cost Share (also indicated as Healthcare Reform (AC)) tier contains preventive drugs covered under ACA and carries no cost‑sharing.

Formulary placementZero‑Cost Share tier may include generic, single‑source or multi‑source brand drugs that meet preventive guidelines.

Member accessMembers may obtain the Drug Formulary via AlliantPlans.com or by contacting Client Services (866‑403‑2785).

Off-label drug

Off‑label drug ruleOff‑label drugs prescribed for life‑threatening or chronic disabling conditions require pre‑approval by Alliant Health Plans to be covered.

Associated servicesMedically necessary services associated with off‑label drug administration may be covered when pre‑approved.

Request processContact Alliant for prior approval/authorization as required by the medical pharmacy policies.

Therapeutic/Clinically Equivalent

Therapeutic/Clinically Equivalent definitionTherapeutic/Clinically Equivalent drugs are drugs expected to produce similar therapeutic outcomes and are used to support formulary reclassification decisions.

Formulary impactAvailability of Therapeutic/Clinically Equivalent alternatives can trigger reclassification to non‑formulary status or substitution requirements.

Member protectionsMembers with prior use or intolerance may request Non‑Formulary Drug Exceptions and appeal denials per appeal processes.

Acts Beyond Reasonable Control (Force Majeure)

Force majeureActs Beyond Reasonable Control (force majeure) extend performance times and excuse non‑performance for the period of delay; parties must use reasonable efforts to perform obligations.

ExamplesIncludes acts of God, strikes, restrictive government laws or regulations, and other causes beyond a party's control.

Effect on timelinesTime for performance is extended by a period equivalent to the delay caused by the force majeure event.

Balance Billing

Balance billing ruleIn‑Network Providers are prohibited from balance billing Members; Members are not liable for fees in excess of the allowed amount except contractual cost‑share (copay, deductible, coinsurance).

Out‑of‑Network providersOut‑of‑Network providers may bill Members directly for amounts above plan payment; Non‑Covered Services remain Member's responsibility.

Surprise billing contextState and federal surprise billing protections apply for emergency services and define MAC/QPA calculation methods.

Care Received Outside the U.S.

Coverage outside U.S.Only emergency care received outside the United States is covered; non‑emergency care received outside the U.S. is not covered.

Payment processMembers should pay providers at point of service, obtain documentation and submit claims for reimbursement; payment will be based on MAC and benefits are subject to Contract provisions.

Assignment limitationMembers may not assign benefits to foreign providers or facilities.

Coordination with Medicare

Coordination with MedicareUnless federal law requires otherwise, this plan does not duplicate Medicare benefits; where Medicare is responsible, amounts paid by Alliant that should have been paid by Medicare shall be reimbursed to Alliant.

Overpayment recoveryAlliant may recover amounts that should have been paid by Medicare from Members or other payors as appropriate.

Primary/secondary determinationCoordination of Benefits rules determine order of payment when Members have multiple coverages.

Financial Incentives

Financial incentives statementMedical management decisions are based on medical necessity, benefits and Member needs; staff are not rewarded or incented to deny or limit care.

Decision basisDecisions consider clinical appropriateness and local healthcare system factors, not financial incentives to deny care.

Transparency implicationThis statement supports impartiality in utilization management and appeals processes.

Subrogation

SubrogationAlliant has subrogation rights to recover amounts from third parties responsible for a Member's injury or loss for amounts Alliant paid on the Member's behalf.

Right of recoveryIf Alliant pays benefits and the Member recovers money from another source, Alliant is subrogated to the Member's recovery rights for the amount paid.

Priority of repaymentAlliant has the right to be repaid first from any recovery the Member receives, even if the Member is not made whole.

Right of reimbursement

Right of reimbursementAlliant may be repaid from any money the Member recovers for an injury or condition for which Alliant paid benefits; Alliant has first priority for reimbursement.

ScopeRepayment requirement applies regardless of whether recovery includes amounts for pain and suffering or partial claim resolution.

Member obligationMember promises to repay Alliant from any settlement, judgment or recovery received from any source.

Exhaustion of benefits

Exhaustion transition actionsWhen a Member exhausts benefits, Alliant notifies the Member and provides education about other available resources and posts resources on its website.

Notification and assistanceAlliant complies with CMS/NCQA continuity standards and offers assistance to Members transitioning after benefit exhaustion.

Coverage limitsTransition steps do not extend coverage beyond Contract terms; other resources may or may not be covered.

Rescission

Rescission conditionsAlliant may rescind coverage for fraud or intentional misrepresentation after providing 30‑calendar days advance written notice; Member has the right to appeal the rescission.

Effective date of rescissionThe rescission date may be the date of the fraud/ intentional misrepresentation or the original enrollment date, whichever is later.

ExceptionsRescission does not apply for nonpayment of premiums (terminate effective per grace periods) and is subject to appeals processes.

Adverse Benefit Determination

Adverse Benefit DeterminationAn Adverse Benefit Determination is a denial, reduction, termination or rescission of a benefit (including determinations based on medical judgment, experimental status, or lack of medical necessity).

ScopeIncludes denials of payment, coverage level decisions, and rescissions with retroactive effect (except nonpayment based terminations).

Appeals implicationAdverse Benefit Determinations may be appealed through internal and external review processes described in the Appeals section.

Authorized Representative

Authorized RepresentativeAn Authorized Representative is an individual authorized in writing by the Member or by state law to act on the Member's behalf for services, claims, or appeals; Providers may act without express consent for Urgent Care Services.

Appeals roleAn Authorized Representative may file appeals, provide information, and receive plan communications on the Member's behalf.

DocumentationWritten authorization or evidence of state law authority is required to act as an Authorized Representative in non‑urgent contexts.

Final Adverse Benefit Determination / Claim types

Final Adverse Benefit DeterminationA Final Adverse Benefit Determination is an Adverse Benefit Determination upheld after internal appeal or deemed final if internal appeal timeframe elapses without determination.

Post‑Service ClaimA Post‑Service Claim is an Adverse Benefit Determination rendered for services already provided.

Pre‑Service and Urgent ClaimsA Pre‑Service Claim is for services not yet provided; an Urgent Care Services Claim is a pre‑service claim where applying non‑urgent timeframes could seriously jeopardize life/health or cause severe unmanaged pain.

Post-Service Claim and audit risk

Post‑service claim definitionA Post‑Service Claim is an Adverse Benefit Determination for a service already provided (used in appeals and external review contexts).

Audit denial causesClaims may be denied on audit if services are not ordered by a physician, not documented in the medical record, not medically necessary, miscoded, unbundled, or otherwise Non‑Covered per Contract.

Provider obligationProviders must submit clean claims in a nationally accepted format and retain supporting documentation to avoid denials or repayment requests.

Pre-Service Claim

Pre‑Service Claim definitionA Pre‑Service Claim is an Adverse Benefit Determination rendered for a service that has not yet been provided; often tied to prior authorization decisions.

Appeal timeframesPre‑service appeals have expedited timelines (e.g., 15 calendar days for Level I pre‑service) and may qualify for expedited review when urgent.

Authorization implicationPrior Authorization approvals apply only to services specified in the authorization request and do not guarantee payment if Member is not covered or benefits exhausted.

Urgent Care Services Claim

Urgent Care Services ClaimAn Urgent Care Services Claim is a pre‑service Adverse Benefit Determination where applying non‑urgent appeal timeframes could seriously jeopardize life/health, an unborn child, or cause severe unmanaged pain; expedited internal appeals decision timeframe is 72 hours.

Authorized provider actionA health care provider may act as an Authorized Representative without Member express consent for Urgent Care Services claims to request expedited review.

External review optionMembers may request an expedited External review concurrently with an expedited internal appeal when criteria are met.

Clean Claim

Clean Claim requirementA Clean Claim is a claim submitted in a nationally accepted format that requires no further information, adjustment, or alteration for adjudication by Alliant.

Provider responsibilityProviders must submit clean claims consistent with coding guidelines to avoid processing delays or requests for additional information.

Notification timelinesAlliant will notify providers within specified timeframes if additional information is needed (15 working days electronic / 30 calendar days paper) and complete processing thereafter.

Contract Year

Contract Year definitionContract Year (Benefit Period) is January 1 at 12:01 am through December 31 at 11:59 pm Eastern Time.

Benefit period scopeBenefit Period does not begin before a Member's Effective Date and does not continue after coverage ends; deductible and OOP limits apply per Contract Year.

Reference locationContract Year definition appears in the Definitions section of the Certificate and aligns with the Calendar Year deductible application.

Policy Summary

PayerAlliant Health

PolicyCertificate of Coverage — SoloCare HMO (Individual & Family Plans)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionProviders must call Alliant Medical Management at (800) 865-5922 to obtain Prior Authorization for in‑network inpatient admissions and other services that require authorization.

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Certificate of Coverage — 2026 SoloCare HMO (Individual & Family Plans) — Georgia

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Coverage, Benefits, and Exclusions

inv-01: Coverage criteria and prior authorization rules

Covered when the following verification and prior authorization rules are met:

Verification of benefits by Member or authorized provider does not guarantee payment or coverage for a specific procedure; verification is not a guarantee of payment.

See verification guidance.

Emergency Medical Services do not require Prior Authorization and Out-of-Network benefits are limited to emergency services only.

Emergency services are covered without prior authorization.

Prior Authorization is required for all in-network inpatient hospital admissions except maternity; for emergency or maternity admissions the provider should notify next business day.

Providers must call Alliant Medical Management at (800) 865-5922 for prior authorization.

Authorizations are limited in scope and subject to contractual coverage rules.

inv-02: Enrollment and Special Enrollment

Enrollment timing and qualifying events:

If You or Your Dependents do not enroll when first eligible, enrollment must wait until the next Open Enrollment Period unless a Special Enrollment Period (SEP) applies.

Late enrollees referenced.

Open Enrollment Period is defined by the federal government and applies whether purchasing through Georgia Access or directly from Alliant Health Plans.

Open Enrollment source.

SEP categories listed.

inv-03: Dependent special cases

Temporary dependent coverage and required timelines:

Newborn provision and waiver option described.

Adopted child enrollment timing.

Foster child proof and timing requirements.

inv-04: Dependent enrollment changes

Rules for adding or removing dependents:

Timeframe to add spouse/stepchildren.

Dependent removal triggers

Divorce triggers removal of a spouse dependent and requires notification to Georgia Access or Client Services.
Death of an enrolled family member triggers removal and may require different coverage arrangements.
Dependent child reaching age 26 results in termination of dependent coverage at end of calendar year in which they turn 26.
Enrolled dependent child becoming totally or permanently disabled may affect coverage continuation per contract rules.

inv-05: Benefit mechanics and financial responsibility

Network, cost-sharing, and benefit application rules:

All Covered Services must be Medically Necessary to be paid under the Contract; Members have direct access to primary and specialty care without PCP referral.

Medical necessity and direct access.

As an HMO, the plan requires use of In-Network providers to use benefits; Members should confirm provider network status prior to visits via AlliantPlans.com or Client Services.

In-Network requirement and verification.

Members outside the service area should contact Client Services to locate an In-Network provider; Alliant may assist with out-of-service area provider location.

Out-of-area assistance.

Cost-sharing mechanics and MAC reference.

Deductible is applied on a calendar year basis; certain preventive services are covered prior to meeting the deductible per preventive guidelines and Summary of Benefits and Coverage.

Deductible application and preventive exceptions.

inv-06: Allergy conditions

Allergy testing and treatment coverage stance:

Standard medically necessary testing and treatment for allergy conditions are covered.

Standard allergy testing and treatment covered.

Non-standard allergy tests are considered Non-Covered Services and are excluded (see 'What is Not Covered').

Non-standard tests excluded; reference exclusions section.

inv-07: Ambulance services

Ambulance coverage requires medical necessity and provider/licensure criteria:

Emergency ambulance staffing and vehicle requirements.

Permitted transport contexts.

Non-emergency ground ambulance requires review.

Air/water ambulance medical necessity and selection rights.

inv-08: Authorized services and member liability

Authorized out-of-network services and member financial responsibility when authorized:

Advance authorization required to apply in-network cost share to out-of-network care.

Member may still be billed for difference between provider charge and MAC.

Alliant will not reimburse Non-Covered Services; Member is responsible for total billed amount for Non-Covered Services or when benefits are exhausted.

Non-Covered Services remain Member liability.

inv-09: Air ambulance coverage rules

Air/water ambulance coverage criteria and billing rules:

Hospital-to-hospital air ambulance criteria.

Exceptional circumstances required for fixed/rotary wing necessity.

Billing and MAC/QPA calculation for emergent air ambulance.

inv-10: Anesthesia coverage

Anesthesia coverage requirements:

Dental patient anesthesia coverage criteria.

Provider and ordering requirements for anesthesia services.

inv-11: Breast cancer services

Breast cancer treatment and reconstructive care coverage:

Inpatient post-mastectomy care and prosthesis limits.

Reconstructive care and preventive screening no-cost provision.

inv-12: Cancer screening

Cancer screening coverage rules:

Breast screening frequency and age thresholds.

Colorectal screening preventive coverage and no-cost condition.

inv-13: Clinical trials

Clinical trial coverage and qualification requirements:

Clinical trial routine cost coverage and medication exclusion.

Qualification and prior authorization requirement for clinical trials.

inv-14: Diabetes management

Diabetes management coverage:

Diabetes services must be prescribed and education provided by qualified personnel.

inv-15: Dialysis treatment

Dialysis coverage:

Dialysis treatment is a Covered Service when Medically Necessary.

Dialysis explicitly listed as covered.

inv-16: DME coverage and limits

DME coverage and payment limits:

DME medical necessity and ordering requirements.

Plan pays rental charges up to the lesser of the purchase price or twelve (12) months of rental charges.

DME rental payment cap.

inv-17: Emergency room services

Emergency room and emergency medical services coverage rules:

Prudent layperson definition of emergency.

ER cost-sharing and surprise billing protections.

inv-18: Eye care coverage

Eye care coverage scope:

Covered eye care is limited to medical conditions (not routine vision care) except for children under age 19; Members may obtain services directly from participating ophthalmologists or optometrists.

Pediatric exception and provider access.

inv-19: Fertility preservation coverage

Fertility preservation coverage rules:

Coverage subject to limits such as age restrictions, lifetime caps, and exclusion of experimental treatments or long-term storage.

inv-20: Additional covered services

Additional covered assistive and habilitative services:

Autism-related habilitative benefit.

Assistant surgeon services are covered when Medically Necessary and rendered in conjunction with a surgery coordinated by the Member's surgeon.

Assistant surgeon coverage condition.

inv-21: Fertility preservation coverage

Fertility preservation (duplicate):

Duplicate fertility preservation block; mirrors earlier criteria.

inv-22: Anesthesia coverage

General anesthesia coverage (duplicate):

General anesthesia scope and provider requirements.

inv-23: Habilitative and speech therapy coverage

Habilitative and speech therapy coverage rules:

Visit limits referenced in Summary of Benefits.

inv-24: Hearing aids coverage

Hearing aid coverage criteria and limits:

Hearing Aids are covered as nonexperimental wearable devices (parts and replacement parts included); personal sound amplification products excluded.

Definition and exclusions for hearing aids.

Monetary limit and frequency for hearing aids (applies to outside Georgia Access plans).

inv-25: Home health coverage

Home health care coverage and conditions:

Certification, plan of care, confinement and visit limits.

Included and excluded home health services.

inv-26: Hospice coverage

Hospice coverage criteria:

Certification, program recognition, and plan of care requirements.

Hospice benefits include inpatient and outpatient hospice services and family support services as specified in the Summary of Benefits and Coverage.

Scope of hospice benefits.

inv-27: Hospital services coverage

Hospital services (inpatient and outpatient) coverage criteria:

Inpatient coverage scope and admission requirement.

Outpatient scope and preferred provider program.

inv-28: Maternity coverage

Maternity care coverage and federal protections:

Federal minimum stay protections and follow-up visits.

For In-Network physician prenatal, delivery and postpartum care, only one copayment (if applicable) will be charged for these services combined as specified.

Single copayment for maternity physician care.

inv-29: Medical, surgical, mental health and other outpatient coverage

Medical, surgical, mental health and other outpatient coverage rules:

Medical and surgical care includes general treatment of illness or injury and usual pre- and post-operative care as outlined in the Summary of Benefits and Coverage.

Medical and surgical coverage summary.

Mental health provider scope and settings.

inv-30: Extracted coverage criteria (partial)

Partial extracted coverage criteria and notable limits:

Medical and surgical care, outpatient services and outpatient surgery are Covered Services when Medically Necessary and as detailed in the Summary of Benefits and Coverage.

General extracted coverage position.

Preventive service inclusion and timing of new guidelines.

Therapy visit limits and provider requirements.

SNF review criteria and limits.

Second medical opinions by an In-Network Provider for proposed surgical interventions or any Covered Service are covered.

Second opinion entitlement.

inv-31: Service coverage criteria

Service coverage criteria, limits and member obligations across multiple areas:

Second medical opinion by an In-Network Provider for proposed surgical interventions or any Covered Service is included as a Covered Service.

Second opinion coverage.

Transplant scope and prior authorization requirement.

Transplant travel reimbursement limit and rules.

Prescription drug program overview and PBM contact.

Formulary governance and member protections.

inv-32: Outpatient Prescription and Pediatric Vision Coverage Criteria

Outpatient prescription drug and pediatric vision coverage criteria:

Tier definitions.

Formulary change triggers and member notice protection.

Off-label pre-approval and medical pharmacy distinction.

Enumerated exclusions and pediatric vision age limit.

inv-33: What Is Not Covered (exclusions)

Services and items expressly excluded from coverage unless otherwise specified:

Exclusions (representative, not exhaustive)

Disposable supplies and personal convenience items (e.g., combs, lotions, bandages) unless Medically Necessary are excluded.
Durable Medical Equipment items specifically excluded (air conditioners, humidifiers, TENS units, certain shoe inserts/orthotics, deluxe equipment, residential structural modifications, duplicate equipment) are not covered.
Infertility services such as artificial insemination, IVF, ZIFT, GIFT, ICSI and related services are excluded.
Vision services and supplies (eyeglasses, contact lenses, routine vision exams) are excluded except where pediatric vision benefits apply.
Various other exclusions include experimental/investigational services, non-medically necessary care, custodial care, certain transplant-related items not listed as covered, routine physicals for employment/travel, and many other enumerated items in the 'What is Not Covered' section.

inv-34: Administrative provisions

Administrative and operational provisions affecting claims and coordination:

Force majeure events may delay or excuse performance obligations, with reasonable efforts expected to perform obligations when possible.

Force majeure provision.

International emergency care rules and reimbursement basis.

Coordination of Benefits rules determine primary/secondary payers and use standard rules (longer plan rule, birthday rule, custody rules, longer policy rule) as detailed in the Certificate.

COB rules summary.

Claims timing and notice obligations.

Medical bill review and audit authority.

inv-35: General coverage stance

General coverage stance:

Coverage limited to eligible Members and subject to contract terms.

inv-36: Audit-based denial criteria

Audit-based denial criteria and documentation requirements:

Grounds for audit-based denials and coding requirements.

Coding standards and review process.

inv-37: Termination and post-exhaustion assistance criteria

Termination and post-exhaustion assistance actions:

When a Member exhausts benefits, Alliant notifies the Member and provides education about other available resources and lists resources on its website.

Transition actions following exhaustion of benefits.

Financial obligations and refund timeline on termination.

Termination triggers

No longer meet eligibility (age or residence) or Dependent reaching age 26 (coverage ends at end of calendar year).
Request for disenrollment: membership ends at midnight on the 14th day following the request (or earlier if accommodated).
Fraud or misrepresentation: Alliant may rescind coverage with 30-calendar day advance written notice; Member has right to appeal and rescission may be retroactive to date of fraud or original enrollment as applicable.

Administrative standards and contact channels.

inv-38: Termination, Premiums, Reinstatement & Appeals Criteria

Termination, premiums, reinstatement and appeals rules:

Comprehensive termination triggers and notice periods.

Premium nonpayment and reinstatement pathways.

Appeals timelines and expedited process.

inv-39: Appeals and External Review Procedural Criteria

Appeals and external review procedural criteria and timelines:

Internal appeal level timelines.

Expedited appeal criteria and 72-hour decision timeframe.

External review filing deadline and contact methods.

inv-40: Coverage-related definitions

Definitions that affect coverage determination and provider billing:

Definition and determination of Covered Services.

Clean Claim requirement and provider responsibilities.

inv-41: Key coverage-informing definitions

Key definitions that inform coverage interpretation:

Dependent age limit and scope.

Essential health benefits inclusion.

Hospital facility definition and 24-hour nursing requirement.

Billing, Coding, and Code-Level Rules

Cost sharing and deductible notesmixed

No codes listed

Claim coding and MAC determinationmixed

Claims may be reprocessed based on claim coding rules; bundled single procedure code may be used rather than multiple billed codes when procedure codes are inclusive.

Air ambulance payment calculationmixed

Anesthesia and inpatient hospital billing guidancemixed

Billing guidancemixed

Medical-pharmacy billing distinctionmixed

Excluded services and items (non-covered)mixedNot Covered

Coding requirementsmixedCovered

CPT/ICD-10/HCPCS/Revenue

Charges must be billed using accurate and appropriate CPT, ICD, HCPCS and Revenue codes per AMA and CMS guidelines.

Appeal forms / referencesmixed

Appeals documentationmixed

Drug classificationmixed

Brand Name Drugs are defined as Single Source Brand (no generic equivalent) or Multi-Source Brand (has generic equivalent).

DME definitionmixed

Calendar year deductible application

Application periodDeductible is applied on a calendar year basis (Jan 1–Dec 31); member responsibility resets each calendar year.

Preventive services exceptionCertain preventive services are covered and reimbursable prior to meeting the Deductible.

Reference for amountsSpecific deductible amounts and how they apply are shown in the Summary of Benefits and Coverage.

Out-of-Network emergency QPA/MAC calculation

Member cost-sharing noteMember pays applicable coinsurance, copayment, or deductible as specified in the policy; Out-of-Network emergency providers may bill the Member for those amounts.

DME rental/payment threshold

Rental payment capPlan pays DME rental charges up to the lesser of the equipment's purchase price or twelve (12) months of rental charges.

Medical necessity and orderingEquipment must be medically necessary, ordered/prescribed by a Physician, appropriate for in‑home use, and related to the patient's physical disorder.

Ongoing proofAlliant may require proof of continuing medical necessity and a Provider statement of expected duration of use.

Preventive screening classification

Age-based mammographyAnnual imaging (digital mammography, tomosynthesis, breast x-ray, breast MRI) covered for women aged 40+, or age 35+ if recommended by a physician.

Colorectal screening guidanceColorectal cancer screening follows USPSTF grades A/B and American Cancer Society guidelines and is covered at no cost when completed per guidelines.

Hearing aid benefit limit

Benefit limitOne hearing aid per hearing‑impaired ear not to exceed $3,000 per hearing aid every 48 months (applies to plans purchased outside Georgia Access).

Included itemsIncludes parts, ear molds, repair and replacement parts, nonimplanted bone‑anchored/conduction devices; personal sound amplification products excluded.

Applicable cost-sharing and conditionsBenefits subject to conditions, limitations, exclusions and cost‑sharing as outlined in the Summary of Benefits and Coverage.

Copayment calculation for multi-month fills

Basis for copay calculationCopayment is expressed as a single fill or for a 31‑day supply, whichever is less; multi‑month fills prorate copayments accordingly.

Pharmacy claim submissionPresent Identification Card at in‑network pharmacy; out‑of‑network pharmacy claims require itemized bill submission.

New FDA drug market availability threshold

Market availability thresholdNewly approved FDA drugs must have been available in the U.S. market for at least 180 days to be covered under the outpatient prescription drug benefit.

Exclusions list referenceSee Outpatient Prescription Drug Benefits exclusions for other non‑covered drug categories and conditions.

Formulary change protectionsMembers with prior use may receive 30 days' written notice before a drug is moved to non‑formulary if they had a prescription within the prior 12 months.

Transplant coverage limits

Documentation requirement

Coding and order complianceClaims must use accurate CPT/ICD‑10/HCPCS/Revenue codes per AMA and CMS guidelines; improper coding or unbundling may affect payment or trigger denial.

Alliant discretionAlliant retains discretion to determine coverage based on claim audit and medical bill review; lack of documentation can lead to repayment recovery or rescission in fraud cases.

External review filing deadline

External review filing deadlineYou must file a request for External review within 123 calendar days from the date of the appeal decision notice.

How to request (medical/pharmacy)For medical and pharmacy prior authorization external appeals, request with Maximus by phone, online, fax, or mail as provided in the External Appeals instructions.

Contract Year period

Contract Year periodContract Year (Benefit Period) is a calendar year commencing Jan 1 at 12:01 am and ending Dec 31 at 11:59 pm Eastern Time.

Deductible application timeframeDeductible and other annual limits apply on a calendar year basis; see Summary of Benefits and Coverage for year‑specific amounts.

Benefit period noteBenefit Period does not begin before a Member's Effective Date and does not continue after coverage ends.

Provider Requirements, Prior Authorization, and Appeals

Prior Authorization

Call Alliant Medical Management for inpatient prior authorization

Prior Authorization phone: (800) 865-5922
Notify Alliant by the next business day for emergency or maternity admissions
Approvals apply only to services outlined in the Prior Authorization request

Documentation Required

Verify provider network status before care

Confirm provider network status before scheduling services. Refer members to AlliantPlans.com or Client Services at (866) 403-2785 to locate In‑Network providers and verify network participation.

Use AlliantPlans.com Find-A-Provider tool to confirm In‑Network status
Client Services phone: (866) 403-2785

Documentation Required

Contact Client Services for out-of-area in-network locators

When a member needs care outside Alliant's service area, contact Alliant Client Services at (866) 403-2785 to attempt to locate an In‑Network provider in the area.

Client Services phone: (866) 403-2785

Prior Authorization

Follow Alliant authorization procedures and timeframes

Urgent Care decisions: as soon as possible but no more than 72 hours
Pre‑service decisions: within 7 calendar days (may extend another 7 days)
Concurrent: within 24 hours for urgent requests, otherwise within 7 days
Post‑service review: decision within 30 calendar days

Prior Authorization

Urgent Care definition and expedited prior authorization handling

Urgent Care definition: serious jeopardy to life/health, function, or severe unmanaged pain
Prior Authorization list: AlliantPlans.com or Client Services (866) 403-2785
Expedited decision timeframe for urgent requests: 72 hours

Prior Authorization

Air/water ambulance require medical necessity review

Air/water ambulance require Medical Necessity review by Alliant
Alliant retains the right to select the air ambulance provider
Non‑emergency hospital‑to‑hospital air transport must be Medically Necessary

Prior Authorization

Obtain Prior Authorization for clinical trial routine care

Routine patient care costs for qualifying clinical trials covered with Prior Authorization
Eligibility requires Member status, qualifying diagnosis, referral by an In‑Network provider, acceptance into an approved trial, and Alliant Prior Authorization

Documentation Required

Ensure physician orders and certifications for specific services

Home Health Care: physician certification statement and plan of care required; member must be essentially confined at home
Anesthesia and other services must be ordered by the attending Physician

Documentation Required

Member responsibility to verify in‑network/preferred provider status

Members should verify provider status using the Find‑A‑Provider tool or call Client Services at (866) 403-2785
Alliant may establish Preferred/In‑Network Providers for certain services

Prior Authorization

Prior Authorize all transplant procedures

Prior Authorization phone for transplants: (800) 865-5922
Physician must submit complete medical history, current diagnosis, and surgeon name
Surgery must be performed at an Alliant‑approved Transplant Center

Prior Authorization

Prior Authorization required for select prescription and specialty drugs

Prime Member Services: (844) 451-8288 for prior authorization lists and processes
Most Specialty Drugs typically require Prior Authorization

Prior Authorization

Obtain prior approval for off‑label and many medical pharmacy drugs

Off‑label drug use and many medications under the medical pharmacy benefit require prior approval from Alliant Health Plans; All off‑label drugs must be pre‑approved.

All off‑label drugs must be pre‑approved by Alliant Health Plans
Provider‑administered medical pharmacy medications (infusion, chemotherapy, injectables) commonly require Prior Authorization

Billing Rule

Use correct member identifiers and follow claim submission timelines

Providers must ensure accurate Member name, Group and Member numbers on claims
Member claim submission deadline: 180 days from date of service
Notification timeframe for missing info: 15 working days (electronic) / 30 calendar days (paper)

Billing Rule

Submit claims to Alliant with correct policy information

Submit claims to Alliant with accurate policy/Member information
Members have 180 days from date of service to submit claims for reimbursement

Denial Risk

Be prepared for medical bill review and audits — proper documentation required

All providers must submit Clean Claims as defined by Georgia Department of Community Health
Claims lacking physician orders, adequate documentation, or correct CPT/ICD/HCPCS coding may be denied
Alliant reserves the right to audit claims and perform medical bill review

Documentation Required

Follow procedures for member notifications at benefit exhaustion and termination

Alliant notifies Members who have exhausted benefits and lists other resources on its website
If coverage terminates, member must pay amounts owed for the period prior to termination
Rescission for fraud requires 30‑calendar day advance written notice and is appealable

Prior Authorization

Use designated contacts and addresses for prior authorization appeals

Medical prior authorization appeals: Alliant Health Plans Appeals Department, PO Box 1247 Dalton, GA 30722; Phone: (800) 865-5922; Fax: (866) 634-8917
Pharmacy/Prime appeals: Prime Therapeutics, Phone: (844) 451-8288; Medical Pharmacy appeals: Prime Therapeutics Management, Phone: (800) 424-1799 Option 3

Denial Risk

Request expedited (urgent) pre‑service appeals when clinically necessary

Expedited appeal decision timeframe: 72 hours
Expedited requests may be made by phone or in writing using the same contacts as standard appeals

Documentation Required

Follow required content and submission channels for medical pharmacy PA appeals

Include: member name, member ID number, denial letter date, and reason for review
Mail appeals to: Prime Therapeutics Management, Attn: MP‑3002, P.O. Box 64811, St. Paul, MN 55164‑0811; Fax: (888) 656‑6671; Phone: (800) 424‑1799 Option 3

Documentation Required

Submit claim appeals with required information and use Alliant appeal form

Appeal form available at AlliantPlans.com (Member Appeal Form)
Mail to: Alliant Health Plans Appeals Department, PO Box 1247, Dalton, GA 30722; Fax: (866) 634‑8917

Documentation Required

Submit Clean Claims in accepted national format

Clean Claim definition per Georgia Department of Community Health: nationally accepted format requiring no further information
Failure to submit Clean Claims may delay processing or lead to denials

Note

Direct access to primary and specialty physicians (no Alliant referral required)

Members have direct access to primary and specialty care physicians without needing an Alliant‑approved referral; providers can see members without obtaining a referral from Alliant.

No Alliant referral required for primary or specialty physician access
Members may self‑refer to specialists in‑network

Defined Terms

Member / Subscriber

Subscriber / MemberSubscriber (Member) is the person who applied for coverage; references to 'You/Your' apply to the Subscriber and any covered Dependents.

Alliant namingAlliant Health Plans is referred to as 'We/Us/Our' in the Contract.

Plan identifierThis Certificate governs benefits for the 2026 SoloCare HMO Individual and Family Plans (Georgia).

Coverage / Dependents

Enrollment process referenceEnrollment and Special Enrollment Periods details are provided in the Enrollment and Special Enrollment sections and Summary of Benefits and Coverage.

Member / Subscriber

DefinitionSubscriber or Member is the person covered under the health care plan; child‑only policies are allowed under this plan type.

ScopeReferences to 'You/Your' apply to the Subscriber and any covered Dependents unless otherwise specified.

Contract relationshipThe Certificate is the Contract between the Subscriber and Alliant and replaces prior Certificates.

Dependent / Covered Dependent

Incapacity exceptionMentally or physically disabled Dependents who are totally dependent may remain covered beyond age 26 if certified and previously covered.

Enrollment timingDependents must be enrolled during Open Enrollment or within Special Enrollment Periods; newborns and adopted/foster children have initial 31‑day coverage windows for continuation.

HMO

HMO definitionHealth Maintenance Organization (HMO) requires Members to choose In‑Network physicians, hospitals or other providers to use benefits.

Network verificationMembers should verify provider network status before visits via AlliantPlans.com or Client Services (866‑403‑2785).

Effect on costUsing In‑Network Providers generally results in lower out‑of‑pocket costs due to contracted rates accepted as payment in full.

In-Network Provider

Member actionMembers can locate In‑Network Providers at AlliantPlans.com or by calling Client Services (866‑403‑2785).

Cost implicationChoosing In‑Network care typically reduces copays, coinsurance and other out‑of‑pocket costs compared with Out‑of‑Network care.

MAC

MAC definitionMaximum Allowed Cost (MAC) is the plan's determined reimbursement amount for Covered Services; member pays applicable cost‑share until deductible/copayment/coinsurance met.

Determination factorsMAC may be adjusted based on claim processing rules, coding accuracy, bundled procedure rules, and applicable statutes (e.g., surprise billing laws).

Effect on provider paymentMAC determines plan payment; In‑Network providers accept MAC as payment in full; Out‑of‑Network provider billing may exceed MAC subject to member responsibility rules.

Cost share / Out-of-Pocket Maximum

Cost share componentsCost share includes copayments, deductible and coinsurance amounts that a Member may owe for In‑Network care; specific amounts are in the Summary of Benefits and Coverage.

Out‑of‑pocket maximumOnce the Member reaches the Out‑of‑Pocket Maximum (including Deductible), the plan covers 100% of allowed costs for the rest of the year.

Application timingDeductible and Out‑of‑Pocket Maximum are applied on a calendar year basis (Contract Year).

In-Network / Out-of-Network

Surprise billing protectionsMembers cannot be balance‑billed for Out‑of‑Network emergency services per state and federal surprise billing laws; special MAC/QPA calculations apply.

Member verificationMembers are responsible for verifying In‑Network status prior to care to avoid unexpected billing.

approved clinical trial

Coverage scopeRoutine patient care costs for qualifying Members in approved clinical trials are covered; cost of the investigational treatment itself is excluded.

RequirementsMember must be diagnosed with qualifying condition, be a Member, be accepted into an approved trial, be referred by an In‑Network Provider, and receive Prior Authorization.

medical emergency

Implication for careEmergency Medical Services covered in ERs and freestanding emergency rooms; copay waived if admitted; Members cannot be balance‑billed for Out‑of‑Network emergency services.

Relation to urgent careUrgent Care differs from emergency care and is defined by conditions that jeopardize health or function or cause severe unmanaged pain but are not life‑threatening.

Hearing Aid

Examples includedIncludes non‑implanted bone‑anchored/conduction hearing aids and frequency modulation systems.

Benefit limitationsBenefit limits (e.g., $3,000 per aid every 48 months) and applicability depend on plan purchase channel and Summary of Benefits and Coverage.

Habilitative services

Coverage noteServices must be medically necessary and are subject to calendar‑year visit limits as detailed in the Summary of Benefits and Coverage.

Provider requirementServices must be ordered and supervised by an appropriate Provider (Physician) when required.

Urgent Care

Access after hoursMembers needing Urgent or Emergency care after normal business hours can contact Client Services (866‑403‑2785) or visit AlliantPlans.com to locate In‑Network facilities.

Appeals relevanceUrgent Care determinations may qualify for expedited internal appeals with a 72‑hour decision timeframe.

In-Network / Preferred Provider

Member responsibilityMembers are responsible for confirming In‑Network status prior to receiving services to understand cost sharing and network applicability.

Alliant discretionAlliant may establish Preferred or In‑Network Providers for certain services to manage quality and cost.

Preventive care

When not preventiveIf a Member has symptoms or a diagnosed condition, related services are considered diagnostic and not covered under preventive‑only rules.

Reference for guidelinesFor details and covered preventive services, see Alliant's preventive guidelines on the provider website.

Telemedicine

Payment basisPayment for telemedicine services is based on the negotiated rate or current MAC for the service provided.

Use casesTelemedicine may replace in‑person consultations when real‑time communication is possible and clinically appropriate.

Donor Costs

Donor costs definitionDonor Costs are all direct and indirect costs incurred in connection with removing, preserving and transporting an organ or tissue from a donor or self‑donor.

Coverage relationDonor Costs are defined separately from Facility Transplant and Professional Provider transplant services; coverage subject to Contract terms.

Exclusions noteCertain transplant‑related items (e.g., donor travel) may have specific limits or exclusions; see the Transplant section for details.

Facility Transplant

Facility TransplantFacility Transplant means all Medically Necessary facility services and supplies in connection with a covered transplant except donor costs and antirejection drugs.

ScopeIncludes inpatient facility charges, operating room, nursing and related facility services required for the transplant.

Prior AuthorizationTransplant services require Prior Authorization and must be performed at Alliant‑approved Transplant Centers per policy.

Medically appropriate

Medically appropriate'Medically appropriate' for transplant means the recipient or self‑donor meets Alliant's established criteria for the transplant.

Selection criteriaTransplant candidates and procedures are reviewed against Alliant's selection and medical necessity criteria during Prior Authorization.

Effect on coverageOnly medically appropriate transplants that meet criteria and are authorized will be covered under the Contract.

Zero-Cost Share

Zero‑Cost Share (AC)Zero‑Cost Share (also indicated as Healthcare Reform (AC)) tier contains preventive drugs covered under ACA and carries no cost‑sharing.

Formulary placementZero‑Cost Share tier may include generic, single‑source or multi‑source brand drugs that meet preventive guidelines.

Member accessMembers may obtain the Drug Formulary via AlliantPlans.com or by contacting Client Services (866‑403‑2785).

Off-label drug

Off‑label drug ruleOff‑label drugs prescribed for life‑threatening or chronic disabling conditions require pre‑approval by Alliant Health Plans to be covered.

Associated servicesMedically necessary services associated with off‑label drug administration may be covered when pre‑approved.

Request processContact Alliant for prior approval/authorization as required by the medical pharmacy policies.

Therapeutic/Clinically Equivalent

Formulary impactAvailability of Therapeutic/Clinically Equivalent alternatives can trigger reclassification to non‑formulary status or substitution requirements.

Member protectionsMembers with prior use or intolerance may request Non‑Formulary Drug Exceptions and appeal denials per appeal processes.

Acts Beyond Reasonable Control (Force Majeure)

Force majeureActs Beyond Reasonable Control (force majeure) extend performance times and excuse non‑performance for the period of delay; parties must use reasonable efforts to perform obligations.

ExamplesIncludes acts of God, strikes, restrictive government laws or regulations, and other causes beyond a party's control.

Effect on timelinesTime for performance is extended by a period equivalent to the delay caused by the force majeure event.

Balance Billing

Out‑of‑Network providersOut‑of‑Network providers may bill Members directly for amounts above plan payment; Non‑Covered Services remain Member's responsibility.

Surprise billing contextState and federal surprise billing protections apply for emergency services and define MAC/QPA calculation methods.

Care Received Outside the U.S.

Coverage outside U.S.Only emergency care received outside the United States is covered; non‑emergency care received outside the U.S. is not covered.

Assignment limitationMembers may not assign benefits to foreign providers or facilities.

Coordination with Medicare

Overpayment recoveryAlliant may recover amounts that should have been paid by Medicare from Members or other payors as appropriate.

Primary/secondary determinationCoordination of Benefits rules determine order of payment when Members have multiple coverages.

Financial Incentives

Financial incentives statementMedical management decisions are based on medical necessity, benefits and Member needs; staff are not rewarded or incented to deny or limit care.

Decision basisDecisions consider clinical appropriateness and local healthcare system factors, not financial incentives to deny care.

Transparency implicationThis statement supports impartiality in utilization management and appeals processes.

Subrogation

SubrogationAlliant has subrogation rights to recover amounts from third parties responsible for a Member's injury or loss for amounts Alliant paid on the Member's behalf.

Right of recoveryIf Alliant pays benefits and the Member recovers money from another source, Alliant is subrogated to the Member's recovery rights for the amount paid.

Priority of repaymentAlliant has the right to be repaid first from any recovery the Member receives, even if the Member is not made whole.

Right of reimbursement

Right of reimbursementAlliant may be repaid from any money the Member recovers for an injury or condition for which Alliant paid benefits; Alliant has first priority for reimbursement.

ScopeRepayment requirement applies regardless of whether recovery includes amounts for pain and suffering or partial claim resolution.

Member obligationMember promises to repay Alliant from any settlement, judgment or recovery received from any source.

Exhaustion of benefits

Exhaustion transition actionsWhen a Member exhausts benefits, Alliant notifies the Member and provides education about other available resources and posts resources on its website.

Notification and assistanceAlliant complies with CMS/NCQA continuity standards and offers assistance to Members transitioning after benefit exhaustion.

Coverage limitsTransition steps do not extend coverage beyond Contract terms; other resources may or may not be covered.

Rescission

Rescission conditionsAlliant may rescind coverage for fraud or intentional misrepresentation after providing 30‑calendar days advance written notice; Member has the right to appeal the rescission.

Effective date of rescissionThe rescission date may be the date of the fraud/ intentional misrepresentation or the original enrollment date, whichever is later.

ExceptionsRescission does not apply for nonpayment of premiums (terminate effective per grace periods) and is subject to appeals processes.

Adverse Benefit Determination

ScopeIncludes denials of payment, coverage level decisions, and rescissions with retroactive effect (except nonpayment based terminations).

Appeals implicationAdverse Benefit Determinations may be appealed through internal and external review processes described in the Appeals section.

Authorized Representative

Appeals roleAn Authorized Representative may file appeals, provide information, and receive plan communications on the Member's behalf.

DocumentationWritten authorization or evidence of state law authority is required to act as an Authorized Representative in non‑urgent contexts.

Final Adverse Benefit Determination / Claim types

Post‑Service ClaimA Post‑Service Claim is an Adverse Benefit Determination rendered for services already provided.

Post-Service Claim and audit risk

Post‑service claim definitionA Post‑Service Claim is an Adverse Benefit Determination for a service already provided (used in appeals and external review contexts).

Provider obligationProviders must submit clean claims in a nationally accepted format and retain supporting documentation to avoid denials or repayment requests.

Pre-Service Claim

Pre‑Service Claim definitionA Pre‑Service Claim is an Adverse Benefit Determination rendered for a service that has not yet been provided; often tied to prior authorization decisions.

Appeal timeframesPre‑service appeals have expedited timelines (e.g., 15 calendar days for Level I pre‑service) and may qualify for expedited review when urgent.

Authorization implicationPrior Authorization approvals apply only to services specified in the authorization request and do not guarantee payment if Member is not covered or benefits exhausted.

Urgent Care Services Claim

Authorized provider actionA health care provider may act as an Authorized Representative without Member express consent for Urgent Care Services claims to request expedited review.

External review optionMembers may request an expedited External review concurrently with an expedited internal appeal when criteria are met.

Clean Claim

Clean Claim requirementA Clean Claim is a claim submitted in a nationally accepted format that requires no further information, adjustment, or alteration for adjudication by Alliant.

Provider responsibilityProviders must submit clean claims consistent with coding guidelines to avoid processing delays or requests for additional information.

Contract Year

Contract Year definitionContract Year (Benefit Period) is January 1 at 12:01 am through December 31 at 11:59 pm Eastern Time.

Benefit period scopeBenefit Period does not begin before a Member's Effective Date and does not continue after coverage ends; deductible and OOP limits apply per Contract Year.

Reference locationContract Year definition appears in the Definitions section of the Certificate and aligns with the Calendar Year deductible application.