CurrentAlliant HealthPolicy N/A

Certificate of Coverage for 2026 SoloCare PPO - Individual and Family Plans (Georgia)

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This Certificate of Coverage defines coverage terms, member rights/responsibilities, prior authorization rules, and administrative procedures for subscribers and eligible dependents enrolled in the Alliant Health 2026 SoloCare PPO Individual and Family Plans sold through Georgia Access.

Policy Summary

PayerAlliant Health

PolicyCertificate of Coverage for 2026 SoloCare PPO - Individual and Family Plans (Georgia)

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionProvider must call (800) 865-5922 for Prior Authorization for all in-network inpatient hospital admissions (except maternity); notify by next business day for emergency or maternity admissions.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2026plan year referenced

800-865-5922prior authorization contact

866-403-2785member services contact

26dependent age limit

31 daysnewborn automatic coverage

Coverage Criteria and Service Rules

inv-01: Verification and Prior Authorization Criteria

Covered when ALL of the following administrative verification and prior authorization rules are observed:

Verification of benefits does NOT confirm coverage or guarantee payment.

Call Client Services to verify benefits; verification is informational only.

Prior Authorization approvals apply only to the services specified in the prior authorization request and do not guarantee payment for future or related services.

Approvals must exactly match requested services; see AlliantPlans.com for listed services.

ALL of the following

Member is not covered under the Contract at time services are received
Benefits under the Contract have been exhausted (for example, day limits)
Fraud or misrepresentation is present
The service is not a Covered Service under the benefit plan

ALL of the following

For In-Network inpatient admissions (except maternity), the Provider must call (800) 865-5922 to obtain Prior Authorization
For Out-of-Network inpatient admissions, the Member must call (800) 865-5922 to obtain Prior Authorization and must notify within one business day for emergency or maternity admissions to avoid denial
Emergency services do not require Prior Authorization, but notification requirements still apply as stated above

Operational requirement

Alliant may require submission of medical records and documentation; failure to obtain required prior authorization and requested records may result in no benefits payable.

inv-02: Eligibility, enrollment and benefit application

Eligibility and enrollment rules (Member and Dependent):

ALL of the following

Spouse if not legally separated (domestic partners generally not eligible unless law requires)
Dependent children through the end of the calendar year they attain age 26
Legally adopted children from date legal responsibility assumed (application + premium within 31 days)
Children for whom Subscriber assumes legal guardianship, stepchildren, and children required to be covered by court decree
Children who are mentally or physically disabled and totally dependent regardless of age (certification required)

ALL of the following

Open Enrollment period as defined by federal government
Special Enrollment Periods for qualifying events (loss of coverage, household size change, move, gaining ICHRA/QSEHRA eligibility, enrollment/plan error)

ALL of the following

If not enrolled when first eligible, must wait until next Open Enrollment unless SEP applies
Failure to add spouse/stepchildren within 31 days of marriage makes them Late Enrollees

ALL of the following

Newborns automatically covered for first 31 days; to continue coverage must submit application and premium within 31 days; if submitted between 31 and 60 days coverage reinstated retroactively
Adopted children eligible from date legal responsibility assumed; application and premium within 31 days required for continuous coverage; 31–60 day late submission reinstates retroactively
Foster children require confirmation of valid foster relationship provided by Member; application and premium within 31 days required; 31–60 day late submission reinstates retroactively

ALL of the following

Events that trigger removal include divorce, death, dependent reaching age 26, or dependent becoming totally/permanently disabled
If purchased through Georgia Access notify Georgia Access; otherwise notify Client Services for forms

ALL of the following

In-Network care may require copayments/coinsurance per Summary of Benefits; deductible applied on calendar year basis
Many preventive services covered In-Network with no deductible/copay/coinsurance
Plan is a PPO with In-Network and Out-of-Network benefit sets; verify provider network status on AlliantPlans.com or via Client Services

Operational note

To add/remove dependents or change coverage contact Client Services at (866) 403-2785 or follow Georgia Access notification rules if purchased through Georgia Access.

inv-03: Coverage criteria and service rules

Coverage and medical necessity criteria for specific services and general service rules:

ALL of the following

All Covered Services must be Medically Necessary whether provided in-network or out-of-network

ALL of the following

Emergency ambulance services are covered when Medically Necessary and criteria met (licensed vehicle, appropriately staffed, transported to nearest capable facility)
Scheduled ground ambulance non-emergency transports must be Medically Necessary and are subject to review
Air/water ambulance services are subject to Medical Necessity review; Alliant may select the air ambulance provider

ALL of the following

Alliant determines MAC for Out-of-Network reimbursement and may apply QPA rules for emergent air ambulance services in accordance with law
Alliant may reduce payments to avoid duplicate billing for incidental/included services; in-network providers must bill within contracted amounts

ALL of the following

Non-covered services are not reimbursable and member is responsible for billed amounts for Non-Covered Services
No annual or lifetime dollar limits apply to Essential Health Benefits

ALL of the following

If no in-network provider exists Alliant may authorize in-network cost sharing to apply to out-of-network services; member may still owe difference between MAC and provider charge

Operational note

Claims and medical necessity determinations follow Alliant medical management processes; providers should obtain authorizations where required to avoid claim denials.

inv-04: Coverage criteria for services in this section

Air ambulance and related transport coverage criteria (hospital-to-hospital and exceptional circumstances):

ALL of the following

Covered when Medically Necessary for transfer to the nearest hospital with medically appropriate facilities (e.g., burn, cardiac, trauma, critical care)

ALL of the following

Fixed or rotary wing air ambulance may be Medically Necessary only if all emergency ambulance criteria are met AND at least one of: immediate rapid transport needed not possible by land; pickup inaccessible by land; great distances or time obstacles; land transport time poses health threat; patient pronounced dead after call or en route

ALL of the following

All scheduled ground ambulance services for non-emergency transports must be Medically Necessary (excludes acute facility-to-acute facility transport)

Operational/billing note

For Out-of-Network emergent air ambulance services member cost-sharing limited to In-Network amount; MAC/QPA calculation rules apply as specified.

inv-05: Covered services and criteria (section)

Service-specific coverage criteria (selected services):

ALL of the following

Dialysis is a Covered Service; Out-of-Network benefits apply if an Out-of-Network provider is elected

ALL of the following

Covered when Medically Necessary, ordered by a Physician, appropriate for in-home use, meets durability and medical-purpose criteria
Plan pays rental up to lesser of purchase price or 12 months of rental; Provider must certify medical necessity and expected duration

ALL of the following

Emergency room services covered per prudent layperson standard; copayment may apply but waived if admitted; no balance billing for out-of-network emergency services per surprise billing laws

ALL of the following

Medical eye care covered when provided by participating ophthalmologist or optometrist; routine vision excluded except for children under age 19

ALL of the following

Standard fertility preservation covered when infertility results from medically necessary treatment for cancer, sickle cell disease, or lupus; may include evaluations, meds, procedures, cryopreservation and up to one year storage subject to limits

ALL of the following

Covered when Medically Necessary, ordered by attending Physician, and connected to a Covered Procedure; includes CRNA-administered anesthesia

ALL of the following

Medically necessary habilitative services (PT/OT/ST and certain DME) covered with calendar year visit limits; refer to Summary of Benefits

ALL of the following

If plan purchased outside Georgia Access, benefit for children ≤18: one hearing aid per impaired ear up to $3,000 per aid every 48 months, subject to SBC conditions

ALL of the following

Covered as intermittent skilled care in the home per plan limits; visit = up to four hours; requires physician certification and written plan of care
Claims reviewed to verify services are skilled and medically consistent with diagnosis

ALL of the following

Hospice covered when attending Physician certifies life expectancy ≤6 months and program is Alliant-approved with RN coordination

ALL of the following

In-network admissions should be arranged by Member's physician; inpatient room charges covered on semiprivate basis; length of stay determined by medical necessity

inv-06: Covered services and limitations (partial)

Summarized covered services and key limitations:

ALL of the following

Benefits payable when services are within state scope of practice (NP, PA, PAA, LAT)

ALL of the following

Requires physician order and supervision; covered to treat functional deficits; subject to calendar-year visit limits per Summary of Benefits

ALL of the following

Covered subject to contract cost-sharing; federal law ensures minimum lengths of stay (48 hours vaginal, 96 hours cesarean) and access to two post-discharge follow-up visits if discharged earlier

ALL of the following

Inpatient and outpatient benefits available as outlined in the Summary of Benefits and Coverage

ALL of the following

Outpatient services covered when medically necessary; verify In-Network status via AlliantPlans.com or Client Services

ALL of the following

Covered for at-risk women age 35 and older with annual CA-125, transvaginal ultrasound, and pelvic exam

ALL of the following

In-Network preventive services meeting federal/state guidelines covered at no cost; Out-of-Network preventive services paid at MAC and subject to cost-sharing

ALL of the following

Physical, occupational, and speech therapy covered when medically necessary and subject to combined calendar-year maximum visits per Summary of Benefits

ALL of the following

Prosthetic appliances covered if medically necessary; reconstructive surgery covered to restore function or correct congenital/trauma/post-surgical deformity

Operational note

Members should consult the Summary of Benefits and Coverage for applicable copayments, deductibles, limits, and visit maximums.

inv-07: preventive care

Preventive services coverage requirements and cost-sharing stance:

ALL of the following

Services with USPSTF A/B ratings, ACIP immunizations, HRSA child/adolescent and women's preventive guidelines are covered with no deductible, copayments, or coinsurance when provided In-Network (Alliant pays 100% of allowed amount)

ALL of the following

New government recommendations become covered for plan years beginning one year after issuance (or as ACA requires)

ALL of the following

Paid at MAC and subject to deductible, coinsurance, and potential provider balance billing

Operational note

Alliant may impose reasonable coverage limits when frequency/method/setting not specified consistent with ACA and Georgia law.

inv-08: diagnostic tests, prosthetics, reconstructive surgery

Selected diagnostic tests, prosthetics, and reconstructive surgery criteria:

ALL of the following

PSA test covered annually for men age 45 and over; may be covered for men over 40 if ordered by a physician

ALL of the following

Covered if medically necessary and ordered by a Physician; includes artificial limbs, accessories, external breast prostheses after mastectomy, arm/leg braces (with attached shoes) and specified orthotics

ALL of the following

Covered when Medically Necessary to restore function altered by disease, trauma, congenital anomaly, or to correct post-surgical deformity; excludes services otherwise excluded in Certificate

Pediatric vision cross-reference

See Pediatric Vision section for vision-specific device/exam coverage for members under age 19.

inv-09: assistant and second opinion

Coverage rules for surgical assistance and second opinions:

ALL of the following

Covered when payable to a surgical first assistant, performed at Physician request, within scope of license, and not payable if employed by the Physician or Hospital

ALL of the following

Second opinions by an In-Network Provider are covered for proposed surgical interventions or any Covered Service where a second opinion is requested

Operational note

Members may seek a second opinion from an In-Network provider; contact Client Services for assistance.

inv-10: skilled nursing facility care

Skilled nursing facility (SNF) coverage criteria and limits:

ALL of the following

SNF services covered when Skilled Convalescent Care is medically necessary and consistent with diagnosis (favorable prognosis, predictable recovery, and services more intense than residence but less than acute hospital)

ALL of the following

Semiprivate/wardroom charges, special care rooms, pathology/radiology, physical/speech therapy, oxygen therapy, inpatient drugs and dressings when continuous physician care and 24-hour nursing required

ALL of the following

Benefits not provided when care is primarily custodial, when maximum recovery reached, for chronic brain syndromes without specific medical need, or when benefit limit reached; calendar-year visit limits apply per Summary of Benefits

Operational note

Contact Client Services for specific SNF benefit limits and to verify coverage prior to placement.

inv-11: telemedicine

Telemedicine coverage criteria:

ALL of the following

Telemedicine is covered when provided by a duly licensed provider via secure real-time audio, video, or data communications with patient present and participating

ALL of the following

Payment based on negotiated rate or current MAC for the service provided

Operational note

Telemedicine may substitute for in-person visits when realtime communication standards are met; verify provider licensure and network status.

inv-12: transplant coverage

Transplant coverage and prior authorization requirements:

ALL of the following

Covered transplants include medically appropriate human organ or tissue transplants (cornea, lung, heart/heart-lung, liver, kidney, pancreas, kidney/pancreas) and specified autologous/allogeneic hematopoietic stem cell transplants per criteria

ALL of the following

Covered services include donor costs (organ harvesting), post-operative care including antirejection drugs (if prescription drugs covered), and certain transplant-related chemotherapy as specified

ALL of the following

Transplants at Non-Alliant Transplant Network Facilities are not covered even if facility is participating; blood/blood derivatives (except hematopoietic stem cells) are not considered transplants for benefit purposes

ALL of the following

All transplant procedures must be Prior Authorized, be Medically Necessary, and not Experimental/Investigational per Alliant criteria; call (800) 865-5922 to obtain prior authorization

Operational note

Transplant prior authorization and selection criteria are part of benefit administration and do not constitute treatment recommendations.

inv-13: transplant ancillary benefits

Transplant-related ancillary benefits and limits:

ALL of the following

Pre-approved transplant recipients and a support person may be reimbursed for transportation, lodging, and food up to a combined maximum of $10,000 per covered transplant

ALL of the following

Travel benefits available only for covered members who are transplant recipients; donors are not eligible

ALL of the following

Antirejection drugs following a covered transplant are covered as Prescription Drugs only if Prescription Drug benefits apply under the Contract

Operational limits

Reimbursements follow IRS mileage, rental, and GSA lodging/per diem rules; certain costs (within 200 miles, laundry, phone, alcohol/tobacco, premium travel classes) excluded.

inv-14: urgent care services

Urgent care coverage criteria and definition:

ALL of the following

Urgent Care: medical care for conditions that could seriously jeopardize life/health or ability to regain maximum function or would cause severe unmanaged pain; not life-threatening and not an emergency

ALL of the following

Urgent Care services rendered at Urgent Care Centers are covered as outlined in the Summary of Benefits and Coverage

Operational note

For after-hours urgent care assistance contact Client Services or use AlliantPlans.com to locate in-network urgent care facilities.

inv-15: prescription drugs

Outpatient prescription drug program rules, formulary and prior authorization requirements:

ALL of the following

Prime Therapeutics, LLC is the PBM administering outpatient prescription drug benefits; contact Prime Member Services for formulary and benefit questions

ALL of the following

Only drugs included on the Drug Formulary may be Covered Services when dispensed In-Network; the formulary is maintained by a physician/pharmacist committee

ALL of the following

Copayment/coinsurance tiering determined by Summary of Benefits; copayment expressed per single fill or 31-day supply; multi-month fills prorate (e.g., 90-day fills require multiple copayments)

ALL of the following

A limited number of prescription drugs, including most specialty drugs and many medical-benefit-administered drugs, require Prior Authorization; if not approved the drug is not eligible for coverage

ALL of the following

Specialty drugs often require special handling and Prior Authorization and may be dispensed by contracted specialty pharmacies; drugs administered by providers (infusions, chemotherapy) are paid under the medical benefit and often require Prior Authorization

ALL of the following

Outpatient prescription drug exclusions include internet/mail-order out-of-network, newly approved FDA drugs <180 days in U.S., OTC items, cosmetic drugs, certain injectables without Prior Authorization, experimental/investigational drugs, and other listed exclusions

Operational note

For a list of drugs requiring Prior Authorization contact Prime Member Services or review the formulary on AlliantPlans.com.

inv-16: Outpatient prescription drug and pediatric vision coverage criteria

Outpatient prescription drug, specialty drug, medical-pharmacy, formulary management, and pediatric vision rules:

ALL of the following

Covered: prescription drugs prescribed by a Provider and included on the Drug Formulary when dispensed In-Network; retail prescriptions dispensed per formulary

ALL of the following

Prior Authorization required for a limited number of prescription drugs, including most Specialty Drugs and many medical-benefit drugs; nonapproved drugs are not eligible for coverage

ALL of the following

Tiered cost sharing applies (Generic, Preferred Brand, Non-Preferred, Specialty, Zero-Cost Share); DAW penalty applies when choosing brand over available generic (member pays difference)

ALL of the following

Formulary may be modified for specified reasons; members notified at least 30 days prior if a drug used in last 12 months moves to non-formulary and therapeutic equivalents exist

ALL of the following

Drugs administered by a licensed provider during visits (infusions, chemotherapy, blood products) are covered under the medical benefit and often require Prior Authorization

ALL of the following

Routine vision exams and prescribed lenses/frames covered for persons up to but not including age 19 when Medically Necessary and billed by Providers; specific exclusions apply (contact lenses not covered, certain lens treatments excluded, surgical refractive procedures excluded)

Operational note

Members should consult the Summary of Benefits and Coverage and Prime Therapeutics for pharmacy-specific rules and prior authorization lists.

inv-17: Pediatric vision and exclusions

Pediatric vision benefits and prominent exclusions that affect coverage determinations:

ALL of the following

Comprehensive vision examinations and prescribed lenses/frames are covered for members under age 19 when Medically Necessary and billed by Providers; contact lens evaluations and follow-up covered but contact lenses themselves are not covered

ALL of the following

Replacement lenses/frames only as specified in Summary of Benefits; many specific materials and special services excluded (safety/sports glasses, progressive lenses, certain tints, orthoptics, low vision aids); surgical refractive procedures excluded

ALL of the following

Certificate lists numerous non-covered services (e.g., many transplants not listed as covered, experimental/investigational services, many DME items, cosmetic procedures, routine general vision) which are member financial responsibility if rendered

ALL of the following

In-Network providers prohibited from balance billing; Out-of-Network providers may bill members for amounts over MAC; non-emergency care outside U.S. not covered except emergency care

Operational note

Members nearing age limits (e.g., turning 19) should verify termination of pediatric vision benefits and plan for alternatives.

inv-18: Claims, COB, and Member Programs Criteria

Claims, Coordination of Benefits, member programs, and administration rules that affect coverage:

ALL of the following

Non-emergency care outside the United States is not covered; only emergency care abroad is eligible and must be paid by member and submitted for reimbursement based on MAC

ALL of the following

This plan is always secondary to any Group Coverage; order of benefits follows standard rules (longer-plan rule, birthday rule, dependent/subscriber rules) to determine primary vs secondary

ALL of the following

Benefits do not duplicate Medicare unless federal law requires this plan to be primary; plan is not a Medicare supplement

ALL of the following

In-Network providers file claims directly; Out-of-Network providers may not file and members may need to pay and submit itemized claims; members generally have 180 days to submit claims
Alliant may audit claims and require Clean Claims; failure to submit clean claims or requested records may result in denial or recovery actions

ALL of the following

Population Health Management, Case Management and Complex Case Management are available at no cost; contact Member Care Line for referrals

Operational note

Members should provide correct insurance information to providers and contact Client Services for assistance with claim submissions and program enrollment.

inv-19: Billing, recovery, subrogation, and member rights

Billing, recovery, subrogation, and member rights rules governing payments and recoveries:

ALL of the following

Benefit payment is made to the submitter of the claim: provider if provider submits, member if member submits; member remains responsible to pay provider if reimbursed

ALL of the following

In-Network providers file claims and member is not responsible for filing; Out-of-Network providers may not file and member may need to pay and submit itemized bill for reimbursement

ALL of the following

Alliant may recover payments made in error from members or providers; provider recoveries generally limited to 12 months except in fraud cases; plan has subrogation and reimbursement rights if member has third-party recovery
Members must notify Alliant of legal action/settlement and may be required to repay Alliant from recoveries; plan may retain priority to be reimbursed first

ALL of the following

In-Network providers prohibited from balance billing; Out-of-Network providers may bill members for amounts above MAC

ALL of the following

Members and providers must cooperate with audits and appeals; plan provides language and disability access services and grievance processes

Operational note

Members should include Member and Group IDs and itemized bills when submitting claims; contact Client Services for claim inquiries.

inv-20: Termination, premium, and reinstatement criteria

Conditions under which membership terminates and rules for premium handling and reinstatement:

ALL of the following

Coverage ends when member no longer meets eligibility requirements or moves out of service area
Dependents coverage ends at end of calendar year they turn 26 (or other specified age limits for benefits like pediatric vision)
Coverage may be rescinded for fraud or intentional misrepresentation with 30-day advance written notice and member right to appeal

ALL of the following

Member-requested disenrollment ends at midnight on 14th day after request (earlier date may be accommodated at Alliant discretion)

ALL of the following

Premium due by first day of month; grace periods: 3 months for Georgia Access APTC purchasers (hold on payment after first month until premium received), 31 days for non-APTC purchasers and off-exchange purchasers; failure to pay by end of grace period results in termination
If terminated for nonpayment, reinstatement only during Open Enrollment or qualifying SEP

ALL of the following

Except for fraud, Alliant will return unearned premium within 30 days less amounts due on claims; Alliant will provide at least 180 days notice if discontinuing benefits or 90 days if withdrawing product from market

Operational note

Members should respond to premium notices promptly and contact Client Services to resolve billing or disenrollment questions.

inv-21: Appeal timelines and external review

Internal appeal windows, expedited decision timings, and external review rights:

ALL of the following

Level I Internal Appeal must be filed within 180 calendar days from notice of adverse determination
Optional Level II Internal Appeal may be filed within 60 calendar days from Level I denial (not required before External review)

ALL of the following

Level I pre-service: 15 calendar days; Level I post-service: 30 calendar days; Optional Level II pre/post-service: 15/30 days respectively
Expedited (pre-service) appeals decided within 72 hours

ALL of the following

After completing Internal appeals, member may request External review within 123 calendar days from date of appeal decision notice
Expedited External review available when expedited internal appeal requested or standard timeline would place life/health in danger or decision involves admission/continued stay/emergency care and member not discharged
External review requests may be submitted to Maximus by phone, online, fax, or mail per instructions

Operational contacts

Medical Prior Authorization Appeals mailed/faxed to Alliant Appeals Dept PO Box 1247 Dalton, GA 30722; Phone: (800) 865-5922; Fax: (866) 634-8917. Pharmacy appeals route to Prime Therapeutics contacts.

inv-22: Definition-driven coverage rules

Definitions whose meanings drive coverage determinations and exclusions:

ALL of the following

Cosmetic Surgery defined as non-medically necessary procedures to change appearance that do not restore function or correct disease; such services are excluded from coverage

ALL of the following

Covered Services are Medically Necessary services not excluded or Experimental/Investigational and provided per Contract; when multiple options equally effective, the least costly option is the Covered Service

ALL of the following

Experimental and/or Investigational services (including drugs, devices, procedures, or services in clinical trials or lacking credible evidence) are not reimbursable; Alliant has discretion to determine this status

ALL of the following

Hearing Aid defined as nonexperimental wearable device to aid hearing; personal sound amplification products do not qualify

Operational note

Interpretation of these definitions affects medical necessity and exclusion determinations; Alliant retains authority to apply these definitions.

Coding, Billing, and Claim Rules

Neutral code referencemixed

Cost-sharing and deductible rulesmixed

No codes listed

Claim coding and MAC impactmixed

Claims processed using coding rules (CPT/HCPCS/ICD) may affect determination of MAC; bundled vs multiple code examples described.

Air ambulance billing rulemixed

MAC for Out-of-Network emergent air ambulance services is the lesser of provider's billed charges or the QPA; member pays In-Network cost-sharing amount applied to In-Network deductible for emergent air ambulance.

Dialysis CPT/HCPCSmixedCovered

Dialysis treatment is a Covered Service. If an Out-of-Network Provider is elected, Out-of-Network benefits apply.

Ovarian cancer surveillance testsmixedCovered

CA-125	Serum tumor marker used in ovarian cancer surveillance
Transvaginal ultrasound	Imaging modality for ovarian surveillance
Pelvic examination	Pelvic examination included in surveillance

Prescription drug billing guidancemixed

Formulary determines covered prescription drugs; pharmacy MAC used for pricing and copayments expressed per single fill or 31-day supply with multi-month fills prorated as described.

Formulary / DAW cost-share rulemixedCovered

DAW	Dispense As Written (DAW) penalty — member pays difference between brand and generic when choosing brand over available generic

Vision services (placeholder)mixed

No codes listed

Coding and Billing Standardsmixed

CPT/HCPCS/ICD-10/Revenue

Claims must be billed using accurate CPT, ICD, HCPCS and Revenue codes per applicable guidelines; providers must submit Clean Claims; Alliant may audit and deny benefits if claims are not clean or records missing.

Adverse Benefit Determination (appeals)mixed

Definition: denial, reduction, termination, rescission, or determination based in whole or in part on medical judgment including experimental or not medically necessary determinations.

Documentation for appealsmixed

Members may submit supporting evidence, records, and documentation for appeals; copies of documents related to the appeal provided free of charge.

Covered Services determinationmixedCovered

Covered Services are medically necessary services defined in the Member's Contract, not excluded, not experimental/investigational, provided per the Contract; when multiple options equally effective exist, the least costly option is the Covered Service; subject to MAC.

inv-36: Verification of benefits — not a guarantee of payment.

Verification of benefitsA benefits inquiry or verification of benefits does NOT confirm coverage for a specific procedure and is NOT a guarantee of payment.

Who may verifyMembers or their authorized healthcare providers may verify benefits by contacting Client Services during regular business hours.

Prior Authorization noteIf the verified service requires Prior Authorization, contact Prior Authorization at (800) 865-5922.

inv-37: Deductible application period — calendar year basis.

Deductible periodDeductible applies on a calendar year basis (January 1–December 31).

Preventive servicesCertain preventive services are covered and reimbursable prior to meeting the deductible as stated in the Summary of Benefits and Coverage.

Reference termContract Year defined as calendar year beginning January 1 at 12:01 am and ending December 31 at 11:59 pm Eastern Time.

inv-38: QPA / MAC calculation references for emergency services — No Surprises Act methodology and Georgia references.

QPA / MAC methodology (Georgia emergency services)For Out‑of‑Network emergency services in Georgia, MAC is calculated per OCGA 33‑20E‑4 using comparators such as verifiable contracted amounts and recent verifiable in‑network amounts; Alliant may deem a higher amount appropriate given complexity.

QPA / MAC methodology (outside Georgia)For Out‑of‑Network emergency services outside Georgia, QPA is calculated per the federal No Surprises Act using the lesser of billed charges or the 2019 median contracted rate adjusted for inflation, or APCD/Fair Health or a derived amount per 45 CFR 153.710(c).

Impact on member billingAmounts paid exclude member cost‑share; Out‑of‑Network providers may bill members for amounts above MAC consistent with policy and surprise billing protections.

inv-39: DME rental cap — plan pays lesser of purchase price or 12 months rental.

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

Ordering requirementsDME must be ordered/prescribed by a Physician and certified in writing for medical necessity and expected length of need.

Continuing necessityAlliant may require proof of continuing medical necessity at any time and may limit payment accordingly.

inv-40: Hearing aid benefit limit — $3,000 per ear every 48 months.

Hearing aid benefit limitFor plans purchased outside Georgia Access, benefit provides one hearing aid per impaired ear not to exceed $3,000 per aid every 48 months (applies to children ≤18 under OCGA provisions).

DefinitionHearing Aid includes nonexperimental wearable instruments and parts; personal sound amplification products do not qualify.

Benefit scopeBenefit subject to conditions, limitations, exclusions, cost‑sharing and Copayment requirements in the Summary of Benefits and Coverage; applies only to plans purchased outside Georgia Access.

inv-41: DME rental vs purchase limit — reiteration of rental/purchase lesser-of rule.

Rental vs purchase ruleFor Durable Medical Equipment, the plan pays up to the lesser of the purchase price or twelve (12) months of rental charges (rental cap applies instead of purchase if lesser).

Provider certificationProvider must order/prescribe DME and certify medical necessity and expected duration in writing.

Continuing reviewAlliant may require proof of continuing medical necessity and documentation to support DME claims.

inv-42: Ovarian surveillance age threshold — age 35 and older.

Age thresholdOvarian cancer surveillance testing is covered for at‑risk women age 35 years and older.

At‑risk criteria (examples)At‑risk defined by family history (first/second‑degree relatives with ovarian cancer), clusters of female relatives with breast cancer, nonpolyposis colorectal cancer, or positive BRCA1/BRCA2 mutation.

Surveillance testsAnnual surveillance includes CA‑125 serum tumor marker, transvaginal ultrasound, and pelvic examination.

inv-43: copayment basis — copayment expressed per single fill or 31-day supply with examples for multi-month fills.

Copayment basisCopayment is expressed as a single fill or for a 31‑day supply, whichever is less; where copayments exist they follow the Summary of Benefits and Coverage.

Multi‑month fillsFor multi‑month fills (e.g., 90‑day retail), copayment is required for each month (example: 3 copayments for a 90‑day retail fill; 2.5 copayments for a 90‑day mail‑order fill).

Pharmacy ID usePresent your ID at In‑Network pharmacy; In‑Network pharmacies will submit the claim on your behalf; Out‑of‑Network pharmacy claims require itemized submission by member.

inv-44: Supply-based copayment application — multi-month fills prorated across months (examples for 90-day fills).

Supply‑based copayment applicationCopayment is expressed per single fill or 31‑day supply; multi‑month fills are prorated so members pay the equivalent monthly copayment (e.g., 3 copayments for a 90‑day retail fill or 2.5 copayments for a 90‑day mail‑order fill).

Copay calculationWhen multiple month fills are available, copayment/proration aligns with method of distribution (retail vs mail‑order) as described in the Summary of Benefits and Coverage.

PBM administrationPrime Therapeutics administers outpatient prescription drug benefits; contact Prime Member Services for formulary and copay questions.

inv-45: out-of-country coverage — emergency care only outside U.S.

Coverage scope outside U.S.Non‑emergency care outside the United States is not covered; Contract benefits apply only to emergency care and/or treatment received outside the U.S.

Member payment and documentationMembers must pay the foreign provider at time of service and submit bills, receipts and medical narratives for reimbursement consideration; payment based on MAC.

Assignment limitationBenefits may not be assigned to foreign providers or facilities.

inv-46: Clean Claim Requirement — claims must be Clean Claims; audits and potential denials if records missing.

Clean Claim requirementProviders must submit Clean Claims (nationally accepted format complying with coding guidelines); claims requiring further information are not Clean Claims.

Audit and recordsAlliant may request and review medical records and audit claims; benefits will not be payable if provider fails to submit a Clean Claim, obtain required Prior Authorization, or provide requested complete/legible records.

Potential denialsAlliant may deny or adjust benefits based on medical bill review findings including missing physician order, lack of documentation, unbundling, miscoding, or services excluded by the Contract.

inv-47: Expedited appeal decision time — 72 hours for expedited appeals.

Expedited appeal decision timeAn expedited (pre‑service) appeal will be completed within seventy‑two (72) hours (three calendar days) from receipt of the request.

Level I timeframesLevel I pre‑service appeals: 15 days; Level I post‑service appeals: 30 days from receipt.

Provider involvementThe provider has the right to discuss the appeal outcome with a physician or other appropriate reviewer as part of the appeal process.

inv-48: Cost-effectiveness threshold — when options equally effective, the least costly option is considered Covered Service.

Cost‑effectiveness ruleWhen more than one treatment option is available and options are equally effective, the Covered Service is the least costly option that is no less effective than any other option.

ApplicationThis cost‑effectiveness preference is applied when determining Covered Services in accordance with all other Contract provisions and MAC considerations.

Treatment selection impactSelection of a more costly option that is no more effective may not be considered the Covered Service under the Contract.

Provider Actions, Prior Authorizations, and Operational Requirements

Prior Authorization

In‑Network prior authorization: provider must call (800) 865-5922

For all in‑network inpatient hospital admissions (except maternity), the provider must call Prior Authorization at (800) 865-5922. Providers should notify Alliant by the next business day for emergency or maternity admissions; non‑urgent authorizations may be requested during normal business hours. Emergency Medical Services do not require prior authorization.

Provider call required for ALL in‑network inpatient admissions (except maternity).
Notify Alliant by next business day for emergency or maternity admissions to avoid issues.
Non‑urgent prior authorizations requested during normal business hours.
Emergency services do NOT require prior authorization.

Prior Authorization

Out‑of‑Network prior authorization: member must call (800) 865-5922

Members (or their representatives) must call Prior Authorization at (800) 865-5922 for all out‑of‑network inpatient hospital admissions. The member must notify Alliant within 1 business day of an emergency or maternity admission or the claim may be denied. Emergency Medical Services do not require prior authorization.

YOU (the Member) must call for Prior Authorization for ALL out‑of‑network inpatient admissions.
Notify Alliant within 1 business day of emergency or maternity admission to avoid denial.
Emergency services do NOT require prior authorization.

Denial Risk

Prior authorization is not a guarantee of coverage or payment

Prior Authorization approvals apply only to the services specified in the request and are not a guarantee of coverage or payment; approval does not extend to other services and benefits may be denied if the member is not covered, benefits are exhausted, or fraud/misrepresentation exists.

Prior Authorization is NOT a guarantee of coverage or future payment.
Approvals apply only to services outlined in the Prior Authorization request or listed on AlliantPlans.com.
Coverage may still be denied if member is not covered at time of service, benefits exhausted, or fraud/misrepresentation is involved.

Documentation Required

Use AlliantPlans.com or Client Services (866‑403‑2785) to locate In‑Network providers

Refer members to AlliantPlans.com or Client Services at (866) 403-2785 to locate in‑network providers and facilities. Providers should direct members to these resources for lists and assistance.

Provider/member resource for network lookup: AlliantPlans.com.
Client Services phone for assistance: (866) 403-2785.

Documentation Required

Notify Georgia Access or Alliant for enrollment changes; follow required timeframes

When enrollment changes occur (adding/removing dependents, marriage, divorce, newborn/adopted/foster additions), members who purchased through Georgia Access must notify Georgia Access; members who purchased outside Georgia Access must notify Alliant in writing or contact Client Services at (866) 403-2785 and submit required enrollment forms within stated timeframes (e.g., 31 days for many additions).

If purchased through Georgia Access: notify Georgia Access for enrollment changes.
If purchased outside Georgia Access: notify Alliant in writing or contact Client Services at (866) 403-2785.
Follow timing requirements (e.g., add spouse/stepchildren within 31 days; newborns covered 31 days—apply for continuation within timeframe).

Prior Authorization

Providers call Medical Management (800‑865‑5922); authorization decision timeframes specified

To authorize benefits or services, providers should call the Medical Management Department at (800) 865-5922. Alliant uses urgent, concurrent, pre‑service, and post‑service review processes with specified decision timeframes: urgent decisions as soon as possible but no more than 72 hours; pre‑service decisions within 7 calendar days (may extend 7 days); concurrent decisions within 24 hours for urgent requests or 7 days otherwise; post‑service reviews decided within 30 days.

Provider authorization contact: Medical Management Dept (800) 865-5922.
Urgent Care authorization decision: as soon as possible, but no more than 72 hours.
Pre‑service decision: within 7 calendar days (may extend another 7 days if needed).
Concurrent decisions: within 24 hours for urgent requests; otherwise within 7 days.
Post‑service review decision timeframe: within 30 calendar days.

Documentation Required

Prior Authorization list available on AlliantPlans.com or via Client Services

A listing of benefits that require Prior Authorization is available on AlliantPlans.com or by calling Client Services at (866) 403-2785; the Prior Authorization list is subject to change.

Prior Authorization list available at AlliantPlans.com.
Client Services can provide the list: (866) 403-2785.
List is subject to change.

Billing Rule

Alliant may authorize in‑network cost share for out‑of‑network care when no in‑network provider exists

If no in‑network provider is available for a covered service, Alliant may authorize application of in‑network cost‑share amounts (deductible, copayment, coinsurance) to services from an out‑of‑network provider if the member contacts Alliant in advance; the member may still owe the difference between the MAC and the out‑of‑network provider's charge.

Authorization required in advance to apply in‑network cost share to out‑of‑network care.
Member remains potentially liable for provider charges exceeding the MAC even when in‑network cost share is applied.
Contact Client Services for authorization: (866) 403-2785.

Prior Authorization

Scheduled ground ambulance transports require medical necessity review

Scheduled non‑emergency ground ambulance transports must be medically necessary and are subject to Alliant review; providers should obtain medical necessity review prior to scheduled transports.

All scheduled ground ambulance non‑emergency transports (except acute facility-to-acute facility) must be medically necessary.
Services are subject to review by Alliant.

Prior Authorization

Air ambulance and clinical trial participation require Alliant review/prior authorization

Air ambulance services and participation in clinical trials require Alliant medical necessity review or Prior Authorization; Alliant may select the air ambulance provider for transport. For clinical trials, routine patient care costs require Prior Authorization and referral by an in‑network provider.

Air ambulance services are subject to Alliant medical necessity review; Alliant may select the air ambulance provider.
Hospital‑to‑hospital air ambulance must be medically necessary.
Participation in qualifying clinical trials requires referral by an in‑network provider and Prior Authorization from Alliant for routine patient care costs.

Documentation Required

DME must be prescribed by a physician with written certification of medical necessity

Durable medical equipment must be ordered/prescribed by a Physician; the provider must certify in writing the medical necessity and expected length of need. Alliant may require proof of continuing medical necessity, and payment is limited to the lesser of purchase price or 12 months rental.

Physician order/prescription required for DME.
Provider must certify medical necessity in writing and state expected duration.
Alliant may require proof of continuing medical necessity.
Plan pays rental up to lesser of purchase price or 12 months of rental charges.

Prior Authorization

Home Health requires physician certification and written plan of care; claims reviewed for skilled services

Home health care requires a Physician's certification and a written plan of care; services must be intermittent skilled care (visits up to four hours) and members must be essentially confined at home. Claims will be reviewed to verify services are skilled and medically consistent with the diagnosis.

Physician certification statement and written plan of care required.
Home Health visit: up to four hours; services are intermittent skilled care.
Member must be essentially confined at home.
Claims reviewed to verify services are skilled and medically consistent with diagnosis.

Prior Authorization

Hospice requires physician certification (≤6 months) and Alliant‑approved hospice program

Hospice care requires the attending physician to certify the patient is terminal with a life expectancy of six months or less, and the hospice program must be recognized/approved by Alliant, physician‑directed, RN‑coordinated, organized for homecare, use a hospice team, and provide around‑the‑clock care.

Physician must certify life expectancy of six months or less.
Hospice program must be recognized/approved by Alliant.
Program must be physician‑directed, RN‑coordinated, include organized homecare, a hospice team, and 24/7 availability.

Prior Authorization

Federal law protects minimum postpartum stay lengths; prior authorization cannot be required for those stays

Federal law prohibits restricting the minimum postpartum inpatient stay to less than 48 hours for vaginal delivery or 96 hours for cesarean delivery, and the Contract may not require prior authorization for those lengths of stay; if discharged earlier, two post‑discharge follow‑up visits must be available within the protected period.

Minimum protected postpartum stay: 48 hours (vaginal) or 96 hours (cesarean) — cannot be restricted by prior authorization.
If discharged earlier, member has access to two post‑discharge follow‑up visits within that period.
Length of stay determined by attending physician.

Prior Authorization

All transplants require prior authorization (call 800‑865‑5922) and Alliant medical criteria

All transplant procedures must be prior authorized by calling (800) 865-5922, be determined Medically Necessary, and not be Experimental or Investigational per Alliant criteria; physicians must submit complete medical history, diagnosis, and surgeon name, and transplants must be at an Alliant‑approved transplant center.

Prior Authorization required for all transplant procedures: call (800) 865-5922.
Transplant must be Medically Necessary and not Experimental/Investigational per Alliant criteria.
Physician must submit complete medical history, current diagnosis, and surgeon name.
Surgery must be performed at an Alliant‑approved Transplant Center.

Prior Authorization

Prescription drugs (including specialty drugs) often require prior authorization; non‑approved drugs are not covered

A limited number of prescription drugs (including most specialty drugs and many medical‑benefit administered drugs) require Prior Authorization for medical necessity; if prior authorization is not approved, the drug is not eligible for coverage. Contact Prime Member Services for lists and appeals.

Prior Authorization required for select prescription drugs and most specialty drugs.
Medical‑benefit administered drugs (infusions, chemotherapy, injectables) often require prior authorization.
If Prior Authorization is not approved, the drug will not be eligible for coverage.
Contact Prime Member Services for lists: (844) 451-8288; Medical Pharmacy Services: (800) 424-1799.

Documentation Required

No benefits payable if provider fails to obtain required prior authorizations and submit Clean Claims/records

Alliant may require prior authorization approvals and medical documentation; if a provider fails to obtain required prior authorizations or submit requested records and a Clean Claim, Alliant will not pay benefits. Providers must submit Clean Claims and provide medical records upon request for audits and claim adjudication.

Providers must submit Clean Claims; Alliant may audit claims and request medical records.
No benefits payable if provider fails to obtain required prior authorization and submit requested documentation.
Claims adjudication follows federal coding/billing guidelines; providers must bill using accurate CPT/ICD/HCPCS codes.

Billing Rule

Claims filing: in‑network providers file claims; out‑of‑network may require member submission

In‑network providers will file claims directly with Alliant and members are not responsible for filing when an in‑network provider submits the claim. When services are provided by an out‑of‑network provider, that provider is not required to file; members may need to pay at time of service and submit an itemized claim (including Member and Group ID, dates, places, nature of services) for reimbursement.

In‑Network providers file claims; members not responsible for filing when provider submits claim.
Out‑of‑Network providers may not file claims; members may need to pay up front and submit itemized bills for reimbursement.
Claims submitted by member must include Member and Group ID, itemization of dates, places, and services.

Documentation Required

Initiate complaints via Client Services (866‑403‑2785); provider complaints handled same way

Members and providers should contact Client Services at (866) 403-2785 to initiate complaints; provider‑related complaints are also handled via Client Services. Follow Alliant's complaint process and, if dissatisfied, file a formal complaint and then an appeal as outlined.

Initial complaint contact: Client Services (866) 403-2785.
Provider‑related complaints handled via Client Services.
If unresolved, member may file a formal complaint and pursue appeal rights per the Contract.

Prior Authorization

How to submit prior authorization appeals and expedited (72‑hour) appeals

Medical prior authorization appeals may be filed by the member or an authorized representative using the appeal form on AlliantPlans.com and mailed/faxed to Alliant Health Plans Appeals Dept (PO Box 1247, Dalton, GA 30722; Phone: (800) 865-5922; Fax: (866) 634-8917). Pharmacy appeals use Prime Therapeutics or Prime Medical Pharmacy Appeals contacts. Expedited (urgent) pre‑service appeals may be requested by phone or in writing and will be decided within 72 hours.

Medical prior authorization appeals: use Alliant appeal form (AlliantPlans.com) and mail/fax to Appeals Dept; Phone: (800) 865-5922; Fax: (866) 634-8917.
Pharmacy prior authorization appeals: contact Prime Therapeutics (phone/fax) or Prime Medical Pharmacy Appeals (contact in chunk 224/140).
Expedited pre‑service appeals: may be requested by phone or writing; decision within 72 hours.

Documentation Required

Cooperate with Alliant during complaint/appeal reviews; teleconference and evidence sharing provided

During complaint and appeal reviews providers and members must cooperate fully with Alliant; Alliant will offer telephone conferences at no charge and will provide any new or additional evidence used in the appeal to the member. Reviews consider the services without regard to the initial determination or provider network status.

Cooperate fully with Alliant in complaint/appeal reviews or risk waiving timely processing.
Alliant will offer telephone conferencing at no charge.
Alliant will provide any new or additional evidence used in the appeal to the member for review.
Appeals are reviewed regardless of initial determination or provider status.

Note

Direct Access: members may see primary and specialty physicians without Alliant referral

Members have direct access to primary and specialty care physicians without the need for an Alliant‑approved referral (Direct Access). Providers should not require an Alliant referral for routine primary or specialty visits unless otherwise specified in the Contract.

Direct Access permits seeing primary and specialty physicians without Alliant referral.
Providers should not require Alliant referral for routine primary/specialty care unless Contract states otherwise.

Note

Defined Terms

inv-74: Pronoun definitions — 'We/Us/Our' = Alliant Health Plans; 'You/Your' = Member/Subscriber.

We/Us/OurRefers to Alliant Health Plans (the issuer of the Certificate of Coverage).

You/YourRefers to the Member — the Subscriber and any covered Dependents.

ContextThese pronoun definitions apply throughout the Certificate as the parties to the Contract.

inv-75: Subscriber/Member definition — the purchaser and covered dependents.

Subscriber/MemberThe person who purchased the coverage (Subscriber) and any covered Dependents are Members under the Contract.

Dependent scopeEligible Dependents include spouse (if not legally separated) and children through the end of the year they attain age 26, among other categories defined in Eligibility.

Coverage basisCoverage exists while terms of the Contract are met and required premiums are paid.

inv-76: Subscriber or Member — purchaser and covered dependents (alternate).

Subscriber or MemberThe Subscriber is the individual who applied for coverage; covered Dependents enrolled with the Subscriber are also Members.

Eligibility examplesEligible Dependents include legally adopted children from date legal responsibility assumed and stepchildren when added per enrollment rules.

Enrollment timing noteFailure to enroll eligible dependents within specified timeframes can make them Late Enrollees subject to Open Enrollment rules.

inv-77: In-Network Provider — definition and cost-sharing implications.

In‑Network Provider definitionAn In‑Network Provider is a healthcare provider who is part of Alliant's network or has a contract with Alliant Health Plans.

Cost‑sharing implicationUsing In‑Network providers typically results in lower member cost‑sharing because providers accept predetermined allowed amounts.

Provider lookupMembers can find In‑Network providers at AlliantPlans.com or by calling Client Services at (866) 403‑2785.

inv-78: Preferred Provider Organization (PPO) — plan type description.

PPO descriptionPreferred Provider Organization (PPO) is a comprehensive benefit plan offering choice of providers with two benefit sets: In‑Network and Out‑of‑Network.

Member choiceMembers may choose providers each time they seek care; In‑Network choices generally yield lower out‑of‑pocket costs.

Check SBCBenefit differences between In‑Network and Out‑of‑Network care are shown in the Summary of Benefits and Coverage.

inv-79: Maximum Allowed Cost (MAC) — definition and reimbursement role.

Maximum Allowed Cost (MAC)MAC is the amount used to determine reimbursement for Covered Services; for Out‑of‑Network services reimbursement is based on the plan's MAC and members may be liable for differences between MAC and provider charges.

Claim processing impactClaims processing rules (coding, bundling) may affect determination of MAC; improper coding can result in MAC being based on a single inclusive code rather than multiple billed codes.

Emergency service QPA linkageFor emergency services, MAC/QPA calculations follow state (OCGA) or federal No Surprises Act methods described in the Contract.

inv-80: Copayment / Out-of-Pocket — definition and examples (ER copayment waiver noted).

Copayment / Out‑of‑Pocket definitionA Copayment is a flat‑dollar cost‑sharing amount a Member pays for a Covered Service (distinct from Coinsurance which is percentage‑based).

Emergency room copayIf applicable, emergency room Copayment is waived when a Member is admitted to the hospital through the emergency room.

Pharmacy copay expressionFor prescription drugs, copayment is expressed as a single fill or for a 31‑day supply; multi‑month fills require prorated/monthly copayments as described in the pharmacy section.

inv-81: Autism — definition as used in policy.

Autism definitionAutism is a developmental neurological disorder, usually appearing in the first three years of life, characterized by compulsive, ritualistic behavior and impaired social interaction and communication.

Coverage noteContract provides habilitative/rehabilitative services and other therapy/counseling necessary to develop, maintain, or restore functioning for individuals with ASD, subject to Contract limits.

CertificationServices must meet Contract conditions, limitations, exclusions, and cost‑sharing as outlined for neurological disorders.

inv-82: Medical emergency — definition reference.

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

Emergency actionsIf you require emergency care, go to the emergency room or call 911; ER copayment may be waived if admitted.

Balance‑billing protectionYou cannot be balance‑billed for Out‑of‑Network emergency services per state and federal surprise billing laws.

inv-83: Hearing Aid — definition and exclusions.

Hearing Aid definitionHearing Aid means any nonexperimental wearable instrument or device to aid impaired hearing and includes parts, ear molds, repair and replacement parts; personal sound amplification products do not qualify.

Benefit applicabilityWhere applicable (plans purchased outside Georgia Access), hearing aid benefits and limits are specified in the Summary of Benefits and Coverage.

ExclusionsPersonal sound amplification products are expressly excluded from qualifying as Hearing Aids.

inv-84: Home Health Care visit — definition of visit duration (up to 4 hours).

Home Health Care visit durationA Home Health Care visit consists of up to four (4) hours of skilled care in the member's home.

Program elementsProgram provides intermittent skilled care (observation, evaluation, teaching, nursing) established and approved in writing by attending Physician; visits have calendar‑year limits per the Summary of Benefits.

Benefit interactionHome Health Care services do not reduce outpatient therapy benefits available under Physical, Occupational, or Speech Therapy sections.

inv-85: Licensed mid-level providers — who is included.

Licensed mid‑level providers includedIncludes Nurse Practitioners (NP), Physician Assistants (PA), Physician Assistant Anesthetists (PAA), and Athletic Trainers (LAT) when performing services within their Georgia scope of practice.

Coverage conditionBenefits payable for Covered Services provided by licensed mid‑level providers when acting within scope of practice.

State scopeScope of practice is defined by the state of Georgia and governs benefit eligibility for services rendered by mid‑level providers.

inv-86: Preventive care (In-Network) — federal/state law-aligned preventive services covered with no member cost-share.

Preventive care coverage (In‑Network)Preventive services meeting USPSTF A/B, ACIP immunizations, HRSA child/adolescent and women's guidelines are covered with no deductible, copayments, or coinsurance when provided In‑Network (Alliant pays 100% of allowed amount).

Implementation timingNew government recommendations become covered for plan years beginning one year after issuance (or as required by ACA); plan year is calendar year.

Out‑of‑Network preventive servicesOut‑of‑Network preventive services are paid at MAC and remain subject to deductible, coinsurance, and potential provider balance billing.

inv-87: Telemedicine — definition of telemedicine service modalities.

Telemedicine definitionTelemedicine is clinical services provided through secure real‑time audio, video, or other electronic communications allowing assessment, diagnosis, consultation, treatment, and management remotely; patient must be present and participating.

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

Use caseTelemedicine can replace in‑person visits for consultations when real‑time communication is possible.

inv-88: Urgent Care — definition and examples of urgent conditions.

Urgent Care definitionUrgent Care is medical care for conditions that could seriously jeopardize life/health or ability to regain function, or would subject the patient to severe unmanaged pain; not life threatening and not an emergency.

Setting distinctionUrgent Care conditions are typically treated at Urgent Care Centers rather than emergency rooms; coverage follows Summary of Benefits and Coverage.

See exclusionsRefer to Limitations and Exclusions for Non‑Covered Services related to urgent care.

inv-89: Specialty Drugs — definition and handling requirements for specialty medications.

Specialty Drugs definitionSpecialty Drugs are typically high‑cost injectable, infused, oral or inhaled medications that require close supervision, special handling, and often prior authorization.

Handling requirementsSpecialty Drugs often require temperature‑controlled packaging, overnight delivery, and may be dispensed via contracted specialty pharmacies; most require Prior Authorization.

Medical pharmacy linkSome specialty medications administered by providers are covered under the medical benefit and often require Prior Authorization.

inv-90: Off-label drug — definition and pre-approval requirements for off-label use in life-threatening or chronic disabling conditions.

Off‑label drug definitionAn off‑label drug is prescribed for a use different from the FDA‑approved marketing indication.

Pre‑approval requirementOff‑label drugs for life‑threatening or chronic disabling conditions require pre‑approval by Alliant Health Plans to be covered.

Associated servicesMedically necessary services associated with administration of pre‑approved off‑label drugs are also covered per Contract terms.

inv-91: Balance billing — definition of balance billing and member protections.

Balance billing definitionBalance billing occurs when a provider bills You for the difference between what Your insurance pays (MAC) and what they charge for a service.

Member protection In‑NetworkIn‑Network providers are prohibited from balance billing; members are not liable for amounts above the allowed amount except contractual cost‑share.

Out‑of‑Network riskOut‑of‑Network providers may bill members for fees in excess of MAC unless state/federal surprise billing laws apply (e.g., emergency services protections and OCGA/No Surprises Act methods for MAC/QPA).

inv-92: Care received outside the U.S. — emergency-only coverage stance.

Care outside the U.S. stanceNon‑emergency care received outside the United States is not covered; only emergency care/treatment outside the U.S. is eligible for Contract benefits.

Reimbursement processMembers should pay the foreign provider and submit documentation (bills, receipts, medical narrative) for reimbursement based on MAC.

Assignment limitationBenefits may not be assigned to foreign providers or facilities.

inv-93: Birthday Rule — definition reference.

Birthday RuleWhen dependent children have dual coverage, the primary plan is the parent whose birthday falls earlier in the calendar year (month and day), per the Birthday Rule.

UsageBirthday Rule applies to determine primary versus secondary coverage among parental plans for dependent children.

Coordination contextThis rule is part of broader COB rules establishing order of benefit payment when multiple plans exist.

inv-94: Care received outside the U.S. (duplicate) — reiteration of emergency-only coverage outside U.S.

Care outside the U.S. (reiteration)Coverage for care received outside the United States is limited to emergency care; non‑emergency care abroad is not covered under the Contract.

Member actionMembers must pay at time of service and submit required documentation for reimbursement consideration (payment based on MAC).

No assignmentBenefits may not be assigned to foreign providers or facilities.

inv-95: Clean Claim — definition and expectations for claims.

Clean Claim definitionA Clean Claim is a claim received for adjudication in a nationally accepted format complying with standard coding guidelines and requiring no further information, adjustment, or alteration.

Provider expectationProviders are required to submit Clean Claims; failure to do so may trigger audits and denial of benefits until complete information is provided.

Relation to auditsAlliant may audit claims and request medical records; Clean Claim status is a prerequisite for prompt adjudication.

inv-96: Subrogation — definition and plan recovery rights.

Subrogation definitionSubrogation is the plan's right to recover amounts paid from anyone responsible for the member's injury or loss by using the member's rights against third parties.

Member dutiesMembers/attorneys must notify Alliant of legal action or settlement discussions ten days prior to settlement or trial to enable Alliant to protect subrogation rights.

Recovery scopeSubrogation rights allow Alliant to recover amounts paid under the plan from third‑party recoveries; Alliant may use member's contractual and legal rights to pursue recovery.

inv-97: Reimbursement — right of reimbursement definition linked to member recoveries.

Right of reimbursementAlliant has a separate right to be repaid from any money the member recovers for an injury or condition for which the plan paid benefits; the plan has priority to be repaid first.

Scope of repaymentRepayment obligation applies even if the member is not made whole and may include settlements or other recoveries from third parties or insurers.

EnforcementFailure to cooperate with reimbursement/subrogation provisions may lead to suspension or termination of benefits under the plan.

inv-98: Recovery — right of recovery for overpayments and retention of recoveries.

Right of recoveryAlliant has authority to recover overpayments from members, providers, vendors or subcontractors and may retain recoveries consistent with recovery policies; it may offset future claims without prior notice if administratively burdensome.

Recovery periodExcept in fraud cases, Alliant will only recover payments from a Provider during the 12 months after the date the payment was made on a claim submitted by the Provider.

Cost‑benefit approachAlliant may decline to pursue recoveries where collection costs exceed the overpayment amount.

inv-99: Adverse Benefit Determination — definition of adverse benefit determination used in appeals.

Adverse Benefit DeterminationAn Adverse Benefit Determination is a denial, reduction, termination, rescission, or failure to provide or make payment (in whole or in part) for a benefit and includes determinations based in whole or in part on medical judgment.

Examples includedIncludes decisions that services are experimental/investigational, not medically necessary, inappropriate, or that initial eligibility is denied.

Appeals relevanceAdverse Benefit Determination is the defined trigger for internal appeals, external review rights, and timelines specified in the appeals section.

inv-100: Adverse Benefit Determination (duplicate) — alternate chunk reference.

Adverse Benefit Determination (duplicate)A denial of a request for service or failure to provide or make payment (in whole or in part) for a benefit; includes reductions, terminations, rescissions and medical‑judgment based decisions.

Effect on appealsA Final Adverse Benefit Determination occurs when internal appeal is upheld or appeal period elapses without determination.

Appeal initiationMembers or authorized representatives have the right to file appeals per the timelines in the appeals section.

inv-101: Authorized Representative — definition and scope.

Authorized RepresentativeAn individual authorized in writing by the member or state law to act on the member's behalf in requesting services, obtaining claim payment, or during internal appeals; for Urgent Care Services a provider may act without express consent.

ScopeAuthorized Representatives can file appeals and obtain information on behalf of the member when properly authorized.

DocumentationAuthorization should be in writing as required by the appeals and administrative procedures.

inv-102: Final Adverse Benefit Determination — definition and when it applies.

Final Adverse Benefit DeterminationA Final Adverse Benefit Determination is an Adverse Benefit Determination upheld after the internal appeal process or when the internal appeal time period elapses without a determination.

External review triggerA Final Adverse Benefit Determination allows the member to seek External Review within specified timeframes per the appeals section.

Appeal implicationFinal determinations are the end point of internal appeals before optional Level II or External review as applicable.

inv-103: Post-/Pre-Service and Urgent Care Services Claim — claim category definitions.

Post‑/Pre‑Service and Urgent Care ClaimsPost‑Service Claim: service already provided; Pre‑Service Claim: service not yet provided; Urgent Care Services Claim: pre‑service claim where delay could seriously jeopardize life/health or cause severe unmanaged pain.

Appeal timing impactClaim classification determines applicable appeal timeframes (e.g., expedited/urgent procedures may apply to Urgent Care Services Claims).

Provider roleProviders may act as Authorized Representatives for Urgent Care Services without express member consent to expedite requests.

inv-104: Bodily Injury — definition used for subrogation/recovery contexts.

Bodily Injury definitionBodily Injury is injury sustained by a Member from an unforeseen event that is the direct cause for care received; excludes injuries covered under Workers' Compensation or similar laws.

ContextDefinition used primarily in subrogation, recovery and claims coordination contexts within the Contract.

Recovery implicationsBodily Injury recoveries may trigger subrogation/reimbursement rights described in the Contract.

inv-105: After-Hours Office Visit — definition reference.

After‑Hours Office VisitCare rendered as a result of a condition that has an onset after the Physician's business hours.

Access guidanceMembers can contact Client Services or the website to locate in‑network facilities for after‑hours needs.

DistinctionAfter‑hours visits are distinct from urgent or emergency services per the Contract definitions.

inv-106: Ambulatory Facility — definition for outpatient surgical facility.

Ambulatory FacilityA licensed facility with physician staff where outpatient surgical procedures are performed without overnight stay; offers continuous physician and RN services; does not include a physician's office.

Licensure requirementAmbulatory Facilities must be licensed by the appropriate state agency to qualify.

Coverage implicationServices at Ambulatory Facilities are covered when Medically Necessary and billed per Contract provisions.

inv-107: Applicant — definition used in enrollment context.

ApplicantThe individual who applied for this Contract.

RoleApplicant information forms part of the Application for Enrollment and the Contract records.

Relation to Effective DateThe Contract takes effect on the Effective Date as confirmed by Alliant based on application/enrollment processing.

inv-108: Application for Enrollment — definition and allowed formats (electronic).

Application for EnrollmentThe original and any subsequent forms completed and signed by the Subscriber seeking coverage; may be electronic.

UseApplication details determine eligibility, Effective Date, and enrollee information incorporated into the Contract.

FormatElectronic submissions are acceptable forms for the Application for Enrollment.

inv-109: Autism (duplicate) — definition present in definitions list.

Autism (duplicate)A developmental neurological disorder usually appearing in the first three years of life, affecting social interaction and communication; defined in the Contract.

Benefit period contextDefinitions reference benefit and contract period terms (e.g., calendar year) when applying services or age limits.

Coverage noteHabilitative/rehabilitative services for autism are provided per Contract conditions and limits.

inv-110: Brand Name Drugs — definition and single vs multi-source brand distinction.

Brand Name DrugsA Brand Name Drug is under patent by its original innovator/marketer; includes Single Source Brand (no generic) and Multi‑Source Brand (has generic equivalent).

Formulary impactFormulary determines covered Brand and Generic drugs; DAW and tiering rules affect member cost‑share.

PBM rolePrime Therapeutics administers outpatient prescription drug benefits and formulary management for the plan.

inv-111: Chemical Dependency Treatment Facility — licensing and program supervision requirements (Georgia reference).

Chemical Dependency Treatment FacilityA licensed institution for chemical dependency treatment (inpatient/outpatient) under a physician‑supervised prescribed program; must be licensed/registered/approved by Georgia authority or accredited by The Joint Commission.

Program supervisionProgram must include diagnostic and therapeutic facilities and supervision by a licensed Physician as required by state law.

Coverage conditionServices provided must meet Medically Necessary and Contract criteria to be covered.

inv-112: Clean Claim (duplicate) — claim format and compliance expectations.

Clean Claim (duplicate)A Clean Claim is defined as a claim in an accepted format complying with coding guidelines and requiring no further information or adjustment by the provider.

Provider responsibilityProviders are required to submit Clean Claims; failure may delay processing or lead to denials pending corrected submission.

Audit linkageAlliant reserves the right to audit claims and request records to confirm Clean Claim status and benefit eligibility.

inv-113: Coinsurance — definition and example.

CoinsuranceThe portion of costs for which a Member is responsible when coverage is expressed as a percentage (e.g., 20% remaining when coverage is 80%); may be capped by Out‑of‑Pocket Limit and is distinct from Copayment.

Interaction with OOPCoinsurance may be reduced by the Out‑of‑Pocket Limit; refer to the Summary of Benefits and Coverage for limits and percent amounts.

Payment timingCoinsurance amounts are typically owed after plan determines allowed amount and member has met applicable deductible unless preventive or other exceptions apply.

inv-114: Combined Limit — definition for combined in/out-of-network limits.

Combined LimitThe Combined Limit is the maximum total of In‑Network and Out‑of‑Network care available for designated health services as shown in the Summary of Benefits and Coverage.

ApplicationCombined Limits cap access to certain services across both network tiers when specified in the Summary of Benefits.

Member referenceRefer to the Summary of Benefits and Coverage for specific Combined Limit amounts applicable to services.

inv-115: Complications of Pregnancy — definition relevant to maternity coverage.

Complications of PregnancyConditions requiring hospital confinement that are distinct diagnoses adversely affected or caused by pregnancy (e.g., preeclampsia, acute nephritis) are Complications of Pregnancy.

Not includedNormal pregnancy‑related conditions such as false labor, occasional spotting, or morning sickness are not considered Complications of Pregnancy.

Coverage implicationComplications are covered when Medically Necessary and distinct from routine maternity care per the Maternity section.

inv-116: Congenital/developmental Anomaly — definition reference.

Congenital/developmental AnomalyA condition present at birth regardless of cause; may be hereditary or due to gestational influences.

Coverage noteServices to treat congenital anomalies are evaluated for medical necessity and covered per Contract definitions and exclusions.

DocumentationAppropriate medical documentation is required to support coverage for corrective or reconstructive procedures related to congenital anomalies.

inv-117: Contract — definition of the Certificate and related documents comprising the Contract.

Contract contentsThe Contract consists of the Certificate, the Alliant Formulary, any amendments/riders, and the Application for Enrollment; amendments/riders control in event of conflict.

Legal effectThis Certificate replaces and overrides prior Contracts and becomes effective on the Effective Date as confirmed by Alliant.

Member obligationsBenefits provided under the Contract are subject to meeting Contract terms and payment of required premiums.

inv-118: Contract Year — calendar year contract period definition.

Contract Year definitionA Contract Year (policy year) is the calendar year beginning January 1 at 12:01 am and ending December 31 at 11:59 pm Eastern Time.

Relation to preventive coveragePlan year for preventive care timing is based on the calendar year; new government recommendations become covered for plan years starting one year after issuance.

Deductible alignmentDeductible and many benefit limits apply on a calendar year basis consistent with the Contract Year definition.

inv-119: Coordination of Benefits — COB provision overview.

Coordination of Benefits (COB)COB is a process to avoid payment delays and duplication when a person is covered by multiple plans by establishing the order in which plans pay and information transfer rules.

Primary/secondary rulesIndividual non‑group plans use rules (longer‑plan rule, birthday rule, etc.) to determine primary versus secondary status as described in the Contract.

Effect on benefitsWhen this plan is secondary, payment may be reduced by amounts payable by the primary plan; services not eligible under both plans are not subject to COB.

inv-120: Copayment — definition and use.

Copayment definitionA Copayment is a flat‑dollar cost‑sharing amount a Member pays for a Covered Service, usually at time of service; distinct from Coinsurance.

CollectionCopayments may be collected by the provider at time of service and are shown in the Summary of Benefits and Coverage.

Difference from coinsuranceCopayment is a fixed dollar amount while Coinsurance is a percentage of allowed charge; both are forms of member cost‑share.

inv-121: Cosmetic Surgery — definition and examples of non-covered cosmetic procedures.

Cosmetic Surgery definitionAny non‑medically necessary surgery or procedure primarily intended to improve appearance that does not restore function or correct disease; examples include rhinoplasty, lipectomy, mammoplasty and related procedures.

Coverage stanceCosmetic Surgery is excluded as Non‑Covered unless otherwise specified (e.g., reconstructive surgery after mastectomy may be covered if Medically Necessary).

ExamplesIncludes augmentation/reduction procedures, treatments relating to consequences of cosmetic surgery, and other non‑therapeutic appearance procedures.

inv-122: Covered Dependent — definition of dependents eligible for coverage.

Covered DependentAny Dependent in a Subscriber's family who meets Eligibility requirements and has enrolled and paid required Premiums is a Covered Dependent.

Dependent categoriesDependents include spouse and children until attaining age 26, including natural, adopted, stepchildren and certain foster children per eligibility rules.

Enrollment requirementDependents must be enrolled and meet premium requirements to obtain Covered Dependent status; timing rules affect Late Enrollee status.

inv-123: Cosmetic Surgery (duplicate) — alternate chunk reference.

Cosmetic Surgery (duplicate)Non‑medically necessary procedures primarily to change appearance and not to restore function are excluded; examples listed in the Contract.

Coverage exceptionsReconstructive procedures to restore function or correct disease/injury may be covered if Medically Necessary and meet Contract criteria.

Member guidanceRefer to the 'What Is Not Covered' section and Summary of Benefits to determine applicable exclusions and potential exceptions.

inv-124: Covered Dependent (duplicate) — alternate chunk reference.

Covered Dependent (duplicate)A Dependent meeting Eligibility and Premium requirements who is enrolled under a Subscriber's family coverage is a Covered Dependent.

Enrollment timingSpecial enrollment periods and newborn/adoption rules govern timing for adding dependents to maintain continuous coverage.

Termination triggersCoverage for a Dependent ends when they no longer meet age or eligibility requirements or upon removal events such as divorce or death.

inv-125: Covered Services — definition of covered services and exclusion criteria.

Covered Services definitionCovered Services are Medically Necessary health care services, treatment and supplies defined as Covered Services in the Contract, not excluded, and not Experimental/Investigational.

Least‑cost ruleWhen multiple treatment options are equally effective, the least costly option that is no less effective is the Covered Service.

Subject to MAC and exclusionsCovered Services determinations consider the MAC, Contract exclusions, and all other Contract provisions.

inv-126: Creditable Coverage — definition and 90-day gap threshold.

Creditable CoverageCoverage under another health plan with no greater than a 90‑day gap qualifies as Creditable Coverage.

ExamplesIncludes Medicare, Medicaid, employer‑based coverage, individual policies, spouse's coverage, and similar arrangements as defined by OCGA 33‑30‑15.

Benefit transfer impactCreditable Coverage status can affect eligibility for special enrollment and preexisting condition considerations per applicable rules.

inv-127: Custodial Care — definition and examples of non-skilled care.

Custodial CareCare that does not require professional or technical skills (including room and board) or care where member has reached maximum function and unlikely to improve; generally non‑covered as skilled care.

Coverage implicationCustodial Care is excluded from Skilled Nursing Facility and Home Health Care coverage unless specific skilled services are needed and documented.

Documentation requirementMedical documentation must demonstrate skilled needs to qualify services otherwise considered custodial for coverage purposes.

inv-128: Deductible — calendar year application of deductible.

Deductible definitionThe Deductible is the portion of the bill the member must pay before medical expenses become reimbursable and is applied on a calendar year basis.

Summary of BenefitsSpecific deductible amounts and application rules are shown in the Summary of Benefits and Coverage.

Preventive exceptionCertain preventive services may be covered prior to meeting the deductible per Contract rules.

inv-129: Dependent — coverage up to age 26 and scope of dependent definitions.

Dependent definitionDependent includes spouse and all children until attaining age 26, including natural, adopted, stepchildren, certain foster children, and children required to be covered by court decree.

Disability exceptionMentally or physically disabled dependent children who are totally dependent on the Subscriber for support may remain covered beyond age 26 with required certification.

Enrollment timingSpecific rules apply for newborns, adopted and foster children regarding application deadlines to retain continuous coverage.

inv-130: Detoxification — definition for licensed facility detox services.

DetoxificationAssistance in a licensed facility to eliminate intoxicating substances or dependence factors under physician supervision, minimizing physiological risk.

Facility requirementFacility must be licensed by the appropriate regulatory authority to provide detoxification services.

Coverage scopeDetoxification services are covered when Medically Necessary and meet Contract requirements.

inv-131: Developmental Delay — definition and screening context.

Developmental DelayA statistical variation in reaching developmental milestones as defined by standardized screening tests; alone it is not an illness and services should target functional deficits.

Service objectiveServices should be aimed at treating or promoting recovery of specific functional deficits identified by screening.

Coverage linkageCoverage for related services is subject to Medical Necessity and Contract limits for habilitative/rehabilitative benefits.

inv-132: Direct Access — member access to primary and specialty care without referral.

Direct AccessMembers have access to primary and specialty care physicians without the need for an Alliant‑approved referral.

Member actionMembers may see participating providers directly; check network status or call Client Services for assistance locating providers.

ScopeDirect Access applies to covered services within the Contract and subject to any Prior Authorization requirements where specified.

inv-133: Durable Medical Equipment — definition and Alliant criteria for DME.

Durable Medical Equipment (DME)Equipment determined by Alliant that is durable, used in treatment of disease or injury, suitable for use outside an inpatient setting, and not normally useful to those without disease/injury.

Coverage conditionsDME must be ordered by a Physician, meet durability and medical‑purpose criteria, and provider must certify medical necessity and expected duration; rental vs purchase payment rules apply.

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

inv-134: Effective Date — definition indicating when benefits begin.

Effective DateThe date on which benefits begin for each member; Contract takes effect on the Effective Date as confirmed by Alliant.

Coverage start timeCoverage begins at 12:01 a.m. on the Effective Date as determined by Alliant and confirmed in notice.

No retroactive coverageBenefits are not provided for services before the Effective Date unless otherwise specified by Contract provisions (e.g., newborn automatic 31‑day coverage).

inv-135: Elective Surgical Procedure — definition and scheduling implications.

Elective Surgical ProcedureA surgical procedure that is not an emergency and may be scheduled or delayed by the Member.

Authorization implicationElective procedures may require Prior Authorization per the Authorization section; scheduling should consider Prior Authorization timelines.

Coverage criteriaElective procedures are covered only if Medically Necessary and not otherwise excluded by the Contract.

inv-136: Emergency Medical Services — definition and prudent layperson standard.

Emergency Medical ServicesA condition with acute symptoms so severe that a prudent layperson would expect lack of immediate attention to result in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of an organ/part.

ER actionSeek emergency room care or call 911; ER copayment may be waived if admitted.

Balance‑billing protectionMembers are protected from balance‑billing for Out‑of‑Network emergency services under state and federal surprise billing laws.

inv-137: Essential Health Benefits — definition of EHB categories per PPACA.

Essential Health Benefits (EHB)Categories of benefits defined under PPACA including ambulatory, emergency, hospitalization, maternity/newborn, mental health/substance use, prescription drugs, rehabilitative/habilitative services, lab, preventive/wellness, chronic disease management, and pediatric services (including vision).

No annual/lifetime limitsThe Contract indicates no annual or lifetime dollar limits for Covered Services that are Essential Health Benefits.

ApplicationEHB scope informs coverage determinations for services falling within these categories per federal requirements.

inv-138: Experimental and/or Investigational — definition and evidentiary expectations.

Experimental/Investigational definitionServices (drugs, biologics, procedures, devices) that are not commonly accepted by the majority of U.S. practitioners or lack credible evidence of benefit and/ or are in clinical trials are considered Experimental and/or Investigational and are not reimbursable.

Evidence standardReliable evidence includes published authoritative literature, clinical trial protocols, informed consent, and accepted guidelines (AMA, FDA, NCCN, NIH).

Alliant discretionAlliant has full authority to interpret, administer and apply the Experimental/Investigational definition in making coverage decisions.

inv-139: Frame — eyeglass frame definition (standard frames only).

FrameStandard eyeglass frames, excluding lenses.

Pediatric vision contextFrames for pediatric vision benefits are subject to the Pediatric Vision section limits and exclusions.

ExclusionsSpecial/unusual frame types may be excluded unless specified in the Summary of Benefits.

inv-140: Generic Drugs — definition and equivalence to brand drugs.

Generic DrugsPrescription drugs that are not Brand Name Drugs but are made of equivalent ingredients and typically have lower cost‑share.

Formulary placementGeneric tier placement affects copayment/coinsurance per the Summary of Benefits and Coverage.

DAW implicationsDispense‑As‑Written (DAW) penalties may apply when choosing brand over available generic, affecting member cost‑share.

inv-141: Hearing Aid (duplicate) — extended definition including parts and nonimplanted devices.

Hearing Aid (extended)Nonexperimental wearable instruments to aid hearing including parts and nonimplanted bone conduction/anchored devices; personal sound amplification products do not qualify.

Benefit limit reminderWhen applicable, benefit limited to one hearing aid per impaired ear up to $3,000 per aid every 48 months for plans purchased outside Georgia Access.

Coverage conditionsHearing aid services and supplies are subject to medical necessity, limitations, exclusions and cost‑sharing as outlined in the Summary of Benefits.

Policy Summary

PayerAlliant Health

PolicyCertificate of Coverage for 2026 SoloCare PPO - Individual and Family Plans (Georgia)

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date

Next Review Date

SourceLink

On This Page

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Certificate of Coverage for 2026 SoloCare PPO - Individual and Family Plans (Georgia)

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Coverage Criteria and Service Rules

inv-01: Verification and Prior Authorization Criteria

Covered when ALL of the following administrative verification and prior authorization rules are observed:

Verification of benefits does NOT confirm coverage or guarantee payment.

Call Client Services to verify benefits; verification is informational only.

Prior Authorization approvals apply only to the services specified in the prior authorization request and do not guarantee payment for future or related services.

Approvals must exactly match requested services; see AlliantPlans.com for listed services.

ALL of the following

Member is not covered under the Contract at time services are received
Benefits under the Contract have been exhausted (for example, day limits)
Fraud or misrepresentation is present
The service is not a Covered Service under the benefit plan

ALL of the following

For In-Network inpatient admissions (except maternity), the Provider must call (800) 865-5922 to obtain Prior Authorization
For Out-of-Network inpatient admissions, the Member must call (800) 865-5922 to obtain Prior Authorization and must notify within one business day for emergency or maternity admissions to avoid denial
Emergency services do not require Prior Authorization, but notification requirements still apply as stated above

Operational requirement

Alliant may require submission of medical records and documentation; failure to obtain required prior authorization and requested records may result in no benefits payable.

inv-02: Eligibility, enrollment and benefit application

Eligibility and enrollment rules (Member and Dependent):

ALL of the following

Spouse if not legally separated (domestic partners generally not eligible unless law requires)
Dependent children through the end of the calendar year they attain age 26
Legally adopted children from date legal responsibility assumed (application + premium within 31 days)
Children for whom Subscriber assumes legal guardianship, stepchildren, and children required to be covered by court decree
Children who are mentally or physically disabled and totally dependent regardless of age (certification required)

ALL of the following

Open Enrollment period as defined by federal government
Special Enrollment Periods for qualifying events (loss of coverage, household size change, move, gaining ICHRA/QSEHRA eligibility, enrollment/plan error)

ALL of the following

If not enrolled when first eligible, must wait until next Open Enrollment unless SEP applies
Failure to add spouse/stepchildren within 31 days of marriage makes them Late Enrollees

ALL of the following

Newborns automatically covered for first 31 days; to continue coverage must submit application and premium within 31 days; if submitted between 31 and 60 days coverage reinstated retroactively
Adopted children eligible from date legal responsibility assumed; application and premium within 31 days required for continuous coverage; 31–60 day late submission reinstates retroactively
Foster children require confirmation of valid foster relationship provided by Member; application and premium within 31 days required; 31–60 day late submission reinstates retroactively

ALL of the following

Events that trigger removal include divorce, death, dependent reaching age 26, or dependent becoming totally/permanently disabled
If purchased through Georgia Access notify Georgia Access; otherwise notify Client Services for forms

ALL of the following

In-Network care may require copayments/coinsurance per Summary of Benefits; deductible applied on calendar year basis
Many preventive services covered In-Network with no deductible/copay/coinsurance
Plan is a PPO with In-Network and Out-of-Network benefit sets; verify provider network status on AlliantPlans.com or via Client Services

Operational note

To add/remove dependents or change coverage contact Client Services at (866) 403-2785 or follow Georgia Access notification rules if purchased through Georgia Access.

inv-03: Coverage criteria and service rules

Coverage and medical necessity criteria for specific services and general service rules:

ALL of the following

All Covered Services must be Medically Necessary whether provided in-network or out-of-network

ALL of the following

Emergency ambulance services are covered when Medically Necessary and criteria met (licensed vehicle, appropriately staffed, transported to nearest capable facility)
Scheduled ground ambulance non-emergency transports must be Medically Necessary and are subject to review
Air/water ambulance services are subject to Medical Necessity review; Alliant may select the air ambulance provider

ALL of the following

Alliant determines MAC for Out-of-Network reimbursement and may apply QPA rules for emergent air ambulance services in accordance with law
Alliant may reduce payments to avoid duplicate billing for incidental/included services; in-network providers must bill within contracted amounts

ALL of the following

Non-covered services are not reimbursable and member is responsible for billed amounts for Non-Covered Services
No annual or lifetime dollar limits apply to Essential Health Benefits

ALL of the following

If no in-network provider exists Alliant may authorize in-network cost sharing to apply to out-of-network services; member may still owe difference between MAC and provider charge

Operational note

Claims and medical necessity determinations follow Alliant medical management processes; providers should obtain authorizations where required to avoid claim denials.

inv-04: Coverage criteria for services in this section

Air ambulance and related transport coverage criteria (hospital-to-hospital and exceptional circumstances):

ALL of the following

Covered when Medically Necessary for transfer to the nearest hospital with medically appropriate facilities (e.g., burn, cardiac, trauma, critical care)

ALL of the following

Fixed or rotary wing air ambulance may be Medically Necessary only if all emergency ambulance criteria are met AND at least one of: immediate rapid transport needed not possible by land; pickup inaccessible by land; great distances or time obstacles; land transport time poses health threat; patient pronounced dead after call or en route

ALL of the following

All scheduled ground ambulance services for non-emergency transports must be Medically Necessary (excludes acute facility-to-acute facility transport)

Operational/billing note

For Out-of-Network emergent air ambulance services member cost-sharing limited to In-Network amount; MAC/QPA calculation rules apply as specified.

inv-05: Covered services and criteria (section)

Service-specific coverage criteria (selected services):

ALL of the following

Dialysis is a Covered Service; Out-of-Network benefits apply if an Out-of-Network provider is elected

ALL of the following

Covered when Medically Necessary, ordered by a Physician, appropriate for in-home use, meets durability and medical-purpose criteria
Plan pays rental up to lesser of purchase price or 12 months of rental; Provider must certify medical necessity and expected duration

ALL of the following

Emergency room services covered per prudent layperson standard; copayment may apply but waived if admitted; no balance billing for out-of-network emergency services per surprise billing laws

ALL of the following

Medical eye care covered when provided by participating ophthalmologist or optometrist; routine vision excluded except for children under age 19

ALL of the following

Standard fertility preservation covered when infertility results from medically necessary treatment for cancer, sickle cell disease, or lupus; may include evaluations, meds, procedures, cryopreservation and up to one year storage subject to limits

ALL of the following

Covered when Medically Necessary, ordered by attending Physician, and connected to a Covered Procedure; includes CRNA-administered anesthesia

ALL of the following

Medically necessary habilitative services (PT/OT/ST and certain DME) covered with calendar year visit limits; refer to Summary of Benefits

ALL of the following

If plan purchased outside Georgia Access, benefit for children ≤18: one hearing aid per impaired ear up to $3,000 per aid every 48 months, subject to SBC conditions

ALL of the following

Covered as intermittent skilled care in the home per plan limits; visit = up to four hours; requires physician certification and written plan of care
Claims reviewed to verify services are skilled and medically consistent with diagnosis

ALL of the following

Hospice covered when attending Physician certifies life expectancy ≤6 months and program is Alliant-approved with RN coordination

ALL of the following

In-network admissions should be arranged by Member's physician; inpatient room charges covered on semiprivate basis; length of stay determined by medical necessity

inv-06: Covered services and limitations (partial)

Summarized covered services and key limitations:

ALL of the following

Benefits payable when services are within state scope of practice (NP, PA, PAA, LAT)

ALL of the following

Requires physician order and supervision; covered to treat functional deficits; subject to calendar-year visit limits per Summary of Benefits

ALL of the following

Covered subject to contract cost-sharing; federal law ensures minimum lengths of stay (48 hours vaginal, 96 hours cesarean) and access to two post-discharge follow-up visits if discharged earlier

ALL of the following

Inpatient and outpatient benefits available as outlined in the Summary of Benefits and Coverage

ALL of the following

Outpatient services covered when medically necessary; verify In-Network status via AlliantPlans.com or Client Services

ALL of the following

Covered for at-risk women age 35 and older with annual CA-125, transvaginal ultrasound, and pelvic exam

ALL of the following

In-Network preventive services meeting federal/state guidelines covered at no cost; Out-of-Network preventive services paid at MAC and subject to cost-sharing

ALL of the following

Physical, occupational, and speech therapy covered when medically necessary and subject to combined calendar-year maximum visits per Summary of Benefits

ALL of the following

Prosthetic appliances covered if medically necessary; reconstructive surgery covered to restore function or correct congenital/trauma/post-surgical deformity

Operational note

Members should consult the Summary of Benefits and Coverage for applicable copayments, deductibles, limits, and visit maximums.

inv-07: preventive care

Preventive services coverage requirements and cost-sharing stance:

ALL of the following

Services with USPSTF A/B ratings, ACIP immunizations, HRSA child/adolescent and women's preventive guidelines are covered with no deductible, copayments, or coinsurance when provided In-Network (Alliant pays 100% of allowed amount)

ALL of the following

New government recommendations become covered for plan years beginning one year after issuance (or as ACA requires)

ALL of the following

Paid at MAC and subject to deductible, coinsurance, and potential provider balance billing

Operational note

Alliant may impose reasonable coverage limits when frequency/method/setting not specified consistent with ACA and Georgia law.

inv-08: diagnostic tests, prosthetics, reconstructive surgery

Selected diagnostic tests, prosthetics, and reconstructive surgery criteria:

ALL of the following

PSA test covered annually for men age 45 and over; may be covered for men over 40 if ordered by a physician

ALL of the following

Covered if medically necessary and ordered by a Physician; includes artificial limbs, accessories, external breast prostheses after mastectomy, arm/leg braces (with attached shoes) and specified orthotics

ALL of the following

Covered when Medically Necessary to restore function altered by disease, trauma, congenital anomaly, or to correct post-surgical deformity; excludes services otherwise excluded in Certificate

Pediatric vision cross-reference

See Pediatric Vision section for vision-specific device/exam coverage for members under age 19.

inv-09: assistant and second opinion

Coverage rules for surgical assistance and second opinions:

ALL of the following

Covered when payable to a surgical first assistant, performed at Physician request, within scope of license, and not payable if employed by the Physician or Hospital

ALL of the following

Second opinions by an In-Network Provider are covered for proposed surgical interventions or any Covered Service where a second opinion is requested

Operational note

Members may seek a second opinion from an In-Network provider; contact Client Services for assistance.

inv-10: skilled nursing facility care

Skilled nursing facility (SNF) coverage criteria and limits:

ALL of the following

SNF services covered when Skilled Convalescent Care is medically necessary and consistent with diagnosis (favorable prognosis, predictable recovery, and services more intense than residence but less than acute hospital)

ALL of the following

Semiprivate/wardroom charges, special care rooms, pathology/radiology, physical/speech therapy, oxygen therapy, inpatient drugs and dressings when continuous physician care and 24-hour nursing required

ALL of the following

Benefits not provided when care is primarily custodial, when maximum recovery reached, for chronic brain syndromes without specific medical need, or when benefit limit reached; calendar-year visit limits apply per Summary of Benefits

Operational note

Contact Client Services for specific SNF benefit limits and to verify coverage prior to placement.

inv-11: telemedicine

Telemedicine coverage criteria:

ALL of the following

Telemedicine is covered when provided by a duly licensed provider via secure real-time audio, video, or data communications with patient present and participating

ALL of the following

Payment based on negotiated rate or current MAC for the service provided

Operational note

Telemedicine may substitute for in-person visits when realtime communication standards are met; verify provider licensure and network status.

inv-12: transplant coverage

Transplant coverage and prior authorization requirements:

ALL of the following

Covered transplants include medically appropriate human organ or tissue transplants (cornea, lung, heart/heart-lung, liver, kidney, pancreas, kidney/pancreas) and specified autologous/allogeneic hematopoietic stem cell transplants per criteria

ALL of the following

Covered services include donor costs (organ harvesting), post-operative care including antirejection drugs (if prescription drugs covered), and certain transplant-related chemotherapy as specified

ALL of the following

Transplants at Non-Alliant Transplant Network Facilities are not covered even if facility is participating; blood/blood derivatives (except hematopoietic stem cells) are not considered transplants for benefit purposes

ALL of the following

All transplant procedures must be Prior Authorized, be Medically Necessary, and not Experimental/Investigational per Alliant criteria; call (800) 865-5922 to obtain prior authorization

Operational note

Transplant prior authorization and selection criteria are part of benefit administration and do not constitute treatment recommendations.

inv-13: transplant ancillary benefits

Transplant-related ancillary benefits and limits:

ALL of the following

Pre-approved transplant recipients and a support person may be reimbursed for transportation, lodging, and food up to a combined maximum of $10,000 per covered transplant

ALL of the following

Travel benefits available only for covered members who are transplant recipients; donors are not eligible

ALL of the following

Antirejection drugs following a covered transplant are covered as Prescription Drugs only if Prescription Drug benefits apply under the Contract

Operational limits

Reimbursements follow IRS mileage, rental, and GSA lodging/per diem rules; certain costs (within 200 miles, laundry, phone, alcohol/tobacco, premium travel classes) excluded.

inv-14: urgent care services

Urgent care coverage criteria and definition:

ALL of the following

Urgent Care: medical care for conditions that could seriously jeopardize life/health or ability to regain maximum function or would cause severe unmanaged pain; not life-threatening and not an emergency

ALL of the following

Urgent Care services rendered at Urgent Care Centers are covered as outlined in the Summary of Benefits and Coverage

Operational note

For after-hours urgent care assistance contact Client Services or use AlliantPlans.com to locate in-network urgent care facilities.

inv-15: prescription drugs

Outpatient prescription drug program rules, formulary and prior authorization requirements:

ALL of the following

Prime Therapeutics, LLC is the PBM administering outpatient prescription drug benefits; contact Prime Member Services for formulary and benefit questions

ALL of the following

Only drugs included on the Drug Formulary may be Covered Services when dispensed In-Network; the formulary is maintained by a physician/pharmacist committee

ALL of the following

Copayment/coinsurance tiering determined by Summary of Benefits; copayment expressed per single fill or 31-day supply; multi-month fills prorate (e.g., 90-day fills require multiple copayments)

ALL of the following

A limited number of prescription drugs, including most specialty drugs and many medical-benefit-administered drugs, require Prior Authorization; if not approved the drug is not eligible for coverage

ALL of the following

Specialty drugs often require special handling and Prior Authorization and may be dispensed by contracted specialty pharmacies; drugs administered by providers (infusions, chemotherapy) are paid under the medical benefit and often require Prior Authorization

ALL of the following

Outpatient prescription drug exclusions include internet/mail-order out-of-network, newly approved FDA drugs <180 days in U.S., OTC items, cosmetic drugs, certain injectables without Prior Authorization, experimental/investigational drugs, and other listed exclusions

Operational note

For a list of drugs requiring Prior Authorization contact Prime Member Services or review the formulary on AlliantPlans.com.

inv-16: Outpatient prescription drug and pediatric vision coverage criteria

Outpatient prescription drug, specialty drug, medical-pharmacy, formulary management, and pediatric vision rules:

ALL of the following

Covered: prescription drugs prescribed by a Provider and included on the Drug Formulary when dispensed In-Network; retail prescriptions dispensed per formulary

ALL of the following

Prior Authorization required for a limited number of prescription drugs, including most Specialty Drugs and many medical-benefit drugs; nonapproved drugs are not eligible for coverage

ALL of the following

Tiered cost sharing applies (Generic, Preferred Brand, Non-Preferred, Specialty, Zero-Cost Share); DAW penalty applies when choosing brand over available generic (member pays difference)

ALL of the following

Formulary may be modified for specified reasons; members notified at least 30 days prior if a drug used in last 12 months moves to non-formulary and therapeutic equivalents exist

ALL of the following

Drugs administered by a licensed provider during visits (infusions, chemotherapy, blood products) are covered under the medical benefit and often require Prior Authorization

ALL of the following

Routine vision exams and prescribed lenses/frames covered for persons up to but not including age 19 when Medically Necessary and billed by Providers; specific exclusions apply (contact lenses not covered, certain lens treatments excluded, surgical refractive procedures excluded)

Operational note

Members should consult the Summary of Benefits and Coverage and Prime Therapeutics for pharmacy-specific rules and prior authorization lists.

inv-17: Pediatric vision and exclusions

Pediatric vision benefits and prominent exclusions that affect coverage determinations:

ALL of the following

Comprehensive vision examinations and prescribed lenses/frames are covered for members under age 19 when Medically Necessary and billed by Providers; contact lens evaluations and follow-up covered but contact lenses themselves are not covered

ALL of the following

Replacement lenses/frames only as specified in Summary of Benefits; many specific materials and special services excluded (safety/sports glasses, progressive lenses, certain tints, orthoptics, low vision aids); surgical refractive procedures excluded

ALL of the following

Certificate lists numerous non-covered services (e.g., many transplants not listed as covered, experimental/investigational services, many DME items, cosmetic procedures, routine general vision) which are member financial responsibility if rendered

ALL of the following

In-Network providers prohibited from balance billing; Out-of-Network providers may bill members for amounts over MAC; non-emergency care outside U.S. not covered except emergency care

Operational note

Members nearing age limits (e.g., turning 19) should verify termination of pediatric vision benefits and plan for alternatives.

inv-18: Claims, COB, and Member Programs Criteria

Claims, Coordination of Benefits, member programs, and administration rules that affect coverage:

ALL of the following

Non-emergency care outside the United States is not covered; only emergency care abroad is eligible and must be paid by member and submitted for reimbursement based on MAC

ALL of the following

This plan is always secondary to any Group Coverage; order of benefits follows standard rules (longer-plan rule, birthday rule, dependent/subscriber rules) to determine primary vs secondary

ALL of the following

Benefits do not duplicate Medicare unless federal law requires this plan to be primary; plan is not a Medicare supplement

ALL of the following

In-Network providers file claims directly; Out-of-Network providers may not file and members may need to pay and submit itemized claims; members generally have 180 days to submit claims
Alliant may audit claims and require Clean Claims; failure to submit clean claims or requested records may result in denial or recovery actions

ALL of the following

Population Health Management, Case Management and Complex Case Management are available at no cost; contact Member Care Line for referrals

Operational note

Members should provide correct insurance information to providers and contact Client Services for assistance with claim submissions and program enrollment.

inv-19: Billing, recovery, subrogation, and member rights

Billing, recovery, subrogation, and member rights rules governing payments and recoveries:

ALL of the following

Benefit payment is made to the submitter of the claim: provider if provider submits, member if member submits; member remains responsible to pay provider if reimbursed

ALL of the following

In-Network providers file claims and member is not responsible for filing; Out-of-Network providers may not file and member may need to pay and submit itemized bill for reimbursement

ALL of the following

Alliant may recover payments made in error from members or providers; provider recoveries generally limited to 12 months except in fraud cases; plan has subrogation and reimbursement rights if member has third-party recovery
Members must notify Alliant of legal action/settlement and may be required to repay Alliant from recoveries; plan may retain priority to be reimbursed first

ALL of the following

In-Network providers prohibited from balance billing; Out-of-Network providers may bill members for amounts above MAC

ALL of the following

Members and providers must cooperate with audits and appeals; plan provides language and disability access services and grievance processes

Operational note

Members should include Member and Group IDs and itemized bills when submitting claims; contact Client Services for claim inquiries.

inv-20: Termination, premium, and reinstatement criteria

Conditions under which membership terminates and rules for premium handling and reinstatement:

ALL of the following

Coverage ends when member no longer meets eligibility requirements or moves out of service area
Dependents coverage ends at end of calendar year they turn 26 (or other specified age limits for benefits like pediatric vision)
Coverage may be rescinded for fraud or intentional misrepresentation with 30-day advance written notice and member right to appeal

ALL of the following

Member-requested disenrollment ends at midnight on 14th day after request (earlier date may be accommodated at Alliant discretion)

ALL of the following

Premium due by first day of month; grace periods: 3 months for Georgia Access APTC purchasers (hold on payment after first month until premium received), 31 days for non-APTC purchasers and off-exchange purchasers; failure to pay by end of grace period results in termination
If terminated for nonpayment, reinstatement only during Open Enrollment or qualifying SEP

ALL of the following

Except for fraud, Alliant will return unearned premium within 30 days less amounts due on claims; Alliant will provide at least 180 days notice if discontinuing benefits or 90 days if withdrawing product from market

Operational note

Members should respond to premium notices promptly and contact Client Services to resolve billing or disenrollment questions.

inv-21: Appeal timelines and external review

Internal appeal windows, expedited decision timings, and external review rights:

ALL of the following

Level I Internal Appeal must be filed within 180 calendar days from notice of adverse determination
Optional Level II Internal Appeal may be filed within 60 calendar days from Level I denial (not required before External review)

ALL of the following

Level I pre-service: 15 calendar days; Level I post-service: 30 calendar days; Optional Level II pre/post-service: 15/30 days respectively
Expedited (pre-service) appeals decided within 72 hours

ALL of the following

After completing Internal appeals, member may request External review within 123 calendar days from date of appeal decision notice
Expedited External review available when expedited internal appeal requested or standard timeline would place life/health in danger or decision involves admission/continued stay/emergency care and member not discharged
External review requests may be submitted to Maximus by phone, online, fax, or mail per instructions

Operational contacts

inv-22: Definition-driven coverage rules

Definitions whose meanings drive coverage determinations and exclusions:

ALL of the following

Cosmetic Surgery defined as non-medically necessary procedures to change appearance that do not restore function or correct disease; such services are excluded from coverage

ALL of the following

Covered Services are Medically Necessary services not excluded or Experimental/Investigational and provided per Contract; when multiple options equally effective, the least costly option is the Covered Service

ALL of the following

Experimental and/or Investigational services (including drugs, devices, procedures, or services in clinical trials or lacking credible evidence) are not reimbursable; Alliant has discretion to determine this status

ALL of the following

Hearing Aid defined as nonexperimental wearable device to aid hearing; personal sound amplification products do not qualify

Operational note

Interpretation of these definitions affects medical necessity and exclusion determinations; Alliant retains authority to apply these definitions.

Coding, Billing, and Claim Rules

Neutral code referencemixed

Cost-sharing and deductible rulesmixed

No codes listed

Claim coding and MAC impactmixed

Claims processed using coding rules (CPT/HCPCS/ICD) may affect determination of MAC; bundled vs multiple code examples described.

Air ambulance billing rulemixed

Dialysis CPT/HCPCSmixedCovered

Dialysis treatment is a Covered Service. If an Out-of-Network Provider is elected, Out-of-Network benefits apply.

Ovarian cancer surveillance testsmixedCovered

CA-125	Serum tumor marker used in ovarian cancer surveillance
Transvaginal ultrasound	Imaging modality for ovarian surveillance
Pelvic examination	Pelvic examination included in surveillance

Prescription drug billing guidancemixed

Formulary determines covered prescription drugs; pharmacy MAC used for pricing and copayments expressed per single fill or 31-day supply with multi-month fills prorated as described.

Formulary / DAW cost-share rulemixedCovered

DAW	Dispense As Written (DAW) penalty — member pays difference between brand and generic when choosing brand over available generic