Retroactive correction window and reporting obligations

Coverage changes and contribution reimbursements may be made retroactively up to 12 months from the date of discovery if reported to PEBA within 31 days of discovery; terminations are processed no more than 31 days retroactive from proper notification (with limited retiree/continuation exceptions). Providers and Covered Persons must report discovery promptly to PEBA and submit required documentation to support retroactive adjustments.

• Retroactive corrections allowed up to 12 months from discovery if reported to PEBA within 31 days.
• Terminations processed no more than 31 days retroactive from date of proper notification unless PEBA, in its discretion, approves a longer retroactive termination in limited retiree/continuation cases.

Plan payment determination = Allowed Amount

All payments under the Plan are determined based on the Plan's Allowed Amount as established in the Schedule of Reimbursement Rates; for charges not listed, the Allowed Amount is measured against customary local charges or determined by the Third Party Claims Processor.

• Plan payment basis is the Allowed Amount from the Schedule of Reimbursement Rates.
• If a charge is not in the schedule, Allowed Amount is determined by comparison to customary local charges or by the Third Party Claims Processor's determination.

Alternative Treatment Plan approval and notification

An Alternative Treatment Plan must be approved by the treating Physician, the Plan Administrator, and the patient, and the approved plan must be notified to the Third Party Claims Processor.

• Alternative Treatment Plan modifies coinsurance or provides services not otherwise available to permit cost‑effective, less intensive care.
• Approval required from treating Physician, Plan Administrator, and the patient; Third Party Claims Processor must be notified of approval.

Chiropractic services definition (scope & provider)

"Chiropractic Services" means any service payable by the Plan and provided by a licensed chiropractor or a chiropractic clinic.

• Scope: any service payable by the Plan when provided by a licensed chiropractor or chiropractic clinic.

Pre‑approval required for Intermittent home health/skilled nursing

Intermittent (part‑time) Skilled Nursing or Home Health care is subject to pre‑approval by the Utilization Review Agency and limited to specified daily/hour and fixed period limits (e.g., up to four hours/day or up to eight hours/day for fixed periods, typically up to 21 days unless extended by the Plan Administrator).

• Intermittent care definition includes pre‑approval requirement by the Utilization Review Agency.
• Home Health Care services require Prior Authorization by the Utilization Review Agency and are subject to plan limitations and Deductible/Coinsurance requirements.

Medical necessity determinations are discretionary

Determinations of Medical Necessity rely on the Plan's definition and the Plan Administrator, Third Party Claims Processor, and Utilization Review Agency have discretion to utilize and rely on criteria they deem generally accepted when making those determinations.

• Medical Necessity criteria enumerated (appropriate to treat condition; prescribed by a Physician; consistent with recognized medical practices; not primarily convenience; not experimental).
• Plan Administrator, Third Party Claims Processor, and Utilization Review Agency may use any medical/pharmaceutical/behavioral health criteria they determine generally accepted in exercising discretion.

Definition: Prior Authorization and who issues it

Prior Authorization (also called Authorization) is the procedure through which a Covered Person obtains a determination from a Utilization Review Agency that a proposed treatment and any required length‑of‑stay determination are consistent with generally recognized medical standards.

• Prior Authorization is obtained from the Utilization Review Agency.
• Applies to proposed treatment and length‑of‑stay determinations when required.

Second Opinion right for contested Medical Necessity

A Covered Person may obtain a Second Opinion—an examination or evaluation from a second qualified Physician—to confirm or challenge Medical Necessity for recommended elective, non‑Emergency surgical procedures, medical procedures, treatments, or hospitalizations for mental illness or chemical dependency prior to undergoing or continuing treatment.

• Second Opinion applies to elective, non‑Emergency surgical procedures and certain medical/hospitalization treatments for mental illness or chemical dependency.
• Used to confirm or challenge Medical Necessity prior to proceeding.

Utilization Review Agency functions and services

Utilization Review Agency entities are retained by the Plan Administrator to review proposed treatments and length‑of‑stay determinations, receive and investigate Prior Authorization requests, conduct concurrent reviews, perform case management, and provide other utilization review services specified in Article 15.

• Acts under direction and control of the Plan Administrator and notifies Plan Administrator/Third Party Claims Processor of determinations.
• Receives, reviews, verifies, investigates, and monitors Prior Authorization requests (including non‑Emergency hospital admissions, surgical procedures, length‑of‑stay limits, extended care benefits) and performs concurrent review and case management.

Enrollment after release from incarceration — 31‑day window

Eligible Employees, Retirees, and Dependents released from incarceration may enroll by submitting an election of benefits in a manner approved by PEBA within 31 days of release.

• Submission must be within 31 days of release and follow PEBA‑approved procedures.
• Enrollment upon release is a Special Eligibility Situation permitting immediate enrollment.

Drop coverage when gaining other insurance — 31‑day rule & docs

A Covered Employee/Retiree who gains other group health insurance may drop Plan coverage by submitting an election within 31 days; satisfactory documentation of the new coverage must accompany the election and coverage ends at 11:59 p.m. on the last day of the month in which other coverage is gained (or first of month if gained on the first).

• 31‑day election window required and satisfactory documentation must accompany the election.
• Coverage end timing: 11:59 p.m. on last day of month other coverage gained (or first of month if gained on the first).

Drop coverage for Medicaid/CHIP changes — 60‑day window & statement

Gaining or losing Medicaid/CHIP coverage or eligibility for premium assistance permits dropping Plan coverage within 60 days; a satisfactory statement of the circumstances must accompany the election of benefits submitted within that 60‑day window.

• 60‑day election window applies to gain/loss of Medicaid/CHIP or premium assistance.
• A satisfactory statement documenting the circumstances must accompany the revised election of benefits.

Retiree enrollment — 31‑day election deadline

A Retiree (or Employee becoming a Retiree) must submit an election of benefits and any required information within 31 days of the date of Retirement to enroll as a Retiree; failure to submit within 31 days limits enrollment to Open Enrollment or Special Eligibility Situations, and retiree coverage may not become effective earlier than the date of Retirement.

• 31‑day submission requirement for election of benefits and required information following Retirement.
• Retiree coverage effective date cannot be earlier than the Employee's date of Retirement; otherwise enrollment limited to Open Enrollment or Special Situations.

Post‑retirement employment: coverage election and restrictions

If a Retiree returns to Active Employment in an insurance‑eligible position they must elect either Active Employee coverage or decline all coverage; Medicare‑eligible Retirees and Retirees receiving SCRHI Trust Fund funding who return to employment requiring employer contributions may not continue Retiree coverage during that employment; upon termination from such post‑retirement employment the individual may re‑enroll in Retiree coverage by submitting an election within 31 days.

• Returning Retiree must choose Active Employee coverage or decline coverage while employed.
• Medicare‑eligible Retirees and those receiving SCRHI Trust Fund funding who return to jobs requiring employer contributions cannot continue Retiree coverage during that employment.
• Right to re‑enroll within 31 days after termination of post‑retirement employment.

Claims submission, processing, and payment procedure

Providers must submit invoices or completed claim forms to the Plan Administrator; claims are processed by the Third Party Claims Processor and paid according to the Schedule of Benefits after processing and subject to coordination of benefits.

• Submit invoices/claim forms to Plan Administrator as required.
• Claims processed by Third Party Claims Processor and paid per Articles 7A/7B Schedule of Benefits, subject to Coordination of Benefits rules; Third Party Claims Processor may exchange information to implement coordination.

Prior Authorization required for many services — consequences if not obtained

Prior Authorization is required for specified services (including non‑Emergency hospital admissions, certain surgical procedures, length‑of‑stay limits, extended care benefits, home health nursing, DME rental/purchase approvals, and certain ambulance transports). If Prior Authorization is required but not obtained, no benefits are payable for transports or services that require it.

• List of services requiring Prior Authorization includes non‑Emergency hospital admissions, specified surgeries, length‑of‑stay limits, Home Health Care, Skilled Nursing admissions/readmissions, inpatient rehabilitation, outpatient rehab after inpatient, DME approvals, and certain ambulance transports.
• No benefits payable where Prior Authorization is required but not obtained (e.g., ambulance transports under 7A.2.G.b).

Ambulance transport prior authorization and air ambulance condition

Ambulance transport between hospitals and non‑emergency transports require Prior Authorization by the Utilization Review Agency; air ambulance is authorized only if ground transport would endanger the patient. No benefits are payable for transport that requires but does not receive Prior Authorization.

• Inter‑hospital and non‑emergency ambulance transports require Prior Authorization and medical necessity as determined by the Third Party Claims Processor.
• Air ambulance authorized only when ground transport would endanger the Covered Person and not for hospitalizations outside the U.S.
• No benefits if required Prior Authorization is not obtained.

Behavioral Health services require Behavioral Health Manager prior authorization

Outpatient and inpatient treatment for Behavioral Health Disorders, alcoholism, and drug abuse are subject to utilization guidelines and, where applicable, Prior Authorization by the Behavioral Health Manager.

• Behavioral Health Manager establishes utilization guidelines and authorizes care where applicable.
• Prior Authorization by the Behavioral Health Manager required for applicable outpatient and inpatient behavioral health services.

Speech therapy (home) and select surgeries require pre‑approval

Speech therapy is covered for acute/rehabilitative needs and habilitation for ages 6 and under; speech therapy provided in a home setting requires Prior Authorization by the Utilization Review Agency, and certain surgical corrections require pre‑approval by the Utilization Review Agency.

• Speech therapy in a home setting requires Prior Authorization by the Utilization Review Agency.
• Speech therapy coverage limited by age/condition and documentation of functional progress; certain surgical corrections (e.g., TMJ, jaw deformities) require Utilization Review Agency pre‑approval.

Major transplant pre‑approval in writing by Utilization Review Agency

Specified major organ transplants (liver, lung, heart, heart/lung, kidney, intestinal, pancreas) and certain bone marrow/stem cell transplants require written pre‑approval from the Utilization Review Agency; covered transplants must be performed by a Transplant Network member and are subject to Deductible and Coinsurance.

• Pre‑approval in writing by the Utilization Review Agency is required for major organ transplants.
• Transplants must be performed by a Transplant Network member; related expenses subject to Deductible and Coinsurance and certain transplant‑specific caps (e.g., donor identification up to $10,000).

Utilization Review Agency prior authorization list (SNF, Home Health, rehab, IVF, ALT Plan)

Admissions/readmissions to Skilled Nursing Facilities, Home Health Care services, any inpatient rehabilitation care, outpatient rehab following inpatient stays, and IVF procedures require Prior Authorization by the Utilization Review Agency; Alternative Treatment Plan items approved as essential by the Utilization Review Agency are also subject to its authorization.

• Skilled Nursing Facility admissions/readmissions require Prior Authorization.
• Home Health Care services require Prior Authorization and are subject to Deductible/Coinsurance limits.
• Any inpatient rehabilitation care and outpatient rehab after inpatient require Prior Authorization.
• IVF procedures require prior approval from the Utilization Review Agency; Alternative Treatment Plan Allowed Amount may include otherwise non‑covered items if the Utilization Review Agency authorizes them as essential.

Behavioral Health Manager prior authorization and utilization guidance

Behavioral Health services (inpatient, outpatient, partial hospitalization) must follow utilization guidelines established by the Behavioral Health Manager and, where applicable, receive Prior Authorization from the Behavioral Health Manager.

• All care must follow Behavioral Health Manager's utilization guidelines for specified levels of care.
• Prior Authorization by the Behavioral Health Manager required where applicable.

Required Second Opinion covered at 100% of Allowed Amount or Provider's Billed Charge

When a Second Opinion is required by the Utilization Review Agency, the Plan will cover it at 100% of the Allowed Amount or the Provider's Billed Charge, whichever is less.

• Required Second Opinion covered at 100% of Allowed Amount or Provider's Billed Charge (whichever is less).

IVF procedures require Utilization Review Agency prior approval

All IVF procedures must receive prior approval from the Utilization Review Agency as a condition of coverage under the Plan's infertility provisions.

• IVF is explicitly listed as requiring prior approval by the Utilization Review Agency.
• Infertility benefits have additional limits (lifetime maximum $15,000; up to 6 IUI cycles and up to 3 IVF/ZIFT/GIFT cycles) and 30% Coinsurance but IVF prior authorization is mandatory.

ABA and autism services require Behavioral Health Manager prior authorization

Applied Behavioral Analysis (ABA) and related autism services are covered only with Prior Authorization by the Behavioral Health Manager and must follow the Behavioral Health Manager's guidelines and the utilization limits specified in Paragraph 7A.7.

• ABA and speech therapy for Autism Spectrum Disorder require Prior Authorization by the Behavioral Health Manager.
• Services must follow Behavioral Health Manager guidelines and are limited to benefits specified in Paragraph 7A.7.

Prior Authorization and site‑of‑care for physician‑administered specialty drugs

Physician‑administered specialty medications require Prior Authorization, including site‑of‑care requirements to ensure administration at the lowest cost, clinically appropriate site of care.

• Prior Authorization applies to physician‑administered specialty drugs.
• Site‑of‑care requirements are included to ensure lowest cost, clinically appropriate setting.

EGWP enrollment/disenrollment and return to Standard Plan drug benefit

Covered Persons eligible for the EGWP Prescription Drug Plan may elect out and return to the Standard Plan drug benefit; disenrollment is permitted during Medicare Open Enrollment (effective Jan 1 following year) or anytime (effective first of following month) though re‑enrollment to the Standard Plan drug benefit is limited to established enrollment periods.

• EGWP enrollees may elect out and return to Standard Plan drug benefit.
• Disenrollment during Medicare Open Enrollment becomes effective Jan 1 following year; disenrollment anytime is effective first of following month but re‑enrollment to Standard Plan drug benefit restricted to established periods.

Third Party Claims Processor authority to exchange info for coordination of benefits

The Third Party Claims Processor may release to and obtain from other insurers or organizations any information it deems necessary to determine and implement Coordination of Benefits without consent; providers and Covered Persons must furnish requested information for coordination.

• Third Party Claims Processor authorized to exchange information necessary for coordination of benefits without consent.
• Any person claiming benefits must furnish information the Third Party Claims Processor requests to implement Coordination of Benefits.