Page 79 - Aegion PPO SPDs
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Authorized Services
In some circumstances, such as where there is no Network Provider available for the Covered Service, the
Plan may authorize the Network cost share amounts (Deductible and/or Coinsurance) to apply to a claim
for a Covered Service You receive from an Out-of-Network Provider. In such circumstance, You must
contact the Claims Administrator in advance of obtaining the Covered Service. The Plan also may authorize
the Network cost share amounts to apply to a claim for Covered Services if You receive Emergency services
from an Out-of-Network Provider and are not able to contact the Claims Administrator until after the Covered
Service is rendered. If the Plan authorizes a Network cost share amount to apply to a Covered Service
received from an Out-of-Network Provider, You also may still be liable for the difference between the
Maximum Allowed Amount and the Out-of-Network Provider’s charge. Please contact Member Services
for Authorized Services information or to request authorization.
Services Performed During Same Session
The Plan may combine the reimbursement of Covered Services when more than one service is performed
during the same session. Reimbursement is limited to the Plan’s Maximum Allowed Amount. If services
are performed by Out-of-Network Providers, then You are responsible for any amounts charged in excess
of the Plan’s Maximum Allowed Amount with or without a referral or regardless if allowed as an Authorized
Service. Contact the Claims Administrator for more information.
Continuous Coverage
If You were previously covered by a Plan with the Employer and with the Claims Administrator with no break
in coverage, You will receive credit for any accrued Deductibles and Out-of-Pocket amounts. However,
any maximums used under that Plan will be carried over and charged against the maximums of the Plan.
Payment of Benefits
You authorize the Claims Administrator, on behalf of the Employer, to make payments directly to Providers
for Covered Services. The Claims Administrator also reserves the right to make payments directly to You.
Payments may also be made to, and notice regarding the receipt and/or adjudication of claims, an Alternate
Recipient, or that person’s custodial parent or designated representative. Any payments made by the
Claims Administrator will discharge the Employer’s obligation to pay for Covered Services. You cannot
assign Your right to receive payment to anyone else, except as required by a “Qualified Medical Child
Support Order” as defined by ERISA or any applicable Federal law.
Once a Provider performs a Covered Service, the Claims Administrator will not honor a request to withhold
payment of the claims submitted.
Assignment
The coverage and any benefits under the Plan are not assignable by any Member without the written
consent of the Plan, except as provided above.
Notice of Claim
The Plan is not liable, unless the Claims Administrator receives written notice that Covered Services have
been given to You. An expense is considered incurred on the date the service or supply was given. The
notice must be given to the Claims Administrator within 90 days of receiving the Covered Services, and
must have the data the Claims Administrator needs to determine benefits. If the notice submitted does not
include sufficient data the Claims Administrator needs to process the claim, then the necessary data must
be submitted to the Claims Administrator within the time frames specified in this provision or no benefits
will be payable except as otherwise required by law.
If the Claims Administrator has not received the information it needs to process a claim, the Claims
Administrator will ask for the additional information necessary to complete the claim. Generally, You will
receive a copy of that request for additional information, for Your information. In those cases, the Claims
Administrator cannot complete the processing of the claim until the additional information requested has
been received. The Claims Administrator generally will make its request for additional information within
30 days of the Claims Administrator's initial receipt of the claim and will complete its processing of the claim
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In some circumstances, such as where there is no Network Provider available for the Covered Service, the
Plan may authorize the Network cost share amounts (Deductible and/or Coinsurance) to apply to a claim
for a Covered Service You receive from an Out-of-Network Provider. In such circumstance, You must
contact the Claims Administrator in advance of obtaining the Covered Service. The Plan also may authorize
the Network cost share amounts to apply to a claim for Covered Services if You receive Emergency services
from an Out-of-Network Provider and are not able to contact the Claims Administrator until after the Covered
Service is rendered. If the Plan authorizes a Network cost share amount to apply to a Covered Service
received from an Out-of-Network Provider, You also may still be liable for the difference between the
Maximum Allowed Amount and the Out-of-Network Provider’s charge. Please contact Member Services
for Authorized Services information or to request authorization.
Services Performed During Same Session
The Plan may combine the reimbursement of Covered Services when more than one service is performed
during the same session. Reimbursement is limited to the Plan’s Maximum Allowed Amount. If services
are performed by Out-of-Network Providers, then You are responsible for any amounts charged in excess
of the Plan’s Maximum Allowed Amount with or without a referral or regardless if allowed as an Authorized
Service. Contact the Claims Administrator for more information.
Continuous Coverage
If You were previously covered by a Plan with the Employer and with the Claims Administrator with no break
in coverage, You will receive credit for any accrued Deductibles and Out-of-Pocket amounts. However,
any maximums used under that Plan will be carried over and charged against the maximums of the Plan.
Payment of Benefits
You authorize the Claims Administrator, on behalf of the Employer, to make payments directly to Providers
for Covered Services. The Claims Administrator also reserves the right to make payments directly to You.
Payments may also be made to, and notice regarding the receipt and/or adjudication of claims, an Alternate
Recipient, or that person’s custodial parent or designated representative. Any payments made by the
Claims Administrator will discharge the Employer’s obligation to pay for Covered Services. You cannot
assign Your right to receive payment to anyone else, except as required by a “Qualified Medical Child
Support Order” as defined by ERISA or any applicable Federal law.
Once a Provider performs a Covered Service, the Claims Administrator will not honor a request to withhold
payment of the claims submitted.
Assignment
The coverage and any benefits under the Plan are not assignable by any Member without the written
consent of the Plan, except as provided above.
Notice of Claim
The Plan is not liable, unless the Claims Administrator receives written notice that Covered Services have
been given to You. An expense is considered incurred on the date the service or supply was given. The
notice must be given to the Claims Administrator within 90 days of receiving the Covered Services, and
must have the data the Claims Administrator needs to determine benefits. If the notice submitted does not
include sufficient data the Claims Administrator needs to process the claim, then the necessary data must
be submitted to the Claims Administrator within the time frames specified in this provision or no benefits
will be payable except as otherwise required by law.
If the Claims Administrator has not received the information it needs to process a claim, the Claims
Administrator will ask for the additional information necessary to complete the claim. Generally, You will
receive a copy of that request for additional information, for Your information. In those cases, the Claims
Administrator cannot complete the processing of the claim until the additional information requested has
been received. The Claims Administrator generally will make its request for additional information within
30 days of the Claims Administrator's initial receipt of the claim and will complete its processing of the claim
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