This Plan does not have a network agreement that includes charges from hospitals and other facilities. The following explains the Plan's provisions for determination of covered charges for facilities and out-of-network professional providers and the rights granted to providers of service for appealing adverse benefit determinations.
ELAP Claim Review and Audit Program
The Plan has arranged with ELAP Services, LLC (“ELAP”) for a program of facility and out-of-network professional claim review and auditing in order to identify charges billed in error, charges for excessive or unreasonable fees and charges for services which are not medically appropriate. Benefits for claims which are selected for review and auditing may be reduced for any charges that are determined to be in excess of Allowable Claim Limits (as defined below). The determination of Allowable Claim Limits under this Program will supersede any other Plan provisions related to application of a usual, customary or reasonable fee determination.
Facility and out-of-network professional providers will be given a fully detailed explanation of any charges that are found to be in excess of Allowable Claim Limits, and allowed the rights and privileges to file an appeal of the determination which are the same rights and privileges accorded to Plan Participants; and, in return, the facility and out-of-network professional provider must agree not to bill the Plan Participant for charges which were not covered as a result of the claim review and audit. This will in no way affect the rights of the Plan Participant to file an appeal under the Plan. Please refer to the section in the Summary Plan Description regarding procedures for claims and appeals for additional information regarding Participant and provider appeals.
Any Plan Participant who receives a balance-due billing from a medical care provider for these charges should contact ELAP or the Plan Administrator right away for assistance.
The Plan Administrator is identified in the General Information section of the Summary Plan Description, which is available upon request. ELAP may be contacted at:
ELAP Services, LLC
1550 Liberty Ridge
Wayne, PA 19087
Phone: 610-321-1030; Fax 610-321-1031
The Plan Participant must pay for any normal cost-sharing features of the Plan, such as Deductibles, Coinsurance and Copayments, and any amounts otherwise excluded or limited according to the terms of the Plan.
The success of this program will be achieved through a comprehensive review of detailed records including, for example, itemized charges and descriptions of the services and supplies provided. Without this detailed information, the Plan will be unable to make a determination of the amount of Covered Medical Expense that may be eligible for reimbursement. Any additional information required for the audit will be requested directly from the provider of service and the Plan Participant. In the event that the Plan Administrator does not receive information adequate for the claim review and audit within the time limits required under applicable regulations, it will be necessary to deny the claim. Should such a denial be necessary, the Plan Participant and/or the provider of service may appeal the denial in accordance with the provisions which may be found in the section regarding procedures for claims and appeals in the Summary Plan Description.
In the following provisions of the Claim Review and Audit Program, the term "Plan Administrator" shall be deemed to mean ELAP:
“Allowable Claim Limits” means the charges for services and supplies, listed and included as Covered Medical Expenses under the Plan, which are Medically Necessary for the care and treatment of Illness or Injury, but only to the extent that such fees are within the Allowable Claim Limits. Examples of the determination that a charge is within the Allowable Claim Limit include, but are not limited to, the following guidelines:
- Errors, Unbundled and/or Unsubstantiated Charges. Allowable Claim Limits will not include the following amounts:
- Charges identified as improperly coded, duplicated, unbundled and/or for services not performed;
- Charges for treating injuries sustained or illnesses contracted, including infections and complications, which, in the opinion of the Plan Administrator can be attributed to medical errors by the provider;
- Charges that cannot be identified or understood; and
- Charges that cannot be verified from audits of medical records.
- Guidelines. The following guidelines will be used when determining Allowable Claim Limits:
- Facilities. The Allowable Claim Limit for claims by a facility, including but not limited to, hospitals, emergency and urgent care centers, rehabilitation and skilled nursing centers, and any other health care facility, shall be the greater of (I) 112% of the facility’s most recent departmental cost ratio, reported to the Centers for Medicare and Medicaid Services (“CMS”) and published in the American Hospital Directory as the “Medicare Cost Report” (the “CMS Cost Ratio”), or (II) the Medicare allowed amount for the services in the geographic area plus an additional 20%. The Allowable Claim Limit for (I) shall not exceed 250% of the federal non-commercial Medicare allowed amount, except for children’s hospitals, which shall not exceed 350% of the federal non-commercial Medicare allowed amount. If insufficient information is available to identify either the facility’s most recent departmental cost ratio or the Medicare allowed amount, the Allowable Claim Limit shall be either (I) or (II) herein that can be identified.
- Ambulatory Health Care Centers. The Allowable Claim Limit for ambulatory health care centers, including ambulatory surgery centers, which are independent facilities shall be the Medicare allowed amount for the services in the geographic area plus an additional 20%. In the event that insufficient information is available to identify the Medicare allowed amount, the Allowable Claim Limit for such services shall be to the extent available either the outpatient or inpatient Medicare allowed amount for the service, plus an additional 20%.
- Out-of-Network Professional Providers.The Allowable Claim Limits for other out-of-network professional providers shall be determined using the following:
- For general medical and primary care claims, the Medicare allowed amount in the geographic area plus an additional 40%;
- For specialist medical and surgical care claims, the Medicare allowed amount in the geographic area plus an additional 55%;
- For anesthesiologist claims, the Medicare allowed amount in the geographic area plus an additional 100%;
- For ambulance and air ambulance claims, the Medicare allowed amount in the geographic area plus an additional 20%; or
- For other non-facility claims and supplies (such as Durable Medical Equipment, laboratory services and supplies, and mid-level providers etc.), the Medicare allowed amount in the geographic area.
For purposes of determining the proper Allowable Claim Limits for out-of-network professional providers in categories (i), (ii), (iii), (iv) or (v), above, the Plan Administrator shall determine the applicable category for each claim based on the taxonomy code used by the out-of-network professional provider for that claim. The Plan Administrator determines in its sole discretion the type of provider for determining Allowable Claim Limits, as detailed above.
While this Plan typically pays professional providers based on the Medicare allowed amounts above, certain services may be reimbursed at 110% of the Medicare allowed amount for the service. These services may include, but are not limited to, routine diagnostic tests, evaluation services, telehealth and services for ongoing therapy. A full list of services subject to this rule can be found here: www.planlimit.com/pro1. This list will be updated at least annually to reflect the Plan’s current plan design.
- Directly Contracted Providers. The Allowable Claim Limits for Directly Contracted Providers shall be the negotiated rate as agreed under the Direct Agreement.
- Insufficient Information to Determine Allowable Claim Limit. In the event that insufficient information is available to determine Allowable Claim Limits for specific services or supplies using the guidelines listed in Section 2 above as may be applicable, ELAP may apply the following guidelines:
- General Medical and/or Surgical Services. The Allowable Claim Limit for any covered services may be calculated based upon industry-standard resources including, but not limited to, published and publicly available fee and cost lists and comparisons, or any combination of such resources that in the opinion of the Plan Administrator results in the determination of a reasonable expense under the Plan.
- Medical and Surgical Supplies, Implants, Devices. The Allowable Claim Limit for charges for medical and surgical supplies made by a provider may be based upon the invoice price (cost) to the provider, plus an additional 12%. The documentation used as the resource for this determination will include, but not be limited to, invoices, receipts, cost lists or other documentation as deemed appropriate by the Plan Administrator.
- Physician, Medical and Surgical Care, Laboratory, X-ray, and Therapy. The Allowable Claim Limit for these services may be determined based upon the 60th percentile of Fair Health (FH®) Allowed Benchmarks.
Comparable Services or Supplies. In the event that insufficient information is available to determine Allowable Claim Limits for specific services or supplies using the guidelines listed in Section 2 above, Allowable Claim Limits will be determined considering the most comparable services or supplies based upon comparative severity and/or geographic area to determine the Allowable Claim Limit. The Plan Administrator reserves the right, in its sole discretion, to determine any Allowable Claim Limit amount for certain conditions, services and supplies using accepted industry-standard documentation, applied without discrimination to any Covered Person.
In the event that a determination of Allowable Claim Limit for a Claim exceeds the actual Charges billed for the services and/or supplies, the actual Charges billed for the Claim shall be the Allowable Claim Limit.
Provider of Service Appeal Rights
A Claimant may appoint the provider of service as the Authorized Representative with full authority to act on his or her behalf in the appeal of a denied claim. An assignment of benefits by a Claimant to a provider of service will not constitute appointment of that provider as an Authorized Representative. However, in an effort to ensure a full and fair review of the denied claim, and as a courtesy to a provider of service that is not an Authorized Representative, the Plan will consider an appeal received from the provider in the same manner as a Claimant’s appeal, and will respond to the provider and the Claimant with the results of the review accordingly. Any such appeal from a provider of service must be made within the time limits and under the conditions for filing an appeal specified under the section, “Appeal Process,” above. Providers requesting such appeal rights under the Plan must agree to pursue reimbursement for Covered Medical Expenses directly from the Plan, waiving any right to recover such expenses from the Claimant, and comply with the conditions of the section, “Requirements for First Appeal,” above.
For purposes of this section, the provider’s waiver to pursue Covered Medical Expenses does not include the following amounts, which are the responsibility of the Claimant:
- Penalties for failure to comply with the terms of the Plan;
- Charges for services and supplies which are not included for coverage under the Plan; and
- Amounts which are in excess of any stated Plan maximums or limits. Note: This does not apply to amounts found to be in excess of Allowable Claim Limits, as defined in the section, “Claim Review and Audit Program.” The provider must agree to waive the right to balance bill for these amounts.
Also, for purposes of this section, if a provider indicates on a Form UB92 or on a CMS – 1500 Form (or similar claim form) that the provider has an assignment of benefits, then the Plan will require no further evidence that benefits are legally assigned to that provider.
Contact the Claims Administrator or the Plan Administrator for additional information regarding provider of service appeals.