Important: Please see the Notice on the first page of this plan material concerning student health insurance coverage. Notice Regarding Your Student Health Insurance Coverage Your student health insurance coverage, offered by UnitedHealthcare Insurance Company, may not meet the minimum standards required by the health care reform law for restrictions on annual dollar limits. The annual dollar limits ensure that consumers have sufficient access to medical benefits throughout the annual term of the policy. Restrictions for annual dollar limits for group and individual health insurance coverage are $1.25 million for policy years before September 23, 2012; and $2 million for policy years beginning on or after September 23, 2012 but before January 1, 2014. Restrictions on annual dollar limits for student health insurance coverage are $100,000 for policy years before September 23, 2012 and $500,000 for policy years beginning on or after September 23, 2012 but before January 1, 2014. Your student health insurance coverage puts a policy year limit of $500,000 for each Injury or Sickness that applies to the essential benefits provided in the Schedule of Benefits unless otherwise specified. If you have any questions or concerns about this notice, contact Customer Service at 1-800-767-0700. Be advised that you may be eligible for coverage under a group health plan of a parent's employer or under a parent's individual health insurance policy if you are under the age of 26. Contact the plan administrator of the parent's employer plan or the parent's individual health insurance issuer for more information. Table of Contents
Benefits for Treatment of Chemical Dependency and Mental Illness . . . . . . . . . . . .8Benefits for Mammography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9Benefits for Prosthetic Device and Reconstructive Surgery . . . . . . . . . . . . . . . . . . . . .9Benefits for Cytologic Screening . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9Benefits for Colorectal Cancer Screening . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9Benefits for Prostate Screening . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10Benefits for Second Opinion for Newly Diagnosed Cancer . . . . . . . . . . . . . . . . . . . .10Benefits for Clinical Trials for Cancer Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10Human Leukocyte Antigen Testing Benefit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11Benefits for Osteoporosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11Benefits for Maternity Expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11Benefits for Contraceptives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12Benefits for Newborn Hearing Screening . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12Benefits for Dental General Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12Benefits for Autism Spectrum Disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12Benefits for Chiropractic Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13Benefits for Early Intervention Services for Children With Disabilities . . . . . . . . . .13Benefits for Immunizations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14Benefits for Phenylketonuria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14
Definitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14Exclusions and Limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15Collegiate Assistance Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18Notice of Appeal Rights . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18FrontierMEDEX: Global Emergency Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .25Online Access to Account Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .26ID Cards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .26UnitedHealth Allies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27Claim Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Back Cover
We know that your privacy is important to you and we strive to protect the confidentiality ofyour nonpublic personal information. We do not disclose any nonpublic personal informationabout our customers or former customers to anyone, except as permitted or required by law. We believe we maintain appropriate physical, electronic and procedural safeguards toensure the security of your nonpublic personal information. You may obtain a copy of ourprivacy practices by calling us toll-free at 1-800-767-0700 or by visiting us atwww.uhcsr.com. Eligibility
All full-time residential students, international students with F1 status, nursing programstudents and student athletes are automatically enrolled in this insurance Plan atregistration, unless proof of comparable coverage is furnished. All other students enrolledin the School of Arts and Sciences are eligible to enroll in this insurance Plan. Accident coverage for Intercollegiate Sports injuries is provided under a separate policynumber 2013-200188-8. Contact the school for information on the Intercollegiate Sportsplan. Plan information is also available at www.UHCSR.com. Students must actively attend classes for at least the first 31 days after the date for whichcoverage is purchased. Home study, correspondence, and online courses do not fulfill theEligibility requirements that the student actively attend classes. The Company maintains itsright to investigate eligibility or student status and attendance records to verify that thepolicy Eligibility requirements have been met. If the Company discovers the Eligibilityrequirements have not been met, its only obligation is to refund premium. Eligible students who do enroll may also insure their Dependents. Eligible Dependents arethe student’s spouse (husband or wife) and dependent children under 26 years of age. Dependent Eligibility expires concurrently with that of the Insured student. Effective and Termination Dates
The Master Policy on file at the school becomes effective at 12:01 a.m., August 1, 2013. Coverage becomes effective on the first day of the period for which premium is paid or thedate the enrollment form and full premium are received by the Company (or authorizedrepresentative), whichever is later. The Master Policy terminates at 11:59 p.m., July 31, 2014. Coverage terminates on that date or at the end of the period through which premium is paid,whichever is earlier. Dependent coverage will not be effective prior to that of the Insuredstudent or extend beyond that of the Insured student. Refunds of premiums are allowed only upon entry into the armed forces. The Policy is a Non-Renewable One-Year Term Policy. Extension of Benefits After Termination
The coverage provided under the Policy ceases on the Termination Date. However, if anInsured is Totally Disabled on the Termination Date from a covered Injury or Sickness forwhich benefits were paid before the Termination Date, Covered Medical Expenses for suchInjury or Sickness will continue to be paid as long as the condition continues but not toexceed 90 days after the termination date. The total payments made in respect of the Insured for such condition both before and afterthe Termination Date will never exceed the Maximum Benefit. After this "Extension of Benefits" provision has been exhausted, all benefits cease to exist,and under no circumstances will further payments be made. Schedule of Medical Expense Benefits Injury and Sickness Maximum Benefit: $500,000 Paid As Specified Below (For Each Injury or Sickness) Deductible Preferred Provider: $150 (Per Insured Person, Per Policy Year) Deductible Out-of-Network: $250 (Per Insured Person, Per Policy Year) Coinsurance Preferred Provider: 80% except as noted below Coinsurance Out-of-Network: 60% except as noted below Out-of-Pocket Maximum Preferred Providers $5,000 (Per Insured Person, Per Policy Year) Out-of-Pocket Maximum Out-of-Network $10,000 (Per Insured Person, Per Policy Year)
The Policy provides benefits for the Covered Medical Expenses incurred by an Insured Person for loss due to a covered Injury or Sickness up to the Maximum Benefit of $500,000 for each Injury or Sickness. The Preferred Provider for this plan is UnitedHealthcare Options PPO. If care is received from a Preferred Provider any Covered Medical Expenses will be paid at the Preferred Provider level of benefits. If the Covered Medical Expense is incurred due to a Medical Emergency, benefits will be paid at the Preferred Provider level of benefits. In all other situations, reduced or lower benefits will be provided when an Out-of-Network provider is used. Out-of-Pocket Maximum: After the Out-of-Pocket Maximum has been satisfied, Covered Medical Expenses will be paid at 100% up to the policy Maximum Benefit subject to any benefit maximums that may apply. Separate Out-of-Pocket Maximums apply to Preferred Provider and Out-of-Network benefits. The policy Deductible, Copays and per service Deductibles and services that are not Covered Medical Expenses do not count toward meeting the Out-of-Pocket Maximum. Even when the Out-of-Pocket Maximum has been satisfied, the Insured Person will still be responsible for Copays and per service Deductibles. Benefits are subject to the policy Maximum Benefit unless otherwise specifically stated. Benefits will be paid up to the Maximum Benefit for each service as scheduled below. All benefit maximums are combined Preferred Provider and Out-of-Network unless otherwise specifically stated. Covered Medical Expenses include: Preferred Out-of-Network INPATIENT Providers Providers Room and Board Expense, daily semi-private
room rate when confined as an Inpatient andgeneral nursing care provided by the Hospital. Intensive Care Hospital Miscellaneous Expenses, such as the
cost of the operating room, laboratory tests, x-rayexaminations, anesthesia, drugs (excluding takehome drugs) or medicines, therapeutic services,and supplies. In computing the number of dayspayable under this benefit, the date of admissionwill be counted, but not the date of discharge. Preferred Out-of-Network INPATIENT Providers Providers Routine Newborn Care, see Benefits for Physiotherapy Surgeon’s Fees, if two or more procedures are
performed through the same incision or inimmediate succession at the same operativesession, the maximum amount paid will notexceed 50% of the second procedure and 50%of all subsequent procedures. Assistant Surgeon Anesthetist, professional services administered
in connection with Inpatient surgery. Registered Nurse’s Services, private duty Physician’s Visits, non-surgical services when
confined as an Inpatient. Benefits do not applywhen related to surgery. Pre-Admission Testing, payable within 3 OUTPATIENT Surgeon’s Fees, if two or more procedures are
performed through the same incision or inimmediate succession at the same operativesession, the maximum amount paid will not exceed50% of the second procedure and 50% of allsubsequent procedures. Day Surgery Miscellaneous,
scheduled surgery performed in a Hospital,including the cost of the operating room;laboratory tests and x-ray examinations, includingprofessional fees; anesthesia; drugs or medicines;and supplies. Usual and Customary Charges forDay Surgery Miscellaneous are based on theOutpatient Surgical Facility Charge Index. Assistant Surgeon Anesthetist, professional services administered
in connection with outpatient surgery. Physician’s Visits, benefits for Physician’s Visits
do not apply when related to surgery orPhysiotherapy.
Preferred Out-of-Network OUTPATIENT Providers Providers Physiotherapy, See exclusion number 28 for
additional limitations. Physiotherapy includes butis not limited to the following: 1) physical therapy;2) occupational therapy; 3) cardiac rehabilitationtherapy; 4) manipulative treatment; and 5) speechtherapy, unless excluded in the policy. Review of Medical Necessity will be performedafter 12 visits per Injury or Sickness, except asprovided under Benefits for Chiropractic Care. See also benefits for Chiropractic Care. Medical Emergency, facility charge for use of
the emergency room and supplies. Treatmentmust be rendered within 72 hours from time ofInjury or first onset of Sickness.
Diagnostic X-ray Services Radiation Therapy Chemotherapy Laboratory Services Tests & Procedures, diagnostic services and
medical procedures performed by a Physician,other than Physician’s Visits, Physiotherapy, x-raysand lab procedures. The following therapies willbe paid under this benefit: inhalation therapy,infusion therapy, pulmonary therapy andrespiratory therapy. Injections, when administered in the Physician's
office and charged on the Physician's statement. Prescription Drugs, if a covered Prescription
Drug is prescribed in a single dosage amount and
the drug is not manufactured in such single
dosage amount and requires dispensing in a
combination of different manufactured dosage
amounts only one Copayment or Deductible for
the dispensing of the combination of themanufactured dosages that equal the prescribeddosage for such Prescription Drug will apply. Anew Copayment or Deductible will apply to each31 day supply of the Prescription Drug. Maternity, see Benefits for Maternity Expenses. Complications of Pregnancy Elective Abortion Preferred Out-of-Network Providers Providers Ambulance Services Durable Medical Equipment, a written
prescription must accompany the claim whensubmitted. Benefits are limited to the initialpurchase or one replacement purchase per PolicyYear. Durable Medical Equipment includesexternal prosthetic devices that replace a limb orbody part but does not include any device that isfully implanted into the body. Consultant Physician Fees, when requested
and approved by attending Physician. Dental Treatment, made necessary by Injury to
Sound, Natural Teeth only. (Benefits are not subject to the $500,000Maximum Benefit.) Preventive Care Services, medical services that
have been demonstrated by clinical evidence to besafe and effective in either the early detection ofdisease or in the prevention of disease, have beenproven to have a beneficial effect on healthoutcomes and are limited to the following asrequired under applicable law: 1) Evidence-baseditems or services that have in effect a rating of “A” or“B” in the current recommendations of the UnitedStates Preventive Services Task Force; 2)
immunizations that have in effect arecommendation from the Advisory Committee onImmunization Practices of the Centers for DiseaseControl and Prevention; 3) with respect to infants,
children, and adolescents, evidence-informedpreventive care and screenings provided for in thecomprehensive guidelines supported by the HealthResources and Services Administration; and 4) with
respect to women, such additional preventive careand screenings provided for in comprehensiveguidelines supported by the Health Resources andServices Administration. No Deductible, Copays or Coinsurance will beapplied when the services are received from aPreferred Provider. Mental Illness Treatment, see Benefits for
Chemical Dependency and Mental Illness. Substance Use Disorder Treatment, see
Benefits for Chemical Dependency and MentalIllness. Reconstructive Breast Surgery Following Mastectomy, see Benefits for Prosthetic Device Preferred Out-of-Network Providers Providers Diabetes Services, benefits will be provided to
Insureds with gestational, type I or type II diabetesin connection with the treatment of diabetes forMedically Necessary: 1) outpatient self-management training, education and medicalnutrition therapy service when ordered by aPhysician and provided by appropriately licensedor registered healthcare professionals; and 2)Prescription Drugs, equipment, and suppliesincluding insulin pumps and supplies, bloodglucose monitors, insulin syringes with needles,blood glucose and urine test strips, ketone teststrips and tablets and lancets and lancet devices. Preferred Provider Information "Preferred Providers" are the Physicians, Hospitals and other health care providers who have contracted to provide specific medical care at negotiated prices. Preferred Providers in the local school area are: UnitedHealthcare Options PPO.
The availability of specific providers is subject to change without notice. Insureds should always confirm that a Preferred Provider is participating at the time services are required by calling the Company at 1-800-767-0700 and/or by asking the provider when making an appointment for services. "Preferred Allowance" means the amount a Preferred Provider will accept as payment in full for Covered Medical Expenses. "Out-of-Network" providers have not agreed to any prearranged fee schedules. Insureds may incur significant out-of-pocket expenses with these providers. Charges in excess of the insurance payment are the Insured's responsibility. Regardless of the provider, each Insured is responsible for the payment of their Deductible. The Deductible must be satisfied before benefits are paid. The company will pay according to the benefit limits in the Schedule of Benefits. Inpatient Expenses PREFERRED PROVIDERS - Eligible Inpatient expenses at a Preferred Provider will be paid at the Coinsurance percentages specified in the Schedule of Benefits, up to any limits specified in the Schedule of Benefits. Preferred Hospitals include UnitedHealthcare Options PPO United Behavioral Health (UBH) facilities. Call (800) 767-0700 for information about Preferred Hospitals. OUT-OF-NETWORK PROVIDERS - If Inpatient care is not provided at a Preferred Provider, eligible Inpatient expenses will be paid according to the benefit limits in the Schedule of Benefits. Outpatient Hospital Expenses
Preferred Providers may discount bills for outpatient Hospital expenses. Benefits are paidaccording to the Schedule of Benefits. Insureds are responsible for any amounts thatexceed the benefits shown in the Schedule, up to the Preferred Allowance.
Professional & Other Expenses
Benefits for Covered Medical Expenses provided by UnitedHealthcare Options PPO will bepaid at the Coinsurance percentages specified in the Schedule of Benefits or up to anylimits specified in the Schedule of Benefits. All other providers will be paid according to thebenefit limits in the Schedule of Benefits. Maternity Testing
This policy does not cover all routine, preventive, or screening examinations or testing. The following maternity tests and screening exams will be considered for payment according to the policy benefits if all other policy provisions have been met. Initial screening at first visit:
Pregnancy test: urine human chorionic gonatropin (HCG)
Pregnancy-associated plasma protein-A (PAPPA) (first trimester only)
Free beta human chorionic gonadotrophin (hCG) (first trimester only) Each visit: Urine analysis Once every trimester: Hematocrit and Hemoglobin Once during first trimester: Ultrasound Once during second trimester:
Triple Alpha-fetoprotein (AFP), Estriol, hCG or Quad screen test Alpha-fetoprotein(AFP), Estriol, hCG, inhibin-a
Once during second trimester if age 35 or over: Amniocentesis or Chorionic villus sampling (CVS) Once during second or third trimester:
postprandial) Once during third trimester: Group B Strep Culture Pre-natal vitamins are not covered. For additional information regarding Maternity Testing, please call the Company at 1-800-767-0700. Accidental Death and Dismemberment Benefits Loss of Life, Limb or Sight If such Injury shall independently of all other causes and within 180 days from the date of Injury solely result in any one of the following specific losses, the Insured Person or beneficiary may request the Company to pay the applicable amount below in addition to payment under any Medical Expense Benefits. For Loss of:
Member means hand, arm, foot, leg, or eye. Loss shall mean with regard to hands or armsand feet or legs, dismemberment by severance at or above the wrist or ankle joint; withregard to eyes, entire and irrecoverable loss of sight. Only one specific loss (the greater)resulting from any one Injury will be paid. Coordination of Benefits
Benefits will be coordinated with any other eligible medical, surgical or hospital plan orcoverage so that combined payments under all programs will not exceed 100% of allowableexpenses incurred for covered services and supplies. Mandated Benefits Benefits for Treatment of Chemical Dependency and Mental Illness
Benefits will be paid the same as any other Sickness for treatment of Chemical Dependency and Mental Illness subject to the following limitations and conditions: Chemical Dependency
Benefits will be paid for Nonresidential Treatment Programs or partial- or full-Day Program Services. Benefits will be paid for Residential Treatment Programs. Benefits will be paid for Medical or Social Setting Detoxification. Mental Illness
Benefits will be paid as any other Sickness for partial- or full-Day Program Services andResidential Treatment Programs rendered in a psychiatric residential treatment centerlicensed by the department of mental health or accredited by the Joint Commission onAccreditation of Hospitals. Benefits will be paid for inpatient treatment as any other Sickness. Benefits will be paid for the diagnosis or assessment of Mental Illness. Payment of benefitsis not dependent upon findings. Diagnosis or assessment of Mental Illness may be provided by any Physician regardless ofany Preferred Provider Provisions that may apply to other benefits under the policy. For the purposes of this endorsement, the following terms have the meanings as defined. “Chemical dependency” means the psychological or physiological dependence upon andabuse of drugs, including alcohol, characterized by drug tolerance or withdrawal andimpairment of social or occupational role functioning or both. “Day program services” means a structured, intensive day or evening treatment or partialhospitalization program certified by the department of mental health or accredited by anationally recognized organization. “Episode” means a distinct course of chemical dependency treatment separated by at leastthirty days without treatment. “Medical detoxification” means Hospital inpatient or residential medical care to ameliorateacute medical condition associated with Chemical Dependency. “Nonresidential treatment program” means a program certified by the department of mentalhealth involving structured, intensive treatment in a nonresidential setting.
“Mental illness” means any condition or disorder defined by categories listed in the mostrecent edition of the Diagnostic and Statistical Manual of Mental Disorders, except forchemical dependency. “Residential treatment program” means a program certified by the department of mentalhealth involving residential care and structured, intensive treatment. “Social setting detoxification” means a program in a supportive non-Hospital settingdesigned to achieve detoxification, without the use of drugs or other medical intervention,to establish a plan of treatment and provide for medical referral when necessary. Benefits shall be subject to all Deductible, Copayment, Coinsurance, limitations, or any otherprovisions of the policy. Benefits for Mammography
Benefits will be paid the same as any other Sickness for Low-dose Mammography for thepresence of occult breast cancer. Benefits will be provided according to the followingguidelines:
1. A single baseline mammogram for women thirty-five to thirty-nine years of age. 2. A mammogram not less than once every two years for women forty to forty-nine
years of age or more often for women with risk factors to breast cancer ifrecommended by her Physician.
3. A mammogram every year for women fifty and over. 4. A mammogram for any woman, upon the recommendation of a Physician, where
such woman, her mother or her sister has a prior history of breast cancer. “Low-dose mammography” means the x-ray examination of the breast, using equipment dedicated specifically for mammography including but not limited to the x-ray tub, filter, compression device, screens, films, and cassettes, with an average radiation exposure delivery of less than one rad mid-breast, with two views for each breast. Benefits shall be subject to all Deductible, Copayment, Coinsurance, limitations or any other provisions of the policy. Benefits for Prosthetic Device and Reconstructive Surgery
Benefits will be paid the same as any other Sickness for a Mastectomy and the initial prosthetic device or reconstructive surgery necessary to restore symmetry incident to the Mastectomy when recommended by a Physician. No time limit shall be imposed on an Insured Person for the receipt of prosthetic devices or reconstructive surgery while covered under the policy. "Mastectomy" means the removal of all or part of the breast for medically necessary reasons as determined by a Physician. Benefits shall be subject to all Deductible, Copayment, Coinsurance, limitations or any other provisions of the policy. Benefits for Cytologic Screening
Benefits will be paid the same as any other Sickness for a pelvic examination and cytologicscreening (pap smear) for an Insured in accordance with the current American CancerSociety guidelines. Benefits shall be subject to all Deductible, Copayment, Coinsurance, limitations or any otherprovisions of the policy. Benefits for Colorectal Cancer Screening
Benefits will be paid the same as any other Sickness for a colorectal cancer examinationand laboratory tests for cancer for any nonsymptomatic Insured Person in accordance withthe current American Cancer Society guidelines.
Benefits shall be subject to all Deductible, Copayment, Coinsurance, limitations or any otherprovisions of the policy. Benefits for Prostate Screening
Benefits will be paid the same as any other Sickness for a prostate examination andlaboratory tests for cancer for an Insured in accordance with the current American CancerSociety guidelines. Benefits shall be subject to all Deductible, Copayment, Coinsurance, limitations or any otherprovisions of the policy. Benefits for Second Opinion for Newly Diagnosed Cancer
Benefits will be paid the same as any other Sickness for a second opinion rendered by aPhysician specializing in that specific cancer diagnosis area when an Insured with a newlydiagnosed cancer is referred to such Physician specialist by his or her attending Physician. Benefits shall be subject to all Deductible, Copayment, Coinsurance, limitations or any otherprovisions of the policy. Benefits for Clinical Trials for Cancer Treatment
Benefits will be paid the same as any other Sickness for Routine Patient Care Costsincurred for drugs and devices that have been approved for sale by the Food and DrugAdministration (FDA) regardless of whether approved by the FDA for use in treating theInsured’s particular condition for phase II, phase III or phase IV of a clinical trial and isundertaken for the purposes of the prevention, early detection, or treatment of cancer. For Routine Patient Care Costs for phase II to be considered for payment, the clinical trialsmust meet all of the following criteria:
1. Phase II of a clinical trial is sanctioned by the National Institutes of Health (NIH) or
National Cancer Institute (NCI) and conducted at academic or Nation CancerInstitute Center; and
2. The Insured Person is enrolled in the clinical trial. Coverage for phase II clinical trials
will not apply to Insured Persons who are only following the protocol of phase II ofa clinical trial, but not actually enrolled.
For Routine Patient Care Costs for phase III and phase IV to be considered for payment,the clinical trials must meet all of the following criteria:
1. The treatment is provided by (a) one of the National Institutes of Health (NIH); (b)
an NIH Cooperative Group or Center; (c) the FDA in the form of an investigationalnew drug application; (d) the federal Departments of Veterans’ Affairs or Defense;(e) an institutional review board in this state that has an appropriate assuranceapproved by the Department of Health and Human Services assuring compliancewith and implementation of regulations for the protection of human subjects (45CFR 46); or (f) a qualified research entity that meets the criteria for NIH Centersupport grant eligibility.
2. The treating facility and personnel must have the expertise and training to provide
the treatment and treat a sufficient volume of patients.
3. There must be equal or superior noninvestigational treatment alternatives and the
available clinical or preclinical data must provide a reasonable expectation that thetreatment will be superior to the noninvestigational alternatives.
4. Any entity seeking coverage for treatment, prevention, or early detection in a clinical
trial approved by an institutional review board shall maintain and post electronically
a list of the clinical trials meeting the above requirements. The list shall include: (a)the phase for which the trial is approved; (b) the entity approving the trial; (c) theparticular disease; and (d) the number of participants in the trial. If electronicposting is not practical, the entity seeking coverage shall periodically provide awritten list containing this information.
Providers participating in clinical trials shall obtain the Insured’s informed consent forparticipation on the clinical trial in a manner that is consistent with current legal and ethicalstandards. Such documents shall be made available to the Company upon request. “Routine patient care costs” shall include coverage for reasonable and medically necessaryservices needed to administer the drug or device under evaluation in the clinical trialincluding all items and services that are otherwise generally available to a qualified individualexcept: (a) the investigational item or service itself; (b) items and services provided solely tosatisfy data collection and analysis needs and that are not used in the direct clinicalmanagement of the patient; and (c) items and services customarily provided by the researchsponsors free of charge for any enrollee in the trial. The provisions of this section shall not be construed to affect compliance or coverage foroff-label use of drugs not directly affected by this section. Benefits shall be subject to all Deductible, Copayment, Coinsurance, limitations or any otherprovisions of the policy. Human Leukocyte Antigen Testing Benefit
Benefits will be paid the same as any other Sickness for Human Leukocyte Antigen Testing,also referred to as histocompatibility locus antigen testing, for A, B, and DR antigens forutilization in bone marrow transplantation. Benefits will be limited to one such testing perlifetime, not to exceed $75.00. The testing must be performed in a facility which is accredited by the American Associationof Blood Banks or its successors, and is licensed under the Clinical LaboratoryImprovement Act, 42 U.S.C. Section 263a, as amended, and is accredited by the AmericanAssociation of Blood Banks or its successors, the College of American Pathologists, theAmerican Society for Histocompatibility and Immunogenetics (ASHI) or any other nationalaccrediting body with requirements that are substantially equivalent to or more stringentthan those of the College of American Pathologists. At the time of testing, the Insured beingtested must complete and sign an informed consent form that also authorizes the resultsof the test to be used for participation in the National Marrow Donor Program. Benefits shall be subject to all Deductible, Copayment, Coinsurance, limitations or any otherprovisions of the policy. Benefits for Osteoporosis
Benefits will paid the same as any other Sickness for services related to diagnosis,treatment and appropriate management of osteoporosis when such services are providedby a Physician for Insureds with a condition or medical history for which bone massmeasurement is medically indicated. In determining whether testing or treatment ismedically appropriate, due consideration will be given to peer reviewed medical literature. Benefits shall be subject to all Deductible, Copayment, Coinsurance, limitations or any otherprovisions of the policy. Benefits for Maternity Expenses
Benefits will be paid the same as any other Sickness for a minimum of 48 hours forinpatient care following a vaginal delivery or 96 hours following a cesarean section delivery. Post-discharge care will be payable for up to two visits by a registered professional nursewith experience in maternal and child health nursing or a Physician, one of which shall bein the home. A Physician shall determine the location and schedule of the post-dischargevisits. Services shall include, but not be limited to, physical assessment of the newborn andmother, parent education, assistance and training in breast or bottle feeding, education and
services for complete childhood immunizations, the performance of any necessary andappropriate clinical tests and submission of a metabolic specimen satisfactory to the statelaboratory. Such services shall be in accordance with the medical criteria outlined in themost current version of the "Guidelines for Perinatal Care" prepared by the AmericanAcademy of Pediatrics and the American College of Obstetricians and Gynecologists, orsimilar guidelines prepared by another nationally recognized medical organization. Benefits shall be subject to all Deductible, Copayment, Coinsurance, limitations or any otherprovisions of the policy.
Benefits for Contraceptives
The Policyholder provides benefits for Contraceptives the same as any other PrescriptionDrug or device under this policy. “Contraceptives” means all Prescription Drugs and devices approved by the Federal Foodand Drug Administration for use as a contraceptive but shall exclude all drugs and devicesthat are intended to induce an abortion. Benefits shall be subject to all Deductible, Copayment, Coinsurance, limitations or any otherprovisions of the policy. Benefits for Newborn Hearing Screening
Benefits will be paid the same as any other Sickness for Dependent Newborn Infants forhearing screening, necessary rescreening, audiological assessment and follow-up, andinitial amplification. Benefits shall be subject to all Deductible, Copayment, Coinsurance, limitations or any otherprovisions of the policy. Benefits for Dental General Anesthesia
Benefits will be paid the same as any other Sickness for administration of generalanesthesia and Hospital charges for dental care to a Dependent child under the age of five,an Insured who is severely disabled, or an Insured who has a medical or behavioral conditionwhich requires hospitalization or general anesthesia when dental care is provided. Benefits shall be subject to all Deductible, Copayment, Coinsurance, limitations or any otherprovisions of the policy. Benefits for Autism Spectrum Disorder
Benefits will be paid the same as any other Sickness for Diagnosis and Treatment of AutismSpectrum Disorders. Benefits for Applied Behavior Analysis will be paid for Insureds underthe age of 19. Benefits are limited to Medically Necessary treatment that is ordered by the Insured’streating licensed Physician or licensed psychologist, pursuant to the powers granted undersuch licensed Physician’s or licensed psychologist’s license, in accordance with a treatmentplan. Upon request of the Company, the treatment plan shall include all elements necessaryfor the Company to pay claims. Such elements include, but are not limited to, a diagnosis,proposed treatment by type, frequency and duration of treatment, and goals. Except forInpatient services, if an Insured is receiving Treatment for an Autism Disorder, the Companyshall have the right to review the treatment plan not more than once every six monthsunless the Company and the Insured’s treating Physician or psychologist agree that a morefrequent review is necessary. Any such agreement regarding the right to review a treatmentplan more frequently shall only apply to a particular Insured being treated for an AutismSpectrum Disorder and shall not apply to all Insureds being treated for Autism SpectrumDisorders by a Physician or psychologist. The cost of obtaining any review or treatment planshall be borne by the Company.
“Treatment for Autism Spectrum Disorders” means care prescribed or ordered for anindividual diagnosed with an ASD by a licensed physician or licensed psychologist, includingequipment medically necessary for such care, pursuant to the powers granted under thelicensed physician’s or licensed psychologist’s license, including but not limited to:Psychiatric Care; Psychological Care; Habilitative or Rehabilitative Care, including AppliedBehavior Analysis therapy; Therapeutic Care; and Pharmacy care. “Applied behavior analysis” means the design, implementation, and evaluation ofenvironmental modifications, using behavioral stimuli and consequences, to producesocially significant improvement in human behavior, including the use of direct observation,measurement, and functional analysis of the relationship between environment andbehavior. “Autism spectrum disorders” (ASD) means a neurobiological disorder, an illness of thenervous system, which includes Autistic Disorder, Asperger’s Disorder, PervasiveDevelopmental Disorder Not Otherwise Specified, Rett’s Disorder, and ChildhoodDisintegrative Disorder, as defined in the most recent edition of the Diagnostic andStatistical Manual of Mental Disorders of the American Psychiatric Association. “Diagnosis of autism spectrum disorders” means medically necessary assessments,evaluations, or tests in order to diagnose whether an individual has an ASD. “Habilitative or rehabilitative care” means a professional, counseling, and guidance servicesand treatment programs, including applied behavior analysis, that are necessary to developthe functioning of an individual. “Pharmacy Care” means medication used to address symptoms of an ASD prescribed by alicensed Physician, and any health-related services deemed medically necessary todetermine the need or effectiveness of the medications only to the extent that suchmedications are included in the policy. “Psychiatric Care” means the direct or consultative services provided by a psychiatristlicensed in the state in which the psychiatrist practices. “Psychological Care” means direct or consultative services provided by a psychologistlicensed in the state in which the psychologist practices. “Therapeutic Care” means services provided by licensed speech therapists, occupationaltherapists, or physical therapists. Benefits shall be subject to all Deductible, Copayment, Coinsurance, limitations or any otherprovisions of the policy. Benefits for Chiropractic Care
Benefits will be paid the same as any other Sickness for the chiropractic care delivered bya licensed chiropractor. Benefits will include initial diagnosis and clinically appropriate andMedically Necessary services and supplies required to treat the diagnosed disorder. Benefits will be provided for twenty-six (26) visits per policy year. In order to receivebenefits for any additional visits, the Insured must notify the Company prior to receiving anyadditional visits. Review of Medical Necessity will be performed for any follow-up diagnostictests or visits for treatment in excess of the initial twenty-six visits. Benefits shall be subject to all Deductible, Copayment, Coinsurance, limitations or any otherprovisions of the policy. Benefits for Early Intervention Services for Children With Disabilities
Benefits will be paid the same as any other Sickness for Early Intervention Services forchildren from birth to the age of three (3) identified by the Part C early intervention systemas eligible for services and when Early Intervention Services are delivered by an earlyintervention specialist who is a health care professional licensed by the state of Missouriand acts within the scope of their profession. Benefits will be limited to three-thousanddollars ($3,000) per each Insured child Per Policy Year.
“Early Intervention Services” means Medically Necessary speech and language therapy,occupational therapy, physical therapy, and assistive technology devices for children frombirth to age three (3) who are identified by the Part C early intervention system as eligiblefor services under Part C of the Individuals with Disabilities Education Act, 20 U.S.C. Section1431, et seq. Early Intervention Services include services under an active IndividualizedFamily Service Plan that enhances the functional ability without effecting a cure. “Individualized Family Service Plan” means a written plan for providing Early InterventionServices to an eligible child and the child’s family that is adopted in accordance with 20U.S.C Section 1436. The Company shall be billed at the applicable Medicaid rate at the time the covered benefitis delivered and shall pay the Part C early intervention system at such rate for benefitscovered by this mandate. Benefits shall be subject to all Deductible, Copayment, Coinsurance, limitations or any otherprovisions of the policy. Benefits for Immunizations
Benefits will be paid the same as any other Sickness for immunizations of a child from birthto five years of age as provided by department of health regulations. Benefits shall not be subject to any Deductible or Copayment limits. Benefits for Phenylketonuria
Benefits will be paid the same as any other Sickness for formula and Low Protein ModifiedFood Products recommended by a Physician for the treatment of phenylketonuria (PKU) orany inherited disease of amino and organic acids for an Insured less than six (6) years ofage. Benefits will not exceed $5,000 per policy year. “Low protein modified food products” means foods that are specifically formulated to haveless than one gram of protein per serving and are intended to be used under the directionof a Physician for the dietary treatment of any inherited metabolic disease. Low proteinmodified food products do not include foods that are naturally low in protein. Benefits shall be subject to all Deductible, Copayment, Coinsurance, limitations or any otherprovisions of the policy. Definitions COVERED MEDICAL EXPENSES means reasonable charges which are: 1) not in excess of Usual and Customary Charges; 2) not in excess of the Preferred Allowance when the policy includes Preferred Provider benefits and the charges are received from a Preferred Provider; 3) not in excess of the maximum benefit amount payable per service as specified in the Schedule of Benefits; 4) made for services and supplies not excluded under the policy; 5) made for services and supplies which are a Medical Necessity; 6) made for services included in the Schedule of Benefits; and 7) in excess of the amount stated as a Deductible, if any. Covered Medical Expenses will be deemed "incurred" only: 1) when the covered services are provided; and 2) when a charge is made to the Insured Person for such services. DEPENDENT means the spouse (husband or wife) of the Named Insured and their dependent children. Children shall cease to be dependent at the end of the month in which they attain the age of 26 years. If the child is covered under this policy upon the attainment of the limiting age, such child shall remain a dependent under this policy at the option of the Named Insured until the policy Termination Date. The attainment of the limiting age will not operate to terminate the coverage of such child while the child is and continues to be both:
1) Incapable of self-sustaining employment by reason of mental or physical
2) Chiefly dependent upon the Insured Person for support and maintenance.
Proof of such incapacity and dependency shall be furnished to the Company: 1) by the Named Insured; and, 2) within 31 days of the child's attainment of the limiting age. Subsequently, such proof must be given to the Company annually following the child's attainment of the limiting age. If a claim is denied under the policy because the child has attained the limiting age for dependent children, the burden is on the Insured Person to establish that the child is and continues to be handicapped as defined by subsections (1) and (2). INJURY means accidental bodily injury sustained, directly and independently of all other causes; treated by a Physician within 30 days after the date of accident and while the Insured Person is covered under this policy. Covered Medical Expenses incurred as a result of an injury that occurred prior to this policy’s Effective Date will be considered a Sickness under this policy. INPATIENT means an uninterrupted confinement that follows formal admission to a Hospital by reason of an Injury or Sickness for which benefits are payable under this policy. PRE-EXISTING CONDITION means any condition which is diagnosed, treated or recommended for treatment within the 12 months immediately prior to the Insured's Effective Date under the policy. SICKNESS means sickness or disease of the Insured Person which causes loss while the Insured Person is covered under this policy. All related conditions and recurrent symptoms of the same or a similar condition will be considered one sickness. Covered Medical Expenses incurred as a result of an Injury that occurred prior to this policy’s Effective Date will be considered a sickness under this policy. TOTALLY DISABLED means a condition of a Named Insured which, because of Sickness or Injury, renders the Named Insured unable to actively attend class. A totally disabled Dependent is one who is unable to perform all activities usual for a person of that age. USUAL AND CUSTOMARY CHARGES means the lesser of the actual charge or a reasonable charge which is: 1) usual and customary when compared with the charges made for similar services and supplies; and 2) made to persons having similar medical conditions in the locality of the Policyholder. The Company uses data from FAIR Health, Inc. to determine Usual and Customary Charges. No payment will be made under this policy for any expenses incurred which in the judgment of the Company are in excess of Usual and Customary Charges. Exclusions and Limitations
No benefits will be paid for: a) loss or expense caused by, contributed to, or resulting from;or b) treatment, services or supplies for, at, or related to any of the following:
1. Acne; 2. Acupuncture; 3. Allergy including allergy testing; 4. Nicotine addiction, except as specifically provided in the policy;5. Assistant Surgeon Fees;6. Milieu therapy, learning disabilities, except as specifically provided in the Benefits for
the Treatment of Chemical Dependency and Mental Illness behavioral problems,parent-child problems, conceptual handicap, developmental delay or disorder ormental retardation, except as specifically provided in the Benefits for the Treatment ofChemical Dependency and Mental Illness;
8. Injections;9. Congenital conditions, except as specifically provided for Newborn or adopted Infants;
10. Cosmetic procedures, except cosmetic surgery required to correct an Injury for which
benefits are otherwise payable under this policy or for newborn or adopted children;
11. Custodial Care; care provided in: rest homes, health resorts, homes for the aged,
halfway houses, college infirmaries or places mainly for domiciliary or Custodial Care;extended care in treatment or substance abuse facilities for domiciliary or CustodialCare;
12. Dental treatment, except as specifically provided in Benefits for Dental General
Anesthesia or for accidental Injury to Sound, Natural Teeth;
13. Elective Surgery or Elective Treatment; 14. Elective abortion, unless elected by the Policyholder and an additional premium
15. Eye examinations, eyeglasses, contact lenses, prescriptions or fitting of eyeglasses or
contact lenses; vision correction surgery, or other treatment for visual defects andproblems, except when due to a covered Injury or disease process;
16. Flat foot conditions; supportive devices for the foot; subluxations of the foot; fallen
arches; weak feet; chronic foot strain; symptomatic complaints of the feet; and routinefoot care including the care, cutting and removal of corns, calluses, toenails, andbunions (except capsular or bone surgery);
17. Unless coverage is elected by the Policyholder, hearing examinations; hearing aids; or
cochlear implants; or other treatment for hearing defects and problems, except asspecifically provided in Benefits for Newborn Hearing Screening or except as a resultof an infection or Injury. "Hearing defects" means any physical defect of the ear whichdoes or can impair normal hearing, apart from the disease process;
20. Immunizations, except as specifically provided in the policy; preventive medicines or
vaccines, except where required for treatment of a covered Injury or as specificallyprovided in the policy;
21. Injury caused by, contributed to, or resulting from the use of alcoholintoxicants,
hallucinogenics, illegal drugs, or any drugs or medicines that are not taken in therecommended dosage or for the purpose prescribed by the Insured Person'sPhysician;
22. Injury or Sickness for which benefits are paid or payable under any Workers'
Compensation or Occupational Disease Law or Act, or similar legislation;
23. Injury sustained while (a) participating in any intercollegiate or professional sport,
contest or competition; (b) traveling to or from such sport, contest or competition as aparticipant; or (c) while participating in any practice or conditioning program for suchsport, contest or competition;
24. Investigational services;25. Lipectomy;26. Marital or family counseling;
27. Organ transplants, including organ donation;
28. Outpatient Physiotherapy; except for a condition that required surgery or Hospital
Confinement: 1) within the 30 days immediately preceding such Physiotherapy; or 2)within the 30 days immediately following the attending Physician's release forrehabilitation;
29. Participation in a riot or civil disorder; commission of or attempt to commit a felony;
30. Pre-existing Conditions, except for individuals who have been continuously insured
under the student insurance policy for at least 12 consecutive months. The Pre-existing Condition exclusionary period will be reduced by the total number of monthsthat the Insured provides documentation of continuous coverage under a prior healthinsurance policy which provided benefits similar to this policy. This exclusion will not
be applied to an Insured Person who is under age 19;
31. Prescription Drugs, services or supplies as follows:
a. Therapeutic devices or appliances, including: hypodermic needles, syringes,
support garments and other non-medical substances, regardless of intended use,except as specifically provided in the policy;
b. Immunization agents, except as specifically provided in the policy; biological sera,
blood or blood products administered on an outpatient basis;
c. Drugs labeled, “Caution - limited by federal law to investigational use” or
experimental drugs; except as specifically provided in Benefits for Clinical Trials forCancer Treatment;
d. Products used for cosmetic purposes;e. Drugs used to treat or cure baldness; anabolic steroids used for body building;
f. Anorectics - drugs used for the purpose of weight control;
g. Fertility agents or sexual enhancement drugs, such as Parlodel, Pergonal, Clomid,
i. Refills in excess of the number specified or dispensed after one (1) year of date of
32. Reproductive/Infertility services including but not limited to: family planning; fertility
tests; infertility (male or female), including any services or supplies rendered for thepurpose or with the intent of inducing conception; premarital examinations; impotence,organic or otherwise; female sterilization procedures, except as specifically providedin the policy; vasectomy; sexual reassignment surgery; reversal of sterilizationprocedures;
33. Research or examinations relating to research studies, or any treatment for which the
patient or the patient’s representative must sign an informed consent documentidentifying the treatment in which the patient is to participate as a research study orclinical research study, except as specifically provided in Benefits for Clinical Trials forCancer Treatment;
34. Routine Newborn Infant Care, well-baby nursery and related Physician charges;
except as specifically provided in the policy;
35. Preventive Care Services; routine physical examinations and routine testing;
preventive testing or treatment; screening exams or testing in the absence of Injury orSickness; except as specifically provided in the policy;
36. Services provided normally without charge by the Health Service of the Policyholder;
or services covered or provided by the student health fee;
37. Skeletal irregularities of one or both jaws, including orthognathia and mandibular
retrognathia; temporomandibular joint dysfunction; deviated nasal septum, includingsubmucous resection and/or other surgical correction thereof; nasal and sinussurgery, except for treatment of a covered Injury or treatment of chronic purulentsinusitis;
38. Skydiving, parachuting, hang gliding, glider flying, parasailing, sail planing, bungee
jumping, or flight in any kind of aircraft, except while riding as a passenger on aregularly scheduled flight of a commercial airline;
39. Sleep disorders;40. Unless coverage is elected by the Policyholder, speech therapy; naturopathic services;
41. Supplies, except as specifically provided in the policy;
42. Surgical breast reduction, breast augmentation, breast implants or breast prosthetic
devices, or gynecomastia; except as specifically provided in the policy;
43. Travel in or upon, sitting in or upon, alighting to or from, or working on or around any
motorcycle or recreational vehicle including but not limiting to: two- or three-wheeledmotor vehicle; four-wheeled all terrain vehicle (ATV); jet ski; ski cycle; or snowmobile;
44. Skiing; scuba diving; surfing;45. Treatment in a Government hospital, unless there is a legal obligation for the Insured
46. War or any act of war, declared or undeclared; or while in the armed forces of any
country (a pro-rata premium will be refunded upon request for such period notcovered); and
47. Weight management, weight reduction, nutrition programs, treatment for obesity,
surgery for removal of excess skin or fat. Collegiate Assistance Program
Insured Students have access to nurse advice, health information, and counseling support24 hours a day by dialing the number listed on the permanent ID card. CollegiateAssistance Program is staffed by Registered Nurses and Licensed Clinicians who can helpstudents determine if they need to seek medical care, need legal/financial advice or mayneed to talk to someone about everyday issues that can be overwhelming. Notice of Appeal Rights Right to Internal Appeal DEFINITIONS
For the purpose of the Notice of Appeal Rights, the following terms are defined as shownbelow:Adverse Determination means:1. A determination by the Company that, based upon the information provided, a request
for benefits under the Policy does not meet the Company’s requirements for MedicalNecessity, appropriateness, health care setting, level of care, or effectiveness, or isdetermined to be experimental or investigational, and the requested benefit is denied,reduced, in whole or in part, or terminated;
2. A denial, reduction, in whole or in part, or termination based on the Company’s
determination that the individual was not eligible for coverage under the Policy as anInsured Person;
3. Any concurrent, prospective or retrospective review determination that denies, reduces,
in whole or in part, or terminates a request for benefits under the Policy; or
4. A rescission of coverage. Authorized Representative means: 1. A person to whom an Insured Person has given express written consent to represent the
2. A person authorized by law to provide substituted consent for an Insured Person;3. An Insured Person’s family member or health care provider when the Insured Person is
4. In the case of an urgent care request, a health care professional with knowledge of the
Concurrent Review means Utilization Review conducted during a patient’s Inpatient hospitalstay or course of treatment.
Final Adverse Determination means an Adverse Determination involving a Covered MedicalExpense that has been upheld by the Company, at the completion of the Company’s internalappeal process or an Adverse Determination for which the internal appeals process hasbeen deemed exhausted in accordance with this notice. Grievance means a written compliant submitted by or on behalf of an Insured Personregarding the:1. Availability, delivery or quality of health care services, including a complaint regarding an
Adverse Determination made pursuant to Utilization Review
2. Claims payment, handling or reimbursement for health care services; or3. Matters pertaining to the contractual relationship between an Insured Person and a
Prospective Review means Utilization Review performed prior to an admission or course oftreatment. Retrospective Review means Utilization Review of Medical Necessity conducted afterservices have been provided to a patient. Retrospective review does not include the reviewof a claim that is limited to an evaluation of reimbursement levels, veracity of documentation,accuracy of coding, or adjudication for payment. Urgent Care Request means a request for a health care service or course of treatment withrespect to which the time periods for making a non-urgent care request determination:1. Could seriously jeopardize the life or health of the Insured Person or the ability of the
Insured Person to regain maximum function; or
2. In the opinion of a physician with knowledge of the Insured Person’s medical condition,
would subject the Insured Person to severe pain that cannot be adequately managedwithout the health care service or treatment that is the subject of the request.
Utilization Review means a set of formal techniques designed to monitor the use of or evaluate the clinical necessity, appropriateness, efficacy or efficiency of health care services, procedures, providers or facilities. Techniques may include ambulatory review, Prospective Review, second opinion, certification, Concurrent Review, case management, discharge planning, or Retrospective Review. INTERNAL APPEAL PROCESS
An Insured Person or an Authorized Representative may submit a written request for anInternal Review of a Grievance. Upon receipt of the request for an Internal Review of a Grievance, the Company shallprovide the Insured Person with the name, address and telephone of the employee ordepartment designated to coordinate the Internal Review for the Company. With respect toan Adverse Determination involving Utilization Review, the Company shall designate anappropriate clinical peer(s) of the same or similar specialty as would typically manage thecase which is the subject of the Adverse Determination. The clinical peer(s) shall not havebeen involved in the initial Adverse Determination. The written Internal Appeal request should include:1.
A statement specifically requesting an Internal Appeal of the decision;
The Insured Person’s Name and ID number (from the ID card);
The reason the claim should be reconsidered; and
Any written comments, documents, records, or other material relevant to the claim.
The Customer Service Department can be contacted at 800-767-0700 with any questionsregarding the Internal Appeal process. The written request for an Internal Appeal should besent to: UnitedHealthcare StudentResources, PO Box 809025, Dallas, TX 75380-9025. Within 10 working days after receipt of the Grievance, the Company shall provideacknowledgement of receipt of the Grievance and notice that the Insured Person orAuthorized Representative is entitled to:1. Contact the Missouri Department of Insurance, Financial Institutions and Professional
Within 3 days after receipt of a Grievance involving an Adverse Determination, the Companyshall provide notice that the Insured Person or Authorized Representative is entitled to:1. Contact the Missouri Department of Insurance, Financial Institutions and Professional
2. Submit written comments, documents, records, and other material relating to the request
for benefits to be considered when conducting the Internal Review; and
3. Receive from the Company, upon request and free of charge, reasonable access to and
copies of all documents, records and other information relevant to the Insured Person’srequest for benefits.
Prior to issuing or providing a notice of Final Adverse Determination, the Company shallprovide, free of charge and as soon as possible:1. Any new or additional evidence considered by the Company in connection with the
2. Any new or additional rationale upon which the decision was based. The Insured Person or Authorized Representative shall have 10 calendar days to respondto any new or additional evidence or rationale. The company shall complete an investigation within 20 working days after receipt of theGrievance. If the investigation cannot be completed within 20 working days, the InsuredPerson or Authorized Representative will be notified in writing on or before the twentiethworking day with the specific reasons for which additional time is needed for theinvestigation. The investigation shall then be completed within 30 working days thereafter. Within 5 working days after the investigation has been completed, the Company shall notifythe Insured or Authorized Representative in writing of the Company’s decision regardingthe Grievance and of the right to file an External Appeal with the DIFP. The DIFP can be contacted at the following address and telephone number:Missouri Department of Insurance, Financial Institutions and Professional RegistrationConsumer Affairs Division301 W. High Street, Room 830Harry S. Truman State Office BuildingJefferson City, MO 65101(800) 726 [email protected] 15 days after the investigation has been completed, the Company shall also notifythe person who submitted the Grievance of the Company’s resolution of said Grievance. Time periods shall be calculated based on the date the Company receives the request forthe Internal Review, without regard to whether all of the information necessary to make thedetermination accompanies the request.
If the Grievance involves an Adverse Determination, the written notice of Final AdverseDetermination for the Internal Review shall include:1. The titles and qualifying credentials of the reviewers participating in the Internal Review;2. Information sufficient to identify the claim involved in the Grievance, including the
a. the date of service;b. the name health care provider; andc. the claim amount;
3. A statement that the diagnosis code and treatment code and their corresponding
meanings shall be provided to the Insured Person or the Authorized Representative,upon request;
4. For an Internal Review decision that upholds the Company’s original Adverse
a. the specific reason(s) for the Final Adverse Determination, including the denial
code and its corresponding meaning, as well as a description of the Company’sstandard, if any, that was used in reaching the denial;
b. reference to the specific Policy provisions upon which the determination is based;c. a statement that the Insured Person is entitled to received, upon request and free
of charge, reasonable access to and copies of all documents, records, and otherinformation relevant to the Insured Person’s benefit request;
d. if applicable, a statement that the Company relied upon a specific internal rule,
guideline, protocol, or similar criterion and that a copy will be provided free of chargeupon request;
e. if the Final Adverse Determination is based on a Medical Necessity or experimental
or investigational treatment or similar exclusion or limitation, a statement that anexplanation will be provided to the Insured Person free of charge upon request;
f. instructions for requesting: (i) a copy of the rule, guideline, protocol or other similar
criterion relied upon to make the Final Adverse Determination; and (ii) the writtenstatement of the scientific or clinical rationale for the determination;
5. A description of the procedures for obtaining an External Independent Review of the
Final Adverse Determination pursuant to the State’s External Review legislation; and
6. The Insured Person’s right to bring a civil action in a court of competent jurisdiction. 7. Notice of the Insured Person’s right to contact the Director’s office or ombudsman’s
office for assistance with respect to any claim, Grievance or appeal at any time. Expedited Internal Review (EIR) of a Grievance
The Insured Person or an Authorized Representative may submit an oral or written requestfor an Expedited Internal Review (EIR) of a Grievance:1. involving Urgent Care Requests; and2. related to a concurrent review Urgent Care Request involving an admission, availability
of care, continued stay or health care service for an Insured Person who has receivedemergency services, but has not been discharged from a facility.
For the purposes of Missouri’s Grievance register requirements, the request will not beconsidered a Grievance unless the request is submitted in writing. If the EIR request is related to a concurrent review Urgent Care Request, benefits for theservice will continue until the Insured Person has been notified of the final determination.
The Insured Person or the Authorized Representative shall be notified orally of the EIRdecision no more than seventy-two (72) hours after the Company’s receipt of the EIRrequest. Written confirmation of the decision will be provided within three (3) working daysof providing notification of the determination. At the same time an Insured Person or an Authorized Representative files an EIR request,the Insured Person or the Authorized Representative may file:1. An Expedited External Review (EER) request if the Insured Person has a medical
condition where the timeframe for completion of an EIR would seriously jeopardize thelife or health of the Insured Person or would jeopardize the Insured Person’s ability toregain maximum function. EXTERNAL INDEPENDENT REVIEW
An Insured Person or Authorized Representative may file a Grievance with the Director ofthe DIFP when the Insured has received an Adverse Determination or Final AdverseDetermination from the Company. The Insured Person or Authorized Representative maysubmit a request for an External Independent Review without exhausting all remediesavailable under the Company’s Grievance process. The DIFP can be contacted at the following address and telephone number:Missouri Department of Insurance, Financial Institutions and Professional RegistrationConsumer Affairs Division301 W. High Street, Room 830Harry S. Truman State Office BuildingJefferson City, MO 65101(800) 726 [email protected] Standard External Review Process1. After the Grievance is received, the Director shall attempt to resolve as a consumer
complaint and resolve the issue with the Company. If the Director determines the issuecannot be resolved, the Director shall:
a. Refer the unresolved Grievance to an Independent Review Organization from the
b. Provide the IRO, Insured Person or their Authorized Representative, or the Company
with copies of all medical records or any other relevant documents which the Divisionhas received from any party.
2. The Insured Person, Authorized Representative, or the Company may submit additional
information to the DIFP, which the DIFP will forward to the IRO for consideration whenconducting the review. If the Insured Person, Authorized Representative, or theCompany has information which contradicts information already provided to IRO, thenthis information must be provided as additional information. All additional informationshould be received by the DIFP within 15 working days from the date the DIFP mailedthat party copies of the information provided to the IRO
3. If the IRO shall request from the DIFP additional information needed and the DIFP shall
gather the requested information from the Company, Insured Person or, if applicable, theAuthorized Representative and provide it to the IRO. If the Director is unable to obtainthe requested information, the IRO shall base its opinion on the information alreadyprovided.
4. Within 20 days after receipt of the request for external review, the IRO shall provide, to
the Director, its opinion to uphold or reverse the Adverse Determination or Final AdverseDetermination. Under exceptional circumstances, if the IRO requires additional time tocomplete its review, the IRO will request in writing from the Director an extension in thetime to process the review, which will not exceed 5 calendar days.
5. After the Director receives the IRO’s decision, the Director shall, within 25 calendar days
of receiving the IRO’s opinion, provide written notice of the Director’s decision to upholdor reverse the Adverse Determination or Final Adverse Determination to the, theCompany, the Insured Person and, if applicable, the Authorized Representative. In noevent shall the time between the date the IRO receives the request for external reviewand the date the Insured and the Company are notified of the Director’s decision belonger than 45 days.
6. The Director’s decision shall be binding upon the Insured Person and the Company. Upon receipt of a notice of decision reversing the Adverse Determination or Final AdverseDetermination, the Company shall immediately approve the coverage that was the subjectof the Adverse Determination or Final Adverse Determination. II. Expedited External Review (EER) Process1. The Insured Person or an Authorized Representative may make a request for an
Expedited External Review (EER) with the Director at the time the Insured Personreceives:
(i) an Adverse Determination involving a medical condition for which the
timeframe for completing an EIR would seriously jeopardize the life orhealth of the Insured Person or jeopardize the Insured Person’s ability toregain maximum function; or
(ii) an Adverse Determination involving an admission, availability of care,
continued stay or health care service for which the Insured Person receivedemergency services, but has not been discharged from a facility.
An EER may not be provided for retrospective Adverse Determinations or Final AdverseDeterminations. 2. As expeditiously as possible after receipt of the request for EER by the IRO, the IRO
must issue its opinion as to whether the Adverse Determination should be upheld orreversed and submit its opinion to the Director.
3. As expeditiously as possible, but within no more than 72 hours after receipt of the
qualifying EER request, the Director shall then issue a decision. If the notice is notin writing, the Director will provide the written decision within 48 hours after the dateof the notice of determination.
4. Upon receipt of a notice of decision reversing the Adverse Determination or Final
Adverse Determination, the Company shall immediately approve the coverage that wasthe subject of the Adverse Determination or Final Adverse Determination.
III. Experimental or Investigational Treatment External Review Process1. If a request for external review of an Adverse Determination involves a denial of
coverage based on a determination that the health care service or treatmentrecommended or requested is experimental or investigational, the following additionalrequirements must be met.
2. The IRO will complete a preliminary review to determine that:
a. the recommended healthcare service or treatment subject to the Adverse
Determination or Final Adverse Determination is a covered benefit under thePolicy; and
b. the recommended healthcare service or treatment subject to the Adverse
Determination or Final Adverse Determination is not explicitly listed as anexcluded benefit under the Policy.
3. The request for external review of an Adverse Determination involving a denial of
coverage based on the Company’s determination that the health care service ortreatment recommended or requested is experimental or investigational must include acertification from the Insured Person’s Physician stating:
a. Standard health care services or treatments have not been effective in
improving the condition of the Insured Person, or
b. Standard health care services or treatments are not medically appropriate for
c. There is no available standard health care service or treatment covered by the
Company that is more beneficial than the recommended or requested healthcare service or treatment; and
d. The request for external review of an Adverse Determination involving the
denial of coverage based on a determination that the requested treatment isexperimental or investigational shall also include documentation that:
i. The Insured Person’s treating Physician has recommended a health care
service or treatment that the Physician certifies, in writing, is likely to be morebeneficial to the Insured Person, in the Physician’s opinion than any availablestandard health care services or treatments; or
ii. That the Insured Person’s treating Physician, who is a licensed, board-
certified, or board-eligible Physician qualified to practice in the area ofmedicine appropriate to treat the Insured’s condition, has certified in writingthat scientifically valid studies using acceptable protocols demonstrate thatthe health care service or treatment requested by the Insured Person is likelyto be more beneficial to the Insured Person than any available standardhealth care service or treatment.
4. When conducting the external review of an Adverse Determination involving a denial of
coverage based on a determination the health care service or treatment is experimentalor investigational, the IRO shall select 1 or more clinical peers who must be Physiciansor other health care professionals who meet minimum qualifications and through clinicalexperience in the past 3 years are experts in the treatment of the Insured’s condition andknowledgeable about the recommended or requested health care service or treatment.
5. Each clinical reviewer shall provide written opinion to the IRO to uphold or reverse the
Adverse Determination or Final Adverse Determination. The IRO shall provide theopinions to the Director who shall then issue the decision to either uphold or reverse theAdverse Determination or Final Adverse Determination with the same time frames forthe standard and expedited external review procedures.
6. Upon receipt of the Director’s notice of a decision reversing an Adverse Determination
or Final Adverse Determination, the Company shall immediately approve the coverageof the recommended or requested health care service or treatment that was the subjectof the Adverse Determination or Final Adverse Determination.
BINDING EXTERNAL REVIEW
An External Review decision is binding on the Company except to the extent the Companyhas other remedies available under state law. An External Review decision is binding onthe Insured Person except to the extent the Insured Person has other remedies availableunder applicable federal or state law. An Insured Person or an Authorized Representativemay not file a subsequent request for External Review involving the same AdverseDetermination or Final Adverse Determination for which the Insured Person has alreadyreceived an External Review decision. Where to Send External Review Requests
All types of External Review requests shall be submitted to the state insurance departmentat the following address:Missouri Department of Insurance, Financial Institutions and Professional RegistrationConsumer Affairs Division301 W. High Street, Room 830Harry S. Truman State Office BuildingJefferson City, MO 65101(800) 726 [email protected]s Regarding Appeal RightsContact Customer Service at 800-767-0700 with questions regarding the Insured Person’srights to an Internal Appeal and External Review. FrontierMEDEX: Global Emergency Services
If you are a student insured with this insurance plan, you and your insured spouse and minorchild(ren) are eligible for FrontierMEDEX. The requirements to receive these services areas follows:International Students, insured spouse Domestic Partner and insured minor child(ren): Youare eligible to receive FrontierMEDEX services worldwide, except in your home country. Domestic Students, insured spouse and insured minor child(ren): You are eligible forFrontierMEDEX services when 100 miles or more away from your campus address and100 miles or more away from your permanent home address or while participating in aStudy Abroad program. FrontierMEDEX includes Emergency Medical Evacuation and Return of Mortal Remainsthat meet the US State Department requirements. The Emergency Medical Evacuationservices are not meant to be used in lieu of or replace local emergency services such as anambulance requested through emergency 911 telephone assistance. All services must bearranged and provided by FrontierMEDEX; any services not arranged by FrontierMEDEXwill not be considered for payment. Key Services include:
Please visit www.uhcsr.com/frontiermedex for the FrontierMEDEX brochure which includesservice descriptions and program exclusions and limitations. To access services please call:
(800) 527-0218 Toll-free within the United States(410) 453-6330 Col ect outside the United States
Services are also accessible via e-mail at [email protected] When calling the FrontierMEDEX Operations Center, please be prepared to provide:
1. Caller's name, telephone and (if possible) fax number, and relationship to the patient;2. Patient's name, age, sex, and FrontierMEDEX ID Number as listed on your Medical ID
3. Description of the patient's condition;4. Name, location, and telephone number of hospital, if applicable;5. Name and telephone number of the attending physician; and6. Information of where the physician can be immediately reached.
FrontierMEDEX is not travel or medical insurance but a service provider for emergency medicalassistance services. All medical costs incurred should be submitted to your health plan and aresubject to the policy limits of your health coverage. All assistance services must be arranged andprovided by FrontierMEDEX. Claims for reimbursement of services not provided byFrontierMEDEX will not be accepted. Please refer to the FrontierMEDEX information inMyAccount at www.uhcsr.com/MyAccount for additional information, including limitations andexclusions. Online Access to Account Information
UnitedHealthcare StudentResources Insureds have online access to claims status, EOBs, ID Cards, network providers, correspondence and coverage information by logging in to My Account at www.uhcsr.com/myaccount. Insured students who don’t already have an online account may simply select the “create My Account Now” link. Follow the simple, onscreen directions to establish an online account in minutes using your 7-digit Insurance ID number or the email address on file. As part of UnitedHealthcare StudentResources’ environmental commitment to reducing waste, we’ve introduced a number of initiatives designed to preserve our precious resources while also protecting the security of a student’s personal health information. My Account has been enhanced to include Message Center - a self-service tool that provides a quick and easy way to view any email notifications we may have sent. In Message Center, notifications are securely sent directly to the Insured student’s email address. If the Insured student prefers to receive paper copies, he or she may opt-out of electronic delivery by going into My Email Preferences and making the change there.
One way we are becoming greener is to no longer automatically mail out ID Cards. Instead,we will send an email notification when the digital ID card is available to be downloadedfrom My Account. An Insured student may also use My Account to request delivery of apermanent ID card through the mail. ID Cards may also be accessed via our mobile site atmy.uhcsr.com. UnitedHealth Allies
Insured students also have access to the UnitedHealth Allies® discount program. Simply log in to My Account as described above and select UnitedHealth Allies Plan to learn more about the discounts available. When the Medical ID card is viewed or printed, the UnitedHealth Allies card is also included. The UnitedHealth Allies Program is not insurance and is offered by UnitedHealth Allies, a UnitedHealth Group company. Claim Procedure
In the event of Injury or Sickness, students should:
1) Report to the Student Health Service or Infirmary for treatment or referral, or when
not in school, to their Physician or Hospital.
2) Mail to the address below all medical and hospital bills along with the patient's name
and insured student's name, address, social security number and name of theuniversity under which the student is insured. A Company claim form is not requiredfor filing a claim. A written notice of claim must be submitted to the address below within 90 daysafter expense is incurred, or as soon thereafter as reasonably possible. Uponreceipt of a notice of claim, the Company will furnish the Insured the necessaryforms for filing proof of loss. If the person making claim does not receive thenecessary claim forms before the expiration of 15 days after first requesting suchforms, the Insured shall be deemed to have complied with the requirements as tothe proof of loss upon submitting to the Company within 90 days written proofcovering the occurrence, character and extent of the loss for which claim is made.
3) File claim within 90 days of Injury or first treatment for a Sickness. Bills should be
received by the Company within 90 days of service.
4) The Insured’s failure to give notice within such time will not invalidate nor reduce
any claim if it is shown that notice was given as soon as was reasonably possible. Bills submitted after one year will not be considered for payment except in theabsence of legal capacity. UnitedHealthcare Insurance Company
UnitedHealthcare StudentResources Sales / Marketing Services:
805 Executive Center Drive West, Suite 220
Please keep this Certificate as a general summary of the insurance. The Master Policy onfile at the University contains all of the provisions, limitations, exclusions and qualificationsof your insurance benefits, some of which may not be included in this Certificate. TheMaster Policy is the contract and will govern and control the payment of benefits.
This Certificate is based on Policy # 2013-200188-1
After reading this article, you should be able to:define the terms prematurity, extreme prematurity andlist the well-known complications of premature infantsexplain the basic principles of anaesthetizing aRDS may be complicated by air leak (pneumothorax, pneu-Mean survival rates for babies born at 24 weeks and 27 weeks aremomediastinum, pulmonary interstitial emphysema) and lead tocurrently
CURRICULUM VITAE Name: Mr. Apichat Vitta Date of birth: 12-17-1978 Place of birth: Maha-Sarakham Province, Thailand Nationality: Thai Home address: 2/4, Nachuak-Porpan Road, Sub-district Nachuak, District Nachuak, Office Position: Department of Microbiology & Parasitology, Faculty of Medical Science, Naresuan University, Phitsanulok, Thailand 65000 Tel : +66 05