Agmt94 Managed Health Network - Laserfiche WebLink

Browse Search

was not eligible for coverage, OHS will deny coverage accordingly. 5. Medications, medical supplies and medical equipment are excluded. 6. Workers' Compensation, insurance and third party liability recoveries. services and supplies that are otherwise covered under this plan are excluded to the extent that a Member realizes a recovery from any source, including settlements and recoveries derived from workers' compensation, a liable third party, or from other insurance coverage (e.g., homeowners' insurance, under insured and uninsured motorists insurance). Coverage for any condition caused by another person's negligence or intentional act or omission is excluded. This plan will, however, advance the benefits of this plan, subject to an automatic lien against the recovery for the usual, customary and reasonable value. 7. Fitness for duty opinions are excluded. 8. Medical records. Charges associated with copying or transferring medical records are excluded. 9. Mid-year plan changes. Benefits under this plan that are subject to annual benefit limitations, will not be increased, even when a Member becomes covered under two separate OHS plan contracts during the same annual period. 10. Coordination of benefits. This plan does not coordinate benefits with any other plan that may be maintained by a Member. UTILIZATION REVIEW This plan includes prior, concurrent and retrospective review of certain proposed courses of treatment to determine whether the proposed treatment is Medically/Psychologically Necessary and the services are covered under this plan. The determination of the reviewer or professional review organization is not a substitute for the independent judgment of the treating physician as to the course of treatment. utilizatiòn review decisions that are not consistent with a treating physician's determination do not preclude treatment but do determine OHS' coverage for such treatment. PREPAYMENT FEES Employer is responsible for the collection of any applicable Subscriber monthly prepayment fees that are paid in contribution to the expense of this plan. You may obtain information regarding total monthly fees and any necessary payroll deductions from Employer, if applicable. OHS will notify Employer at least 30 days in advance of any change in prepayment fee requirements. - 8 - -¡O--'" ,,, "'"