BLUE CROSS OF CALIFORNIA
TABLE OF CONTENTS
MEDCALL
COMBINED EVIDENCE OF COVERAGE AND DISCLOSURE FORM
TYPES OF PROVIDERS
SUMMARY OF BENEFITS
MEDICAL BENEFITS
YOUR MEDICAL BENEFITS
HOW COVERED EXPENSE IS DETERMINED
DEDUCTIBLES, CO-PAYMENTS, OUT-OF-POCKET AMOUNTS AND MEDICAL BENEFIT MAXIMUMS
CONDITIONS OF COVERAGE
MEDICAL CARE THAT IS COVERED
MEDICAL CARE THAT IS NOT COVERED
PRE-EXISTING CONDITION EXCLUSION
REIMBURSEMENT FOR ACTS OF THIRD PARTIES
COORDINATION OF BENEFITS
BENEFITS FOR MEDICARE ELIGIBLE MEMBERS
MEDICAL MANAGEMENT PROGRAMS
UTILIZATION REVIEW PROGRAM
AUTHORIZATION PROGRAM
THE MEDICAL NECESSITY REVIEW PROCESS
PERSONAL CASE MANAGEMENT
DISAGREEMENTS WITH MEDICAL MANAGEMENT DECISIONS
QUALITY ASSURANCE
HOW COVERAGE BEGINS AND ENDS
HOW COVERAGE BEGINS
HOW COVERAGE ENDS
CONTINUATION OF COVERAGE
POST-COBRA CONTINUATION FOR QUALIFYING MEMBERS
EXTENSION OF BENEFITS
HIPAA COVERAGE AND CONVERSION
GENERAL PROVISIONS
BINDING ARBITRATION
DEFINITIONS
GRIEVANCE PROCEDURES
FOR YOUR INFORMATION