Benjamin v. Oxford Health Ins, IncMOTION for Summary JudgmentD. Conn.April 24, 2017 1 UNITED STATES DISTRICT COURT DISTRICT OF CONNECTICUT AMY BENJAMIN, Plaintiff, vs. OXFORD HEALTH INSURANCE, INC., Defendant. ) ) ) ) ) ) ) ) ) ) ) ) ) ) CIVIL ACTION NO. 3:16cv-00408 (AWT) PLAINTIFF’S MOTION FOR SUMMARY JUDGMENT Plaintiff Amy Benjamin respectfully hereby moves, pursuant to Federal Rule of Civil Procedure 56(a), for summary judgment in her favor for the reasons set forth in her accompanying memorandum of law, the Declaration of Peter S. Sessions, her Local Rule 56(a)1 Statement, and such exhibits and affidavits as may be submitted by either party in conjunction with the parties’ cross-motions. DATED: April 24, 2017 FOR THE PLAINTIFF BY: /s/ Peter S. Sessions Peter S. Sessions, Esq. (admitted pro hac vice) Kantor & Kantor, LLP 19839 Nordhoff Street Northridge, CA 91324 Phone: (818) 886-2525 Fax: (818) 350-6272 e-mail: psessions@kantorlaw.net Case 3:16-cv-00408-AWT Document 64 Filed 04/24/17 Page 1 of 3 2 Ian O. Smith, Esq., ct24135 Local Counsel The Law Office of Ian O. Smith, LLC P.O. Box 33 Tolland, CT 06084 Phone: (860) 539-2156 Fax: (860) 896-9279 e-mail: iansmithlaw@outlook.com Case 3:16-cv-00408-AWT Document 64 Filed 04/24/17 Page 2 of 3 3 CERTIFICATION I, Peter S. Sessions, hereby certify and affirm that a true and correct copy of the above Plaintiff’s Motion for Summary Judgment was served via ECF on the 24th day of April, 2017, upon the following: Michael H. Bernstein, Esq. Matthew P. Mazzola, Esq. SEDGWICK LLP 225 Liberty Street, 28th floor New York, New York 10281-1008 Attorneys for Defendant Dated: Northridge, California April 24, 2017 /s/ Peter S. Sessions Peter S. Sessions (Pro Hac Vice) Case 3:16-cv-00408-AWT Document 64 Filed 04/24/17 Page 3 of 3 UNITED STATES DISTRICT COURT DISTRICT OF CONNECTICUT AMY BENJAMIN, Plaintiff, vs. OXFORD HEALTH INSURANCE, INC., Defendant. ) ) ) ) ) ) ) ) ) ) ) ) ) ) CIVIL ACTION NO. 3:16cv-00408 (AWT) PLAINTIFF’S MEMORANDUM OF LAW IN SUPPORT OF MOTION FOR SUMMARY JUDGMENT Case 3:16-cv-00408-AWT Document 64-1 Filed 04/24/17 Page 1 of 14 i TABLE OF CONTENTS INTRODUCTION .......................................................................................................................... 1 STATEMENT OF FACTS ............................................................................................................. 2 A. Pertinent Policy Provisions .................................................................................. 2 B. Ms. Benjamin’s Treatment at Caron and Her Claim for Benefits ........................ 3 ARGUMENT .................................................................................................................................. 5 A. Standard of Review .............................................................................................. 5 B. Oxford Was Not Permitted to Deny Ms. Benjamin’s Claim in Its Entirety for Failure to Obtain Preauthorization ....................................................................... 6 C. The Court Should Not Remand This Case to Oxford for a Medical Necessity Determination ....................................................................................................... 8 CONCLUSION ............................................................................................................................. 10 Case 3:16-cv-00408-AWT Document 64-1 Filed 04/24/17 Page 2 of 14 ii TABLE OF AUTHORITIES FEDERAL CASES Abatie v. Alta Health & Life Insurance Co., 458 F.3d 955 (9th Cir. 2006) ...................................................................................................... 5 Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101, 109 S. Ct. 948, 103 L. Ed. 2d 80 (1989) .............................................................. 5 Harlick v. Blue Shield of California, 686 F.3d 699 (9th Cir. 2012) .................................................................................................. 8, 9 Kinstler v. First Reliance Standard Life Ins. Co., 181 F.3d 243 (2d Cir. 1999) ....................................................................................................... 5 Lauder v. First Unum Life Ins. Co., 284 F.3d 375 (2d Cir. 2002) ................................................................................................... 8, 9 Locher v. Unum Life Ins. Co. of America, 389 F.3d 288 (2d Cir. 2004) ....................................................................................................... 5 Mitchell v. CB Richard Ellis Long Term Disability Plan, 611 F.3d 1192 (9th Cir. 2010) .................................................................................................... 8 Orndorf v. Paul Revere Life Ins. Co., 404 F.3d 510 (1st Cir. 2005) ....................................................................................................... 5 US Airways, Inc. v. McCutchen, 133 S. Ct. 1537, 185 L. Ed. 2d 654 (2013) ................................................................................. 6 FEDERAL STATUTES 29 U.S.C. § 1102(a)(1) .................................................................................................................... 6 29 U.S.C. § 1104(a)(1)(D) .............................................................................................................. 6 29 U.S.C. § 1133 ............................................................................................................................. 9 29 U.S.C. §§ 1001, et seq................................................................................................................ 1 FEDERAL REGULATIONS 29 C.F.R. § 2560.503-1(g) .............................................................................................................. 9 Case 3:16-cv-00408-AWT Document 64-1 Filed 04/24/17 Page 3 of 14 1 INTRODUCTION This is an action for medical benefits under a group health plan established by Techstyle Contract Fabrics for the benefit of its employees and their dependents. The plan is insured and administered by defendant Oxford Health Insurance, Inc. (“Oxford”) through a policy (the “Policy”) issued by Oxford to the employer. As a result, this action is governed by the Employee Retirement Income Security Act of 1974 (“ERISA”), 29 U.S.C. §§ 1001 et seq. Amy Benjamin is a 54-year-old woman who is covered by the Policy and unfortunately suffers from mental illness. In 2014, she was admitted to Caron Renaissance, a facility that treats behavioral and mental health disorders. Ms. Benjamin submitted to Oxford a claim for benefits under the Policy for her treatment. Oxford denied this claim on the ground that she had not received “preauthorization” for her treatment as required by the Policy. Oxford’s denial violated the terms of the Policy. Although the Policy does provide that certain services (including the services rendered in this case), require preauthorization from Oxford, the penalty for failing to obtain preauthorization is monetary only. The Policy does not authorize Oxford to deny claims in their entirety based on a failure to obtain preauthorization. The Court should therefore overturn the denial in this case and issue summary judgment in Ms. Benjamin’s favor. Case 3:16-cv-00408-AWT Document 64-1 Filed 04/24/17 Page 4 of 14 2 STATEMENT OF FACTS A. Pertinent Policy Provisions The benefit plan provides benefits for covered medical services and treatment incurred by its insureds. BENJAMIN 42-43.1 Because the plan is fully insured by Oxford, Oxford administers all benefits and makes all claim determinations. BENJAMIN 90. Residential treatment for mental illnesses is a covered benefit under the Policy. BENJAMIN 27, 72-73. The Policy provides that certain services require “preauthorization.” Preauthorization is defined as “A decision by Us prior to Your receipt of a Covered Service, procedure, treatment plan, device, or Prescription Drug that the Covered Service, treatment plan, device or Prescription Drug is Medically Necessary.” BENJAMIN 39. The preauthorization requirement applies to mental health services. BENJAMIN 27. The Policy contains an Out-of-Network Benefits Rider which explains the details of obtaining preauthorization. BENJAMIN 123-27. The Rider also explains the consequences of not obtaining preauthorization for services that require it: If You fail to seek Our Preauthorization for benefits subject to this section, We will pay an amount $500 less than We would otherwise have paid for the care, or We will pay only 50% of the amount We would otherwise have paid for the care, whichever results in a greater benefit for You. BENJAMIN 124. 1 Citations preceded by “BENJAMIN” refer to documents included in Oxford’s initial disclosures. True and correct copies of the relevant documents of those disclosures relied upon by Plaintiff in support of her motion are attached as Exhibit B to the concurrently filed Declaration of Peter S. Sessions. Plaintiff retains the citation method used by Oxford for ease of reference. Case 3:16-cv-00408-AWT Document 64-1 Filed 04/24/17 Page 5 of 14 3 B. Ms. Benjamin’s Treatment at Caron and Her Claim for Benefits Ms. Benjamin was admitted to Caron Renaissance (“Caron”), a facility that treats behavioral and mental health disorders, on July 24, 2014. BENJAMIN 158. Prior to her admission, Ms. Benjamin called Oxford in order to ascertain what type of coverage the Policy would provide for her treatment. BENJAMIN 141, 228. Just after her admission, Caron called Oxford as well with similar questions. BENJAMIN 143. Ms. Benjamin was ultimately discharged on October 2, 2014. BENJAMIN 220. After her discharge, Ms. Benjamin submitted to Oxford a claim for benefits under the Policy for her treatment. Oxford denied this claim on the ground that she had not received “preauthorization” for her treatment as required by the Policy. BENJAMIN 158-225. On its Explanations of Benefits, Oxford stated that Ms. Benjamin’s claim was denied for the following reason: “These services were formally denied because they were not authorized in advance.” See, e.g., BENJAMIN 207, 215, 221. On December 18, 2014, Ms. Benjamin submitted a written appeal of this decision. BENJAMIN 228. Ms. Benjamin informed Oxford that she had contacted it on July 11, 2014 and had been told that she was responsible for $500 and was covered for her stay at Caron. She also indicated that Caron had made a similar call on her behalf on July 29, 2014. Id. On February 24, 2015, Oxford denied Ms. Benjamin’s appeal. BENJAMIN 236-37. In its letter, Oxford stated: Based on our review, according to your Benefit Plan, under Section XIV - Freedom PPO Schedule of Benefits, subsection Mental Health & Substance Use Disorder Services (Non- Participating), this request for payment was processed correctly: Case 3:16-cv-00408-AWT Document 64-1 Filed 04/24/17 Page 6 of 14 4 Outpatient Mental Health Care (Including Partial Hospitalization Intensive Outpatient Program Services): Pre-authorization Required Because the claim(s) for this service(s) was processed according to the above plan provision(s), our original determination remains unchanged, and the determination is upheld. BENJAMIN 236. Oxford further stated that its decision “does not reflect any view about the appropriateness of this service(s).” BENJAMIN 236-37. On April 17, 2015, Ms. Benjamin submitted a second-level appeal to Oxford. BENJAMIN 257-66. In her letter, Ms. Benjamin quoted, and attached a copy of, the Policy provisions regarding preauthorization and the monetary penalty for failing to comply. BENJAMIN 257-58. Ms. Benjamin informed Oxford that under these provisions “lack of pre authorization is not grounds for denying payment of these claims.” BENJAMIN 258. On May 21, 2015, Oxford denied Ms. Benjamin’s second-level appeal. BENJAMIN 271- 73. Oxford contended that it had “carefully reviewed the documentation submitted, our payment policies and the limitations, exclusions and other terms of your Benefit Plan, including any applicable Riders, Amendments, and Notices.” BENJAMIN 271. However, it upheld its prior decision, again on the ground that Ms. Benjamin had not complied with Policy provisions. BENJAMIN 271-72. Again, Oxford stated that its “administrative decision does not reflect any view about the appropriateness of this service(s).” BENJAMIN 272. Having exhausted her appeals with Oxford, Ms. Benjamin brought this action. Case 3:16-cv-00408-AWT Document 64-1 Filed 04/24/17 Page 7 of 14 5 ARGUMENT A. Standard of Review The default standard of review in ERISA benefit cases such as this one is de novo. Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101, 109 S. Ct. 948, 103 L. Ed. 2d 80 (1989). A plan administrator is only entitled to deferential review if it can demonstrate that the plan grants it discretionary authority to determine benefit eligibility. Id., 489 U.S. at 114-15. Thus, although ERISA plaintiffs may have the burden of demonstrating that they are entitled to benefits, defendants have the burden of demonstrating that they are entitled to deferential review. Kinstler v. First Reliance Standard Life Ins. Co., 181 F.3d 243, 249 (2d Cir. 1999) (“the party claiming deferential review should prove the predicate that justifies it”). Under de novo review, a court is called upon to determine whether the plaintiff is entitled to benefits under the terms of a plan without deference to either party’s interpretation. Firestone, 489 U.S. at 112. A court does not engage in any preliminary analysis, or apply burden-shifting tests. Instead, it treats the case similarly to a breach of contract case and “simply proceeds to evaluate whether the plan administrator correctly or incorrectly denied benefits[.]” Abatie v. Alta Health & Life Insurance Co., 458 F.3d 955, 963 (9th Cir. 2006) (en banc); see also Locher v. Unum Life Ins. Co. of America, 389 F.3d 288, 296 (2d Cir. 2004) (“[U]pon de novo review, a district court may render a determination on a claim without deferring to an administrator’s evaluation of the evidence.”); Orndorf v. Paul Revere Life Ins. Co., 404 F.3d 510, 518 (1st Cir. 2005) (“de novo review generally consists of the court’s independent weighing of the facts and opinions in that record to determine whether the claimant has met his burden of showing he is [entitled to benefits]”). Case 3:16-cv-00408-AWT Document 64-1 Filed 04/24/17 Page 8 of 14 6 Here, there is no provision in the Policy that grants Oxford discretionary authority and thus the Court should review its decision to deny benefits de novo under the above principles.2 B. Oxford Was Not Permitted to Deny Ms. Benjamin’s Claim in Its Entirety for Failure to Obtain Preauthorization The Supreme Court has held, “The plan, in short, is at the center of ERISA.” US Airways, Inc. v. McCutchen, 133 S. Ct. 1537, 1548, 185 L. Ed. 2d 654 (2013). This is because ERISA requires that “[e]very employee benefit plan shall be established and maintained pursuant to a written instrument,” 29 U.S.C. § 1102(a)(1), and plan administrators must act “in accordance with the documents and instruments governing the plan[.]” 29 U.S.C. § 1104(a)(1)(D). Thus, any actions taken by plan administrators must find support in the terms and conditions of the relevant plan document. Here, the central issue presented by this case is straightforward: did the Policy permit Oxford to deny Ms. Benjamin’s claim in its entirety because she failed to obtain preauthorization for her treatment at Caron? The answer is no. The Policy simply does not contain any provisions that allowed Oxford to do so. The provisions that address preauthorization clearly state that the penalty for failing to obtain preauthorization is a monetary one only: “If You fail to seek Our Preauthorization for benefits subject to this section, We will pay an amount $500 less than We would otherwise have paid for the care, or We will pay only 50% of the amount We would otherwise have paid for the care, whichever results in a greater benefit for You.” BENJAMIN 124. The provision contains no language granting Oxford the authority to deny a claim in its entirety. Under the above 2 Plaintiff submits that the standard of review in this case is not a significant factor. The facts in this case are largely undisputed, and the Policy’s preauthorization provision is straightforward. Case 3:16-cv-00408-AWT Document 64-1 Filed 04/24/17 Page 9 of 14 7 authorities, then, Oxford was required to, at most, impose a monetary penalty. It had no authority to act outside the terms and conditions of the Policy and impose an alternative penalty. Oxford’s denial letters offer no clarification or justification for its decision. Even though Ms. Benjamin’s second-level appeal explicitly pointed out to Oxford the Policy’s preauthorization language, BENJAMIN 257-58, Oxford completely failed to address that provision, and simply issued a boilerplate denial. BENJAMIN 271-73. In doing so, Oxford alleged that it had “carefully reviewed the documentation submitted, our payment policies and the limitations, exclusions and other terms of your Benefit Plan, including any applicable Riders, Amendments, and Notices.” BENJAMIN 271. This was clearly not the case, as it failed to even respond to Ms. Benjamin’s concerns, which were squarely based on the terms of the Policy. It is undisputed that the treatment Ms. Benjamin received from Caron cost tens of thousands of dollars. BENJAMIN 158-225. Thus, if the Policy is applied correctly, the preauthorization provision’s “greater benefit for You” is clearly the $500 penalty. The Court should therefore instruct Oxford to pay the amount of benefits at issue, minus $500, in accordance with the terms and conditions of the Policy.3 Thus, even under a more deferential standard of review, Oxford’s decision should still be overturned. 3 A proper calculation of benefits is complex because it includes consideration of deductibles, out-of-pocket maximums, “allowed amounts” for out-of-network services, and other factors. Plaintiff therefore suggests that if the Court grants her motion, the parties be ordered to meet and confer regarding calculating the appropriate amount at issue. Case 3:16-cv-00408-AWT Document 64-1 Filed 04/24/17 Page 10 of 14 8 C. The Court Should Not Remand This Case to Oxford for a Medical Necessity Determination Plaintiff anticipates that Oxford may argue that even if its decision was incorrect, the Court should not award judgment to Plaintiff, but should instead remand this case to Oxford to determine if the treatment she received at Caron was medically necessary. The Court should decline any such invitation. Oxford had its opportunity to address the medical necessity of Ms. Benjamin’s treatment on several occasions. It chose not to do so when it denied her original claim. BENJAMIN 158-225. It again chose not to do so when it denied her appeal. BENJAMIN 236-37. Finally, it chose not to do so when it denied her second-level appeal. BENJAMIN 271-73. In denying both appeals, Oxford specifically noted that it was foregoing the opportunity to render a medical necessity determination: “Our administrative decision does not reflect any view about the appropriateness of this service(s).” BENJAMIN 236-37, 272. Because Oxford had the opportunity to make a medical necessity determination, and chose not to do so, it has waived the opportunity to raise that defense now. See Lauder v. First Unum Life Ins. Co., 284 F.3d 375, 382 (2d Cir. 2002). In Lauder, the Second Circuit found that the insurer “knew of Lauder’s claim of disability, chose not to investigate it, and chose not to challenge it. It therefore waived its right to rely on lack of disability as a defense to Lauder’s claim.” Id. The rationale for this rule is readily apparent. “[A] contrary rule would allow claimants … to be ‘sandbagged’ by a rationale the plan administrator adduces only after the suit has commenced.” Harlick v. Blue Shield of California, 686 F.3d 699, 720 (9th Cir. 2012), quoting Mitchell v. CB Richard Ellis Long Term Disability Plan, 611 F.3d 1192, 1199 n.2 (9th Cir. 2010). This is clearly unfair to claimants, who are entitled under ERISA to know all of the bases Case 3:16-cv-00408-AWT Document 64-1 Filed 04/24/17 Page 11 of 14 9 for the denial of their claims during the administrative appeal process. 29 U.S.C. § 1133 (plan administrators must explain the “specific reasons for such denial” and provide a “full and fair review” of the denial); 29 C.F.R. § 2560.503-1(g) (plan administrator must give claimant information about the denial, including the “specific plan provisions” on which it is based and “any additional material or information necessary for the claimant to perfect the claim”). In Harlick, the Ninth Circuit held: Blue Shield had discretion to determine whether treatment was medically necessary during the administrative review process of Harlick’s claim. But Blue Shield had to tell Harlick the “specific reasons for the denial” - not just one reason, if there was more than one - and provide a “full and fair review” of the denial. 29 U.S.C. § 1133 (emphases added). Blue Shield told both Harlick and her mother, as well as the DMHC, that medical necessity was not the reason for its denial of Harlick’s claim. It cannot now bring out a reason that it has “held in reserve” and commence a new round of review. 686 F.3d at 720. Here, similarly, Oxford was well aware of Ms. Benjamin’s medical condition and treatment at Caron, and was fully authorized to explore those facts and make a medical necessity determination. BENJAMIN 94 (detailing Oxford’s “utilization review” process). It did not do so.4 Therefore, the result here should be the same as in Lauder and Harlick, i.e., the waiver of any defense based on the merits of Ms. Benjamin’s claim. 4 Oxford also could have performed a medical necessity review at any point during this litigation, and has elected not to do so. Case 3:16-cv-00408-AWT Document 64-1 Filed 04/24/17 Page 12 of 14 10 CONCLUSION The Policy simply did not allow Oxford to deny Ms. Benjamin’s claim wholesale on the ground that she failed to obtain preauthorization, and Oxford has waived any defense based on medical necessity. Thus, Plaintiff respectfully requests that the Court overturn Oxford’s decision and award her benefits under the Policy, minus $500 for the preauthorization penalty, in addition to pre-judgment interest, costs, and reasonable attorney’s fees. DATED: April 24, 2017 FOR THE PLAINTIFF BY: /s/ Peter S. Sessions Peter S. Sessions, Esq. (admitted pro hac vice) Kantor & Kantor, LLP 19839 Nordhoff Street Northridge, CA 91324 Phone: (818) 886-2525 Fax: (818) 350-6272 e-mail: psessions@kantorlaw.net Ian O. Smith, Esq., ct24135 Local Counsel The Law Office of Ian O. Smith, LLC P.O. Box 33 Tolland, CT 06084 Phone: (860) 539-2156 Fax: (860) 896-9279 e-mail: iansmithlaw@outlook.com Case 3:16-cv-00408-AWT Document 64-1 Filed 04/24/17 Page 13 of 14 11 CERTIFICATION I, Peter S. Sessions, hereby certify and affirm that a true and correct copy of the above Plaintiff’s Memorandum of Law in Support of Motion for Summary Judgment was served via ECF on the 24th day of April, 2017, upon the following: Michael H. Bernstein, Esq. Matthew P. Mazzola, Esq. SEDGWICK LLP 225 Liberty Street, 28th floor New York, New York 10281-1008 Attorneys for Defendant Dated: Northridge, California April 24, 2017 /s/ Peter S. Sessions Peter S. Sessions (Pro Hac Vice) Case 3:16-cv-00408-AWT Document 64-1 Filed 04/24/17 Page 14 of 14 1 UNITED STATES DISTRICT COURT DISTRICT OF CONNECTICUT AMY BENJAMIN, Plaintiff, vs. OXFORD HEALTH INSURANCE, INC., Defendant. ) ) ) ) ) ) ) ) ) ) ) ) ) ) CIVIL ACTION NO. 3:16cv-00408 (AWT) DECLARATION OF PETER S. SESSIONS IN SUPPORT OF PLAINTIFF’S MOTION FOR SUMMARY JUDGMENT I, Peter S. Sessions, declare as follows: 1. I am a senior associate in the law firm of Kantor & Kantor LLP, counsel of record for plaintiff Amy Benjamin in the within action. 2. I make this declaration of my own personal knowledge, except for those matters stated on information and belief. If called as a witness, I could and would testify competently to the following. 3. I submit this Declaration and the exhibits annexed hereto in support of Plaintiff’s Motion for Summary Judgment. 4. On October 20, 2016, I received a copy of Defendant Oxford Health Insurance, Inc.’s (“Oxford”) document disclosure, which it produced in compliance with Federal Rule of Case 3:16-cv-00408-AWT Document 64-2 Filed 04/24/17 Page 1 of 3 2 Civil Procedure 26(a). A true and correct copy of the letter accompanying Oxford’s disclosure is attached to this Declaration as Exhibit A. 5. The disclosure contained 593 pages of documents, including information regarding the relevant insurance policy, claim information, explanations of benefits, and correspondence. 6. Attached as Exhibit B to this Declaration are true and correct copies of the relevant portions of Oxford’s disclosure relied upon by Plaintiff in support of her Motion for Summary Judgment. Plaintiff retains the citation method used by Oxford for ease of reference. I declare under penalty of perjury under the laws of the United States that the foregoing is true and correct. Executed this 24th of April, 2017, at Northridge, California. /s/ Peter S. Sessions Peter S. Sessions Peter S. Sessions, Esq. (admitted pro hac vice) Kantor & Kantor, LLP 19839 Nordhoff Street Northridge, CA 91324 Phone: (818) 886-2525 Fax: (818) 350-6272 e-mail: psessions@kantorlaw.net Case 3:16-cv-00408-AWT Document 64-2 Filed 04/24/17 Page 2 of 3 3 CERTIFICATION I, Peter S. Sessions, hereby certify and affirm that a true and correct copy of the above Declaration of Peter S. Sessions in Support of Plaintiff’s Motion for Summary Judgment was served via ECF on the 24th day of April, 2017, upon the following: Michael H. Bernstein, Esq. Matthew P. Mazzola, Esq. SEDGWICK LLP 225 Liberty Street, 28th floor New York, New York 10281-1008 Attorneys for Defendant Dated: Northridge, California April 24, 2017 /s/ Peter S. Sessions Peter S. Sessions (Pro Hac Vice) Case 3:16-cv-00408-AWT Document 64-2 Filed 04/24/17 Page 3 of 3 SedgwickLLP October 19, 2016 Via Federal Express (Overnight) Peter Sessions, Esq. Kantor & Kantor, LLP 19839 Nordhoff St. Northridge, CA 91324 Attornrys for Plaintijf Re: Amy Bef!jamin v. Oxford Health Insurance, Inr~ Civil Action No.: 3:16-cv-00408 (AWT) FileNo. 03246-000321 Dear Peter: ATTORNEYS AT LAW 225 LIBERTY STREET, 28TH FLOOR NEW YORK, NEW YORK 10281-1008 www.sedgwicklaw.com 212.422.0202 phone 212.422.0925 fax Matthew P. Mazzola 212.898.4066 matthew.mazzola@sedgwicklaw.com As you know, this office represents Defendant Oxford Health Insurance, Inc. ("Oxford") in the above- referenced matter. Please find the attached disk containing the document referenced in Oxford's Rule 26(a) Initial Disclosures. Feel free to contact me with any questions or concerns. Very truly yours, 83891893vl Case 3:16-cv-00408-AWT Document 64-3 Filed 04/24/17 Page 1 of 1 August 08, 2014 William Fuchs TECHSTYLE CONTRACT FABRICS 1775 FIFTH AVENUE BAY SHORE, NY 11706 RE: TECHSTYLE CONTRACT FABRICS's (TC23015) Group Enrollment Agreement Dear William Fuchs, Enclosed is an original copy of your group enrollment agreement, which outlines the plan design specifics and the terms and conditions for your Oxford product coverage. This agreement is a legally binding contract between us and TECHSTYLE CONTRACT FABRICS. Payment of premium will constitute acceptance of the terms and conditions of the agreement. It will remain in effect until your anniversary date or according to the terms outlined in Section XIII of the agreement. We appreciate the opportunity to serve you, and we look forward to a continued and long- standing association with your company. If you have any questions about your agreement, please contact your broker or our Client Services department at 1-888-201-4216. Sincerely, Client Services Enclosure Oxford HMO products are underwritten by Oxford Health Plans (NY), Inc., Oxford Health Plans (NJ), Inc. and Oxford Health Plans (CT), Inc. Oxford insurance products are underwritten by Oxford Health Insurance, Inc. © 2012 Oxford Health Plans LLC. All rights reserved. MS-12-483 BENJAMIN 000001 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 1 of 237 Group Policy and Group Enrollment Agreement Oxford Health Insurance, Inc. Covered medical and hospital services in accordance with the terms and provisions of this Policy. Such services will be provided for the Group’s eligible employees (Subscribers) and their Covered Dependents. EFFECTIVE DATE AND TERMS OF POLICY This Policy will be effective on the 1st day of March, 2014 at 12:00 a.m. Eastern Time and will remain in effect for a period of 12 consecutive months, ending on the 28th day of February, 2015 at 11:59 p.m. Eastern Time at which time coverage will terminate (the “Initial Contract Period”). The Policy, and the coverage provided under the Policy, will automatically renew after the end of the Initial Contract Period or any Subsequent Contract Period unless it would otherwise terminate in accordance with Section XIII of this Policy. I. Definitions Policy: Consists of this Group Policy and Group Enrollment Agreement, the Group Application, the individual applications of the Members, the Certificate of Coverage and Member Handbook, the Summary of Benefits and any applicable Amendments or Riders. OHI, Us, We, Our: Oxford Health Insurance, Inc. Members: Subscribers and Covered Dependents. Terms not defined in this Group Policy will have the meaning set forth in the Certificate. of the payment of Premiums, OHI and Group agree that OHI will arrange or pay forIn consideration : 14 Central Park Drive, Hooksett, NH 03106 1-800-444-6222 Subsidy: Any external funding mechanism used by the Group to pay for the member’s cost sharing obligations, such as deductibles, coinsurance, copayments or amounts above the member’s out-of- network benefit level not covered under this Policy. Examples of external funding mechanisms include but are not limited to Gap Cards, Health Reimbursement Account (HRA) plans, voluntary or involuntary supplemental insurance. Our Risk: The likelihood we may be responsible to pay for benefits, administrative services, taxes, assessments or other costs for Coverage to Group. Payment of premium constitutes acceptance of the terms of this Policy. Upon our receipt of the Group's signed application and the first Premium payment, this Policy is deemed executed. Group Name: ("Group") Group Numbers: Effective Date: TECHSTYLE CONTRACT FABRICS TC23015*CSP03 March 1, 2014 This Policy replaces and overrules any previous policy or agreements relating to benefits for Covered medical and hospital services between the Group and us. The terms and conditions of this Policy will, in turn, be overruled by those of any subsequent policy or agreements relating to benefits for Covered medical and hospital Services between the Group and Us. OHINY GEA LS 1109 -1- NYSM_PPO_EHB_01.01.2014_v.3 BENJAMIN 000002 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 2 of 237 PREMIUM RATE SCHEDULEIII. Type of Coverage Total Monthly Premium Single Family $878.39 $2,503.41 $1,493.26 $1,756.78 Parent/Child(ren) Couple : COVERAGEII. Optional Benefit Riders: : We will not be deemed or construed as an employer or plan administrator for any purpose with respect to the administration or provision of benefits under the Group's benefit plan. We are not responsible for fulfilling any duties or obligations of an employer or plan administrator with respect to the Enrolling Group's benefit plan. Subscribers and their Enrolled Dependents are entitled to Benefits for Covered Services subject to the terms, conditions, limitations and exclusions set forth in the Certificate(s) of Coverage and Schedule(s) of Benefits attached to this Policy. Each Certificate of Coverage and Schedule of Benefits, including any Riders and Amendments, describes the Covered Health Services, required Copayments, and the terms, conditions, limitations and exclusions related to coverage. The Group has chosen the following Benefit Plan(s): The Group will notify Us immediately if the Group adds a Subsidy which had not already been disclosed in the Application. Where the Premium Rate Schedule does not include an adjustment for a Subsidy and we learn that the Group provides a Subsidy, we will adjust the Premium Rate Schedule accordingly. Benefit Plan Code/Description: Out-of-Network Deductible: $2,000 Single/$4,000 Family Prescription Drugs: $100 Deductible (waived for Tier 1 Drugs) Tier 1: $10 Copayment Freedom PPO Plan, Freedom Network $20 PCP/$30 Specialist Copayment Out-of-Network Coinsurance: 30% In-Network Deductible: None In-Network Deductible: None Tier 2: $30 Copayment Tier 3: $60 Copayment OHINY GEA LS 1109 -2- NYSM_PPO_EHB_01.01.2014_v.3 BENJAMIN 000003 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 3 of 237 All notices to be given to Us will be addressed to: Oxford Health Insurance, Inc. 14 Central Park Drive Hooksett, NH 03106 IV. ELIGIBILITY Eligible employees of the Group will be full-time employees of the Group who work a minimum of 20 hours per week. In addition, eligible employees of the Group and their eligible family members will meet the eligibility criteria set forth in the Certificate and the requirements set forth below: The eligibility requirements listed in this section of this Policy are material to Our administration of the Policy. During the term of the Policy, We will not permit any change in these eligibility requirements unless We agree, in writing, to such change. V. NOTICE All notices to be given to the Group will be addressed to: TECHSTYLE CONTRACT FABRICS BAY SHORE, NY 11706 attn: William Fuchs : : Covered Dependents: The legal spouse of the Subscriber and any unmarried, dependent children, as defined in the Certificate, are eligible for coverage. Such children are eligible only until the child reaches age 26 or if child is full-time student. Coverage ends on the last day of the Calendar Year. 1775 FIFTH AVENUE Subscribers: Subscribers will be eligible upon commencement of employment. Coverage ends on the date of termination. OHINY GEA LS 1109 -3- NYSM_PPO_EHB_01.01.2014_v.3 BENJAMIN 000004 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 4 of 237 VI. PREMIUM DUE DATE AND PAYMENTS The first day of the month is the “Premium Due Date.” The Group agrees to remit to Us on or before the Premium Due Date the applicable Total Monthly Premium set forth in Section III above for each Member enrolled as of such date. Membership as of such date will be determined by Us in accordance with Our Member records. If a Premium payment is not made in full by Group on or prior to the Premium Due Date, a 30-day Grace Period will be granted to the Group for payment without interest charge. If payment is not received by the expiration of the Grace Period, then the Policy may be terminated by Us pursuant to Section XIII of this document. Premiums outstanding subsequent to the end of the Grace Period will be subject to a late penalty charge of 1.50% of the total Premium amount due. This amount will be calculated for each 30-day period, or portion thereof, that the amount due remains outstanding. If the Policy is terminated for any reason, the Group will continue to be held liable for all Premium payments due and unpaid before the termination, including, but not limited to, Premium payments for any time the Policy is in force during the Grace Period. Notwithstanding any language to the contrary in the Policy, We will have no obligation to provide benefits or pay claims for any Member during any period for which the required Premium payment has not been made, including during any Grace Period. If We provide benefits or pay claims for any Member during any period for which the Premium payment has not been made, such provision of benefits or payment of claims will not constitute a waiver of Our right to discontinue the provision of coverage or payment of claims until such time as the Premium payment is made. VII. PREMIUM ADJUSTMENTS A. If a Member enrolls on or before the fifteenth (15 ) day of a month, the Group will remit to Us on or before the next Premium Due Date an additional Total Monthly Premium for such Member for the month in which the Member enrolled. If a Member enrolls after the fifteenth (15 ) day of a month, no additional Premium payment will be due for such Member for the month in which the Member enrolled. Note: This does not apply to any Group where the Subscribers become eligible for coverage on the first day of the month, per Section IV, “Eligibility.” th th Enrollment. B. credit the Group the total Monthly Premium for such Member for that month. If a Member’s coverage ends after the fifteenth (15 ) day of a month, the Group will not be entitled to any Premium adjustment from Us. Note: This does not apply to any Group whose Subscriber’s lose coverage on the last day of the month, per Section IV, “Eligibility.” If a Member’s coverage ends on or before the fifteenth (15 ) day of a month, We willthTermination. : : We may make retroactive adjustments for any additions or terminations of Members that are not reflected in our records at the time we calculate the total monthly Premium due. We will not grant retroactive credit for any change occurring more than 60 days prior to the date we received notification of the change from the Group. We also will not grant retroactive credit for any calendar month in which a Subscriber has received Benefits. th OHINY GEA LS 1109 -4- NYSM_PPO_EHB_01.01.2014_v.3 BENJAMIN 000005 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 5 of 237 Timing of Premium Rate Changes: Premium taxes, Guarantee or Uninsured Fund Assessments, or Other Governmental Charges:* We will automatically add the Premium Rate increase to the Group’s bill and the Premium Rate Schedule. Other Statutory or Regulatory Changes that Increase Our Risk: Rate Schedule at any time in an amount we determine with a 45-day prior written notice to Group. We may change the Premium Group’s Misrepresentation, Omission or Failure to Follow Our Policies or Procedures: automatically add the Premium Rate increase to the Group’s bill and the Premium Rate Schedule. Premium Rate increases will be implemented prospectively but will include an adjustment for prior periods in which Our Risk increased. We will 1 This includes a change in the interpretation of a law or regulation by a judge, regulator, or other person authorized by law to make a legal interpretation of the law or regulation. Depending on whether the change applies prospectively or retroactively, Premium Rate increases may include an adjustment for prior periods in which the change increased Our Risk. Subsequent Contract Period We may change the Premium Rate Schedule for any Subsequent Contract upon the renewal of the Policy; Period as follows: a change required by statute or regulation increases Our Risk under the Policy; : VIII. PREMIUM RATE CHANGES: Initial Contract Period only for the Initial Contract Period. Premium Rates for the Initial Contract Period will not be changed by Us unless: The Premium Rate Schedule set forth on page one of this Policy will be valid: a change required by statute or regulation increases Our Risk under the Policy, or the Group has made a misrepresentation or omission in the application for coverage or has failed to follow the policies and procedures established by Us in administering and interpreting the Policy and the misrepresentation, omission or failure changes Our Risk under the Policy; or the Group offers a Subsidy which increases Our Risk under the Policy. the Group has made a misrepresentation or omission in the application for coverage or has failed to follow the policies and procedures established by Us in administering and interpreting the Policy and the misrepresentation, omission or failure changes Our Risk under the Policy; the Group offers a Subsidy which increases Our Risk under the Policy; or for any other reason with the required notice. Group offers a Subsidy Which Increases Our Risk: increase to the Group’s bill and the Premium Rate Schedule. Premium Rate increases will be implemented prospectively but will include an adjustment for prior periods in which the Subsidy increased Our Risk. We will automatically add the Premium Rate Renewals: renewal of the Policy. If We fail to give the Group the required advance notice, the Premium Rates in effect prior to the commencement of the Subsequent Contract Period will remain in effect for a period of 45 days after the Group was notified by Us of the new Premium Rates for the Subsequent Contract Period, after which period the new Premium Rates will go into effect. We will provide 45 days written notice of the change of Premium Rates upon the Other Reasons: If we change the Premium Rate for any other reason, we will provide a 90-day prior written notice to the Group. 1 OHINY GEA LS 1109 -5- NYSM_PPO_EHB_01.01.2014_v.3 BENJAMIN 000006 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 6 of 237 C. Provide notification to each Member, within 15 days after termination of the Member’s coverage, of the Member’s right to convert to one of Our individual direct payment contracts, contingent upon the Member having reasonable access to Our Service Area. XII. RESPONSIBILITIES OF GROUP Group agrees to: A. Offer coverage to eligible employees and their eligible family members, as described in Section IV above. It is agreed that eligible employees of the Group will be free to choose Our coverage or any other coverage as may be available through the Group during the initial and subsequent Group Open Enrollment Periods. Every eligible employee of the Group will be given a fair opportunity to elect one of the Group’s coverage options and will not be penalized by the Group because of his or her choice. B. Offer each new employee the opportunity to elect Our coverage as a procedure of employment when he or she becomes an eligible employee as described in the Policy. : IX. MEMBER EFFECTIVE DATES OF COVERAGE Coverage of prospective Members will be subject to Our receipt of an Enrollment Form and applicable monthly Premium for each prospective Member within 31 days of the Member becoming eligible for coverage under the Policy. X. INELIGIBLE MEMBERS If the Group fails to immediately notify Us of a Member’s ineligibility, and the Group has made or continues to make the Premium payments for such Member, We will credit such Premium payment back to the last day of the month immediately prior to the month in which such termination notice is received by Us. We will provide this credit only if We have not authorized or incurred claims for health services for such Member during the period when We were unaware of the Member’s ineligibility. XI. OPEN ENROLLMENT PERIOD The Group will hold a Group Open Enrollment Period at least once each year. During the Group Open Enrollment Period, eligible employees, as determined by the Policy, may elect coverage under the Policy. : : : E. Comply with all policies and procedures established by Us in administering and interpreting the Policy. D. Furnish to Us, on a monthly basis (or as otherwise required), on Our approved forms, such information as may reasonably be required by Us for the administration of the Policy, including any change in a Member’s eligibility status. In addition, We may, at reasonable times, examine the Group’s pertinent records with respect to eligibility and Premium payments hereunder. OHINY GEA LS 1109 -6- NYSM_PPO_EHB_01.01.2014_v.3 BENJAMIN 000007 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 7 of 237 B. The Policy may be terminated by the Group: (i) Upon written notice, in the event of the insolvency or bankruptcy of OHI; (ii) Upon written notice, in the event of the revocation of OHI’s license; (iii) In the event of Our material breach of any of the terms and provisions of the Policy, upon a 45- day prior written notice to Us; XIII. TERMINATION A. The Policy may be terminated by Us on the date we specify: (i) Upon written notice, if any Premium payment or contribution required to be made by the Group is not received by the Premium Due Date, subject to a 30-day grace period; (ii) Upon written notice, if the Group ceases to operate or relocates outside of the Service Area; (iii) If the Group has performed an act or practice that constitutes fraud or made an intentional misrepresentation of material fact under the terms of the Policy. If the Group has provided us with false information material to the execution of the Policy or to the provision of coverage under this Policy, we have the right to rescind this Policy back to the effective date of the Initial Contract Period; (iv) If We cease offering group contracts in New York in accordance with applicable law; (v) If the Group has a Benefit Plan on a product we cease offering in New York in accordance with applicable law; (vi) If the Group ceases to meet the requirements for a group as defined under applicable law; (vii) If the Group ceases to meet the minimum participation, overinsurance, contribution and/or other : (viii) If in connection with this Plan, there is no longer any employee or dependent who lives, resides or (ix) For such other reasons as are acceptable to the Superintendent of Insurance and not inconsistent with the Health Insurance Portability and Accountability Act (HIPAA) (Public Law 104-191). works in the Service Area; or underwriting rules applicable to the Group. (iv) As of the date any Premium change would become effective, by providing Us with written notice (v) Without cause, by giving Us a 60-day advance written notice. of termination not less than 30 days prior to such effective date; or OHINY GEA LS 1109 -7- NYSM_PPO_EHB_01.01.2014_v.3 BENJAMIN 000008 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 8 of 237 XV. APPLICABLE LAW The Policy will be governed by the laws of the State of New York. XVI. INCONSISTENCY In the event of any inconsistency between this Group Policy and Group Enrollment Agreement and the Certificate, the terms of this Group Policy and Group Enrollment Agreement will govern. XVII. AMENDMENTS AND ALTERATIONS Amendments to this Policy are effective 31 days after we send written notice to the Group. Riders are effective on the date we specify. Other than changes to the Premium Rate Schedule, no change will be made to this Policy unless made by an Amendment or a Rider which is signed by one of our authorized executive officers. No other individual has the authority to change the Policy, waive any of its provisions or restrictions, extend the time for making a payment, or bind OHI by making any other commitment or representation. Formal acceptance of an amendment to the Policy by the Group will not be required if: the change has been negotiated by means of a request by the Group and agreed to by Us and such amendment is attached to this Group Policy; if the change is required to bring the Policy into conformance with any applicable law, regulation or ruling of the jurisdiction in which the Policy is delivered or of the federal government; or if the Group makes payment of any applicable Premium on and after the effective date of such amendment. : : : The Policy constitutes the entire agreement between the parties and supersedes all prior and contemporaneous arrangements, understandings, negotiations and discussions of the parties with respect to the subject matter hereof, whether written or oral; and there are no warrantees, representations, or other agreements between the parties in connection with the subject matter hereof, except as specifically set forth herein. No supplement, modification or waiver of the Policy will be binding unless executed in writing by authorized representatives of the parties. XIV. ENTIRE POLICY: Attachments: Amendments requested by the Group and accepted by Us. OXFORD HEALTH INSURANCE, INC. Authorized Signature (Group) DATE: TECHSTYLE CONTRACT FABRICS TITLE: By: Authorized Signature By: TITLE: DATE: Toni Provencher Director OHINY GEA LS 1109 -8- NYSM_PPO_EHB_01.01.2014_v.3 BENJAMIN 000009 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 9 of 237 BENJAMIN 000010 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 10 of 237 N e w Y o r k P P O 10886 BENJAMIN 000011 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 11 of 237 MS-05-1293 In-Area Welcome Letter (1.11) Dear Oxford Member, Welcome, and thank you for selecting Oxford Health Plans. At Oxford, your satisfaction is important to us, and we strive to help make your healthcare experience a positive one. As an Oxford Member, you have access to a series of programs and resources to help you along your road to health: • A robust network of hospitals and providers from a local health plan with over 20 years of experience. If your employer’s plan offers out-of-area coverage, you also have in-network national access outside of Oxford’s tri-state service area through the UnitedHealthcare Choice Plus network. • Our Healthy Bonus®1 program, which consists of special offers and discounts that help you stay healthy and manage special conditions. Members can save on services such as weight loss programs, fitness equipment and publications. • Our web site, www.oxfordhealth.com, which allows you to conduct business (e.g., request an ID card, update or correct any personal information, etc.) and access health information at your convenience. • Healthcare guidance 24 hours a day, seven days a week, from Oxford’s registered nurses through Oxford On-Call® • Healthy Mind Healthy Body® magazine, your source for health information on prevention, nutrition, and exercise, as well as important benefit and coverage information. The following information is enclosed: your new Summary of Benefits, Certificate of Coverage and other important plan information. If you have questions about your coverage, or want to learn more about Oxford's programs and resources, please log on to www.oxfordhealth.com or call Customer Service at the number on your Oxford ID card. Wishing you the best of health, Oxford Health Plans 1 Healthy Bonus offers are not insured benefits and are in addition to, and separate from, your benefit coverage through Oxford Health Plans. These arrangements have been made for the benefit of Members, and do not represent an endorsement or guarantee on the part of Oxford. Offers may change from time to time and without notice and are applicable to the items referenced only. Offers are subject to the terms and conditions imposed by the vendor. Oxford Health Plans cannot assume any responsibility for the products or services provided by vendors or the failure of vendors referenced to make available discounts negotiated with Oxford; however, any failure to receive offers should be reported to Oxford Customer Service by calling the number on your Member ID card. BENJAMIN 000012 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 12 of 237 MS-06-664 Breast Reconstruction (5.06) Reconstructive Breast Surgery Law Effective October 21, 1998, health insurance carriers of group and individual commercial policies that cover mastectomies are required to cover reconstructive surgery or related services following a mastectomy in accordance with the Women’s Health and Cancer Rights Act of 1998. The Act guarantees coverage to any Member who is receiving benefits in connection with a mastectomy and who elects breast reconstruction in connection with that mastectomy. The health insurance company that issues the policy is required to provide coverage (as determined in consultation with the attending physician and the patient) for: Individuals receiving mastectomy-related benefits, coverage will be provided in a manner determined in consultation with the attending physician and the patient for: a. all stages of reconstruction of the breast on which the mastectomy has been performed; b. surgery and reconstruction of the other breast to produce a symmetrical appearance; c. prostheses; and d. treatment of physical complications of the mastectomy, including lymphedema. These benefits will be provided in the same manner as other medical and surgical benefits provided under this plan. If you would like more information about this benefit, please read the enclosed Certificate of Coverage. Important Information BENJAMIN 000013 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 13 of 237 NY-05-610 NY National Medical Support Notice 3.11 National Medical Support Notices The New York State Insurance Department has issued guidance as to how health insurance policyholders and health insurance companies/ health maintenance organizations need to respond when they receive a "National Medical Support Notice" issued by the New York State Division of Child Support Enforcement. These notices require that a non-custodial parent provide health insurance for a dependent child. In some cases the non-custodial parents may not have elected coverage for themselves and may need to be enrolled in order to provide the coverage required pursuant to the National Medical Support Notice. Any party that fails to comply with the court order becomes responsible for any healthcare costs incurred as a result of the non-compliance. Even when the non-custodial parent refuses to sign a required enrollment form, the policyholder and the insurer must take necessary steps to enroll the child even if it means enrolling the non-custodial parent against his/her will. Thank you for your assistance in helping us to process these enrollments in compliance with the Insurance Department's directive. BENJAMIN 000014 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 14 of 237 Cost Sharing Participating Member Responsibility for Cost- Sharing Non-Participating Member Responsibility for Cost-Sharing SECTION XIV - Freedom PPO Schedule of Benefits Platinum Plan TECHSTYLE CONTRACT FABRICS Deductible Individual Family None None $2,000 $4,000 $100 Non-Participating Provider Services Are Not Covered and You Pay the Full Cost Prescription Drug Deductible Individual $100 $200 Pediatric Dental Care Deductible Individual Family $100 $200 Out-of-Pocket Limit Individual Family $3,000 $6,000 $5,000 $10,000 The Allowed Amount is 140% of Medicare. See the Out-of-Network Rider for a description of how We calculate the Allowed Amount. Any charges of a Non-Participating Provider that are in excess of the Allowed Amount do not apply towards the Deductible or Out-of-Pocket Limit. You must pay the amount by which the Non-Participating Provider's charge exceeds Our Allowed Amount. NYSM PPO EHB_01.01.2014_v.2OHINY_SG_PLTNM_SBN_PPO002RX1_2014_v1 03/01/2014 TC23015*CSP03 Page 1 of 15 BENJAMIN 000015 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 15 of 237 Office Visits Participating Member Responsibility for Cost- Sharing Non-Participating Member Responsibility for Cost- Sharing Primary Care Office Visits (or Home Visits) Limits See Benefit For Description $20 Copayment $20 CopaymentMedications Administered in Office 30% Coinsurance after Deductible 30% Coinsurance after Deductible Specialist Office Visits (or Home Visits) See Benefit For Description $30 Copayment $30 CopaymentMedications Administered in Office 30% Coinsurance after Deductible 30% Coinsurance after Deductible Preauthorization Required Preventive Care Well Child Visits and Immunizations* Covered in Full See Benefit For Description Adult Annual Physical Examinations* Covered in Full Non-Participating Provider Services are Not Covered and You Pay the Full Cost Adult Immunizations* Covered in Full Non-Participating Provider Services are Not Covered and You Pay the Full Cost Routine Gynecological Services/Well Woman Exams* Covered in Full Non-Participating Provider Services are Not Covered and You Pay the Full Cost Mammography Screenings* Covered in Full 30% Coinsurance after Deductible 30% Coinsurance after Deductible NYSM PPO EHB_01.01.2014_v.2OHINY_SG_PLTNM_SBN_PPO002RX1_2014_v1 03/01/2014 TC23015*CSP03 Page 2 of 15 BENJAMIN 000016 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 16 of 237 Office Visits Participating Member Responsibility for Cost- Sharing Non-Participating Member Responsibility for Cost- Sharing Limits Sterilization Procedures for Women* Covered in Full Non-Participating Provider Services are Not Covered and You Pay the Full Cost Vasectomy Non-Participating Provider Services are Not Covered and You Pay the Full Cost Bone Density Testing* Covered in Full Non-Participating Provider Services are Not Covered and You Pay the Full Cost Screening for Prostate Cancer Covered in Full Non-Participating Provider Services are Not Covered and You Pay the Full Cost All other preventive services required by USPSTF and HRSA. Covered in Full Non-Participating Provider Services are Not Covered and You Pay the Full Cost $30 Copayment *When preventive services are not provided in accordance with the comprehensive guidelines supported by USPSTF and HRSA. Non-Participating Provider Services are Not Covered and You Pay the Full Cost Use Cost Sharing for Appropriate Service (Primary Care Office Visit; Specialist Office Visit; Diagnostic Radiology Services; Laboratory Procedures & Diagnostic Testing) NYSM PPO EHB_01.01.2014_v.2OHINY_SG_PLTNM_SBN_PPO002RX1_2014_v1 03/01/2014 TC23015*CSP03 Page 3 of 15 BENJAMIN 000017 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 17 of 237 Emergency Care Member Responsibility for Cost- Sharing Member Responsibility for Cost- Sharing Pre-Hospital Emergency Medical Services (Ambulance Services) Limits See Benefit For Description Covered in Full Covered in Full Non-Emergency Ambulance Services See Benefit For Description Covered in Full Covered in Full Preauthorization Required Participating Non-Participating Emergency Department See Benefit For Description $150 Copayment Copayment waived if Hospital admission. $150 Copayment Urgent Care Center See Benefit For Description $50 Copayment 30% Coinsurance after Deductible Preauthorization Required for Out- of-Network Urgent Care Professional Services and Outpatient Care Member Responsibility for Cost- Sharing Member Responsibility for Cost- Sharing Advanced Imaging Services Limits See Benefit For DescriptionCovered in Full 30% Coinsurance after Deductible Participating Non-Participating Performed in a Freestanding Radiology Facility or Office Setting Performed as Outpatient Hospital Services $100 Copayment 30% Coinsurance after Deductible Preauthorization Required Allergy Testing & Treatment See Benefit For Description 30% Coinsurance after Deductible Preauthorization Required Use Cost Sharing for Appropriate Service (Primary Care Office Visit; Specialist Office Visit; Surgery; Laboratory & Diagnostic Procedures) Ambulatory Surgical Center Facility Fee See Benefit For Description 30% Coinsurance after Deductible Preauthorization Required $100 Copayment NYSM PPO EHB_01.01.2014_v.2OHINY_SG_PLTNM_SBN_PPO002RX1_2014_v1 03/01/2014 TC23015*CSP03 Page 4 of 15 BENJAMIN 000018 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 18 of 237 Professional Services and Outpatient Care Member Responsibility for Cost- Sharing Member Responsibility for Cost- Sharing Anesthesia Services (all settings) Limits See Benefit For Description Covered in Full 30% Coinsurance after Deductible Preauthorization Required Participating Non-Participating Autologous Blood Banking See Benefits For Description Covered in Full 30% Coinsurance after Deductible Preauthorization Required Performed in a Specialist Office $30 Copayment Cardiac & Pulmonary Rehabilitation 30% Coinsurance after Deductible Preauthorization Required Performed as Outpatient Hospital Services Performed as Inpatient Hospital Services $30 Copayment Included As Part of Inpatient Hospital Service Cost-Sharing 30% Coinsurance after Deductible 30% Coinsurance after Deductible See Benefits For Description Performed in a PCP Office $20 Copayment Chemotherapy 30% Coinsurance after Deductible Preauthorization Required Performed in a Specialist Office Performed as Outpatient Hospital Services $30 Copayment 30% Coinsurance after Deductible 30% Coinsurance after Deductible See Benefit For Description $300 Copayment NYSM PPO EHB_01.01.2014_v.2OHINY_SG_PLTNM_SBN_PPO002RX1_2014_v1 03/01/2014 TC23015*CSP03 Page 5 of 15 BENJAMIN 000019 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 19 of 237 Professional Services and Outpatient Care Member Responsibility for Cost- Sharing Member Responsibility for Cost- Sharing Chiropractic Services Limits See Benefit For Description $30 Copayment 30% Coinsurance after Deductible Preauthorization Required Participating Non-Participating Performed in a PCP Office $90 Copayment Diagnostic Testing 30% Coinsurance after Deductible Preauthorization Required Performed in a Specialist Office Performed as Outpatient Hospital Services $90 Copayment 30% Coinsurance after Deductible 30% Coinsurance after Deductible See Benefit For Description Performed in a PCP Office $20 Copayment Dialysis 30% Coinsurance after Deductible Preauthorization Required Performed in a Freestanding Center or Specialist Office Setting Performed as Outpatient Hospital Services $30 Copayment 30% Coinsurance after Deductible 30% Coinsurance after Deductible See Benefit For Description $300 Copayment $90 Copayment $30 CopaymentHabilitation Services (Physical Therapy, Occupational Therapy or Speech Therapy) 30% Coinsurance after Deductible Preauthorization Required 60 Visits per Calendar Year for PT/OT/ST combined NYSM PPO EHB_01.01.2014_v.2OHINY_SG_PLTNM_SBN_PPO002RX1_2014_v1 03/01/2014 TC23015*CSP03 Page 6 of 15 BENJAMIN 000020 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 20 of 237 Professional Services and Outpatient Care Member Responsibility for Cost- Sharing Member Responsibility for Cost- Sharing LimitsParticipating Non-Participating $30 CopaymentHome Health Care 25% Coinsurance not subject to Deductible Preauthorization Required 40 Visits per Calendar Year Infertility Services 30% Coinsurance after Deductible Preauthorization Required See Benefit For Description Use Cost Sharing for Appropriate Service (Office Visit; Diagnostic Radiology Services; Surgery; Laboratory Diagnostic Procedures) Performed in a PCP Office $20 Copayment Infusion Therapy 30% Coinsurance after Deductible Preauthorization Required Performed in Specialist Office Performed as Outpatient Hospital Services $30 Copayment 30% Coinsurance after Deductible 30% Coinsurance after Deductible See Benefit For Description $300 Copayment Home Infusion Therapy $30 Copayment 25% Coinsurance not subject to Deductible Home Infusion counts towards Home Health Care Visit Limits Covered in FullInpatient Medical Visits 30% Coinsurance after Deductible Preauthorization Required See Benefit For Description NYSM PPO EHB_01.01.2014_v.2OHINY_SG_PLTNM_SBN_PPO002RX1_2014_v1 03/01/2014 TC23015*CSP03 Page 7 of 15 BENJAMIN 000021 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 21 of 237 Professional Services and Outpatient Care Member Responsibility for Cost- Sharing Member Responsibility for Cost- Sharing Participating LimitsNon-Participating Performed in a PCP Office Covered in Full Laboratory Procedures 30% Coinsurance after Deductible Preauthorization Required Performed in a Freestanding Laboratory Facility or Specialist Office Performed as Outpatient Hospital Services Covered in Full 30% Coinsurance after Deductible 30% Coinsurance after Deductible See Benefit For Description Covered in Full Prenatal Care Maternity & Newborn Care 30% Coinsurance after Deductible Inpatient Hospital Services and Birthing Center Physician and Nurse Midwife Services for Delivery $500 Copayment per admission 30% Coinsurance after Deductible 30% Coinsurance after Deductible See Benefit For Description Covered in Full Breast Pump 30% Coinsurance after Deductible Use Cost Sharing for Appropriate Service (Office Visit; Diagnostic Radiology Services; Surgery; Laboratory & Diagnostic Procedures) Preadmission Testing 30% Coinsurance after Deductible Preauthorization Required See Benefit For Description Covered in Full Covered in Full Preauthorization Required Covered for duration of breast feeding 1 Home Care Visit is Covered at no Cost-Sharing if $300 CopaymentOutpatient Hospital Surgery Facility Charge 30% Coinsurance after Deductible Preauthorization Required See Benefit For Description mother is discharged from Hospital early NYSM PPO EHB_01.01.2014_v.2OHINY_SG_PLTNM_SBN_PPO002RX1_2014_v1 03/01/2014 TC23015*CSP03 Page 8 of 15 BENJAMIN 000022 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 22 of 237 Professional Services and Outpatient Care Member Responsibility for Cost- Sharing Member Responsibility for Cost- Sharing Participating LimitsNon-Participating Performed in a PCP Office Diagnostic Radiology Services 30% Coinsurance after Deductible Performed in a Freestanding Radiology Facility or Specialist Office $90 Copayment 30% Coinsurance after Deductible 30% Coinsurance after Deductible See Benefit For Description $90 Copayment Performed as Outpatient Hospital Services Preauthorization Required $90 Copayment Performed in a Freestanding Radiology Facility or Specialist Office Therapeutic Radiology Services 30% Coinsurance after Deductible Performed as Outpatient Hospital Services $30 Copayment 30% Coinsurance after Deductible See Benefit For Description $300 Copayment $30 CopaymentRehabilitation Services (Physical Therapy, Occupational Therapy or Speech Therapy) 30% Coinsurance after Deductible Preauthorization Required 60 Visits per Calendar Year for PT/OT/ST combined Preauthorization Required $30 CopaymentSecond Opinions on the Diagnosis of Cancer, Surgery & Other 30% Coinsurance after Deductible Preauthorization Required See Benefit For Description NYSM PPO EHB_01.01.2014_v.2OHINY_SG_PLTNM_SBN_PPO002RX1_2014_v1 03/01/2014 TC23015*CSP03 Page 9 of 15 BENJAMIN 000023 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 23 of 237 Professional Services and Outpatient Care Member Responsibility for Cost- Sharing Member Responsibility for Cost- Sharing Inpatient Hospital Surgery Surgical Services (Including Oral Surgery; Reconstructive Breast Surgery; Other Reconstructive Corrective Surgery; Transplants; Interruption of Pregnancy) 30% Coinsurance after DeductibleOutpatient Hospital Surgery Covered in Full 30% Coinsurance after Deductible See Benefit For Description Covered in Full Preauthorization Required Surgery Performed at an Ambulatory Surgical Center Office Surgery Covered in Full $30 Copayment 30% Coinsurance after Deductible 30% Coinsurance after Deductible All Transplants Must be Performed at Designated Facilities Participating LimitsNon-Participating Additional Services, Equipment & Devices Member Responsibility for Cost- Sharing Member Responsibility for Cost- Sharing Participating LimitsNon-Participating ABA Treatment for Autism Spectrum Disorder $30 Copayment 680 Hours Per Calendar YearPreauthorization Required 30% Coinsurance after Deductible Assistive Communication Devices for Autism Spectrum Disorder $20 Copayment Preauthorization Required 30% Coinsurance after Deductible See Benefit For Description NYSM PPO EHB_01.01.2014_v.2OHINY_SG_PLTNM_SBN_PPO002RX1_2014_v1 03/01/2014 TC23015*CSP03 Page 10 of 15 BENJAMIN 000024 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 24 of 237 Additional Services, Equipment & Devices Member Responsibility for Cost- Sharing Member Responsibility for Cost- Sharing Participating LimitsNon-Participating Diabetic Equipment, Supplies Self-Management Education $20 Copayment Preauthorization Required 30% Coinsurance after DeductibleDiabetic Equipment, Supplies and Insulin Diabetic Education $20 Copayment 30% Coinsurance after Deductible See Benefit For Description Durable Medical Equipment & Braces Preauthorization Required Covered in Full 30% Coinsurance after Deductible See Benefit For Description External Hearing Aids Preauthorization Required Covered in Full 30% Coinsurance after Deductible Single Purchase Once Every 3 Years per hearing impaired ear Cochlear Implants Preauthorization Required Covered in Full 30% Coinsurance after Deductible One Per Ear Per Time Covered Hospice Care $500 Copayment per admission 30% Coinsurance after DeductibleInpatient Outpatient $30 Copayment 30% Coinsurance after Deductible 210 Days per Calendar Year Preauthorization Required 5 Visits for Family Bereavement Counseling (30-Day Supply) NYSM PPO EHB_01.01.2014_v.2OHINY_SG_PLTNM_SBN_PPO002RX1_2014_v1 03/01/2014 TC23015*CSP03 Page 11 of 15 BENJAMIN 000025 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 25 of 237 Additional Services, Equipment & Devices Member Responsibility for Cost- Sharing Member Responsibility for Cost- Sharing Participating LimitsNon-Participating Prosthetic Devices Covered in Full 30% Coinsurance after DeductibleExternal Internal Covered in Full 30% Coinsurance after Deductible One prosthetic device, per limb, per lifetime Unlimited Preauthorization Required See Benefit For Description Inpatient Services & Facilities Member Responsibility for Cost- Sharing Member Responsibility for Cost- Sharing Participating LimitsNon-Participating $500 Copayment per admissionInpatient Hospital for a Continuous Confinement (Including an Inpatient Stay for Mastectomy Care, Cardiac Pulmonary Rehabilitation, & End of Life Care) 30% Coinsurance after Deductible Preauthorization Required See Benefit For Description $150 CopaymentObservation Stay 30% Coinsurance after Deductible Preauthorization Required See Benefit For Description $500 Copayment per admissionSkilled Nursing Facility (Includes Cardiac & Pulmonary Rehabilitation) 30% Coinsurance after Deductible Preauthorization Required 200 Days Per Calendar Year Medical Supplies Preauthorization Required Covered in Full 30% Coinsurance after Deductible See Benefit For Description NYSM PPO EHB_01.01.2014_v.2OHINY_SG_PLTNM_SBN_PPO002RX1_2014_v1 03/01/2014 TC23015*CSP03 Page 12 of 15 BENJAMIN 000026 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 26 of 237 Mental Health & Substance Use Disorder Services Member Responsibility for Cost- Sharing Member Responsibility for Cost- Sharing Participating LimitsNon-Participating $500 Copayment per admissionInpatient Mental Health Care (for a continuous confinement when in a Hospital) 30% Coinsurance after Deductible Preauthorization Required See Benefit For Description $30 CopaymentOutpatient Mental Health Care (Including Partial Hospitalization Intensive Outpatient Program Services) 30% Coinsurance after Deductible Preauthorization Required See Benefit For Description $500 Copayment per admissionInpatient Substance Use Services (for a continuous confinement when in a Hospital) 30% Coinsurance after Deductible Preauthorization Required See Benefit For Description $30 CopaymentOutpatient Substance Use Services 30% Coinsurance after Deductible Preauthorization Required Unlimited; Up to 20 Visits a Calendar Year May Be Used For Family Counseling $500 Copayment per admissionInpatient Rehabilitation Services (Physical, Speech & Occupational therapy) 30% Coinsurance after Deductible Preauthorization Required 60 Days Per Calendar Year for PT/OT/ST combined Inpatient Services & Facilities Member Responsibility for Cost- Sharing Member Responsibility for Cost- Sharing Participating LimitsNon-Participating NYSM PPO EHB_01.01.2014_v.2OHINY_SG_PLTNM_SBN_PPO002RX1_2014_v1 03/01/2014 TC23015*CSP03 Page 13 of 15 BENJAMIN 000027 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 27 of 237 Prescription Drugs Member Responsibility for Cost- Sharing Member Responsibility for Cost- Sharing Participating LimitsNon-Participating $10 Copayment not subject to Deductible 30 Day Supply Non-Participating Provider Services Are Not Covered and You Pay the Full Cost See Benefit For Description Retail Pharmacy Tier 1 Tier 2 Tier 3 $30 Copayment after Prescription Drug Deductible $60 Copayment after Prescription Drug Deductible $25 Copayment not subject to Deductible Up to a 90 Day Supply Non-Participating Provider Services Are Not Covered and You Pay the Full Cost See Benefit For Description Mail Order Pharmacy Tier 1 Tier 2 Tier 3 $75 Copayment after Prescription Drug Deductible $150 Copayment after Prescription Drug Deductible Wellness Benefits Member Responsibility for Cost- Sharing Member Responsibility for Cost- Sharing Participating Non-Participating Gym Reimbursement Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse NYSM PPO EHB_01.01.2014_v.2OHINY_SG_PLTNM_SBN_PPO002RX1_2014_v1 03/01/2014 TC23015*CSP03 Page 14 of 15 BENJAMIN 000028 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 28 of 237 Pediatric Dental & Vision Care Member Responsibility for Cost- Sharing Member Responsibility for Cost- Sharing Preventive/Routine Dental Care Pediatric Dental Care 20% Coinsurance after Pediatric Dental Care Deductible Major Dental (Endodontic & Prosthodontics) Orthodontia 50% Coinsurance after Pediatric Dental Care Deductible One Dental Exam & Cleaning Per 6- Month Period Participating LimitsNon-Participating Orthodontia Requires Preauthorization Pediatric Vision Care $20 Copayment One Exam Per 12- Month Period; One Prescribed Lenses & Frames in a 12- Month Period50% Coinsurance 50% Coinsurance after Deductible 50% Coinsurance 20% Coinsurance after Pediatric Dental Care Deductible 50% Coinsurance after Pediatric Dental Care Deductible 50% Coinsurance after Pediatric Dental Care Deductible 50% Coinsurance after Pediatric Dental Care Deductible Exams Lenses & Frames Contact Lenses 50% Coinsurance after Deductible 50% Coinsurance after Deductible Contact Lenses Require Preauthorization NYSM PPO EHB_01.01.2014_v.2OHINY_SG_PLTNM_SBN_PPO002RX1_2014_v1 03/01/2014 TC23015*CSP03 Page 15 of 15 BENJAMIN 000029 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 29 of 237 MS-09-409 Womens Health and Federal Mandate Letter 1.11 Women’s Health and Cancer Rights Act As required by the Women's Health and Cancer Rights Act of 1998, benefits are provided for mastectomy, including reconstruction and surgery to achieve symmetry between the breasts, prostheses, and treatment of complications resulting from a mastectomy (including lymphedema). If you are receiving benefits in connection with a mastectomy, benefits are also provided for the following covered health services, as you determine appropriate with your attending physician: • All stages of reconstruction of the breast on which the mastectomy was performed; • Surgery and reconstruction of the other breast to produce a symmetrical appearance; and • Prostheses and treatment of physical complications of the mastectomy, including lymphedema. The amount you must pay for such covered health services (including copayments, coinsurance and any annual deductible) and the benefit coverage limitations are the same as are required for any other covered health service as described in your Certificate of Coverage or Summary Plan Description. Newborns’ and Mothers’ Health Protection Act Under federal law, group health plans and health insurance issuers offering group health insurance coverage generally may not restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours following a delivery by cesarean section. However, the plan or issuer may pay for a shorter stay if the attending provider (e.g., your physician, nurse midwife, or physician assistant), after consultation with the mother, discharges the mother or newborn earlier. Also, under federal law, plans and issuers may not set the level of benefits or out-of-pocket costs so that any later portion of the 48-hour (or 96-hour) stay is treated in a manner less favorable to the mother or newborn than any earlier portion of the stay. In addition, a plan or issuer may not, under federal law, require that a physician or other health care provider obtain authorization for prescribing a length of stay of up to 48 hours (or 96 hours). However, to use certain providers or facilities, or to reduce your out-of- pocket costs, you may be required to obtain precertification. For information on precertification, call the toll-free Customer Service telephone number on your Oxford member ID card. Notification of Language Assistance Program We understand that we serve an increasingly diverse membership. More than ever, we believe that it is important to accommodate language preferences, especially when it comes to our members accessing care and services to ensure that language is not an obstacle to receiving proper care. We offer language assistance services to limited English proficiency (LEP) members. Language assistance services are provided free of charge to members. If you need assistance or have any questions about these services, please call the toll-free Customer Service telephone number on the back of your Oxford member ID card. BENJAMIN 000030 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 30 of 237 1 OHINY_SG_COC_2014 10886 NY SG FP PPO AGE 26 COC 02.14 This is Your PREFERRED PROVIDER ORGANIZATION CERTIFICATE OF COVERAGE Issued by Oxford Health Insurance, Inc. 48 Monroe Turnpike Trumbull, CT. 06611 1-800 444-6222 This Certificate of Coverage (“Certificate”) explains the benefits available to You under a Group Policy between Oxford Health Insurance, Inc. (hereinafter referred to as “We”, “Us”, or “Our”) and the Group policyholder. This Certificate is not a contract between You and Us. Amendments, riders or endorsements may be delivered with the Certificate or added thereafter. This Certificate offers You the option to receive Covered Services on two benefit levels: In-Network Benefits. In-network benefits are the highest level of coverage available. In-network benefits apply when Your care is provided by Participating Providers in Our Freedom network. You should always consider receiving health care services first through the in-network benefits portion of this Certificate. Out-of-Network Benefits. The out-of-network benefits portion of this Certificate provides coverage when You receive Covered Services from Non-Participating Providers. Your out-of-pocket expenses will be higher when You receive out-of-network benefits. In addition to Cost-Sharing, You will also be responsible for paying any difference between the Allowed Amount and the Non-Participating Provider’s charge. BENJAMIN 000031 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 31 of 237 2 OHINY_SG_COC_2014 10886 NY SG FP PPO AGE 26 COC 02.14 Some Covered services, such as Preventive Care for adults are only Covered when received from Participating Providers and are not Covered as out-of-network benefits. See the Schedule of Benefits in Section XV - Schedule of Benefits of the Certificate for more information. READ THIS ENTIRE CERTIFICATE CAREFULLY. IT DESCRIBES THE BENEFITS AVAILABLE UNDER THE GROUP CONTRACT. IT IS YOUR RESPONSIBILITY TO UNDERSTAND THE TERMS AND CONDITIONS IN THIS CERTIFICATE. This Certificate is governed by the laws of New York State. BENJAMIN 000032 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 32 of 237 3 OHINY_SG_COC_2014 10886 NY SG FP PPO AGE 26 COC 02.14 TABLE OF CONTENTS Section I. Definitions ............................................................................. 05 Section II. How Your Coverage Works ................................................. 12 Network Providers ............................................................................ 12 Preauthorization ................................................................................. 13 Medical Necessity .............................................................................. 13 Important Telephone Numbers and Addresses .............................. 14 Section III. Access to Care and Transitional Care .............................. 15 Section IV. Cost Sharing Expenses and Allowed Amount .................. 18 Section V. Who is Covered .................................................................... 20 Section VI. Covered Services ................................................................ 23 Preventive Care .................................................................................. 23 Ambulance and Pre-Hospital Emergency Medical Services ........... 26 Emergency Services .......................................................................... 27 Outpatient and Professional Services .............................................. 30 Additional Benefits, Equipment & Devices ...................................... 36 Inpatient Services .............................................................................. 42 Mental Health Care and Substance Use Services ........................... 45 Prescription Drug Coverage ............................................................. 47 Wellness Benefits .............................................................................. 56 Pediatric Vision ................................................................................. 57 Pediatric Dental .................................................................................. 57 Section VII. Exclusions and Limitations ............................................... 60 Section VIII. Claim Determinations ....................................................... 63 Section IX. Grievance, Utilization Review & External Appeals ........... 65 Grievance Procedures ....................................................................... 65 Utilization Review .............................................................................. 67 External Appeals ................................................................................ 71 Section X. Coordination of Benefits ..................................................... 76 BENJAMIN 000033 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 33 of 237 4 OHINY_SG_COC_2014 10886 NY SG FP PPO AGE 26 COC 02.14 Section XI. Termination of Coverage .................................................... 79 Section XII. What Happens if You Lose Coverage .............................. 81 Extension of Benefits ........................................................................ 81 Continuation of Coverage ................................................................. 82 Conversion Right to a New Contract After Termination ................. 85 Section XIII. General Provisions .......................................................... 87 Section XIV. Other Covered Services……………………………………..93 Hemophilia Factor Benefits ……………………………………………..94 BENJAMIN 000034 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 34 of 237 5 OHINY_SG_COC_2014 10886 NY SG FP PPO AGE 26 COC 02.14 Section I - Definitions Defined terms will appear capitalized throughout the Certificate. Acute: The sudden onset of disease or injury, or a sudden change in the Member's condition that would require prompt medical attention. Allowed Amount: The maximum amount on which Our payment is based for Covered Services. See Section IV - Cost Sharing Expenses and Allowed Amount of this Certificate for a description of how the Allowed Amount is calculated. If your Non- Participating Provider charges more than the Allowed Amount You will have to pay the difference between the Allowed Amount and the Provider's charge, in addition to any Cost-Sharing requirements. Ambulatory Surgical Center: A Facility currently licensed by the appropriate state regulatory agency for the provision of surgical and related medical services on an outpatient basis. Appeal: A request for Us to review a Utilization Review decision or a Grievance again. Balance Billing: When a Non-Participating Provider bills You for the difference between the Non-Participating Provider’s charge and the Allowed Amount. A Participating Provider may not Balance Bill You for Covered Services. Certificate: This Certificate issued by Oxford Health Insurance, Inc., including the Schedule of Benefits and any attached riders. Children: The Subscriber’s Children, including any natural, adopted or step-children, unmarried disabled Children, newborn Children, or any other Children as described in the "Who is Covered" section of this Certificate. Coinsurance: Your share of the costs of a Covered Service, calculated as a percent of the Allowed Amount for the service that You are required to pay to a Provider. Copayment: A fixed amount You pay directly to a Provider for a Covered Service when You receive the service. The amount can vary by the type of Covered Service. Cost-Sharing: Amounts You must pay for Covered Services, expressed as Coinsurance, Copayments, and/or Deductibles. Cover, Covered or Covered Services: The Medically Necessary services paid for or arranged for You by Us under the terms and conditions of this Certificate. Deductible: The amount You owe before We begin to pay for Covered Services. The Deductible applies before any Coinsurance or Copayments are applied. The Deductible may not apply to all Covered Services. You may also have a Deductible that applies to a specific Covered Service (for example, a Prescription Drug Deductible) that You owe before We begin to pay for a particular Covered Service. Dependents: The Subscriber’s Spouse and Children. BENJAMIN 000035 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 35 of 237 6 OHINY_SG_COC_2014 10886 NY SG FP PPO AGE 26 COC 02.14 Durable Medical Equipment (DME): Durable Medical Equipment is equipment which is: designed and intended for repeated use; primarily and customarily used to serve a medical purpose; generally not useful to a person in the absence of disease or injury; and is appropriate for use in the home. Emergency Condition: A medical or behavioral condition that manifests itself by Acute symptoms of sufficient severity, including severe pain, such that a prudent layperson, possessing an average knowledge of medicine and health, could reasonably expect the absence of immediate medical attention to result in: Placing the health of the person afflicted with such condition or, with respect to a pregnant woman, the health of the woman or her unborn child in serious jeopardy, or in the case of a behavioral condition, placing the health of such person or others in serious jeopardy; Serious impairment to such person’s bodily functions; Serious dysfunction of any bodily organ or part of such person; or Serious disfigurement of such person. Emergency Department Care: Emergency Services You get in a Hospital emergency department. Emergency Services: A medical screening examination which is within the capability of the emergency department of a Hospital, including ancillary services routinely available to the emergency department to evaluate such Emergency Condition; and within the capabilities of the staff and facilities available at the Hospital, such further medical examination and treatment as are required to stabilize the patient. “To stabilize” is to provide such medical treatment of an Emergency Condition as may be necessary to assure, within reasonable medical probability, that no material deterioration of the condition is likely to result from or occur during the transfer of the patient from a Facility, or to deliver a newborn child (including the placenta). Exclusions: Health care services that We do not pay for or Cover. External Appeal Agent: An entity that has been certified by the Department of Financial Services to perform external appeals in accordance with New York law. Facility: A Hospital; ambulatory surgery Facility; birthing center; dialysis center; rehabilitation Facility; Skilled Nursing Facility; hospice; home health agency or home care services agency certified or licensed under Article 36 of the New York Public Health Law; a comprehensive care center for eating disorders pursuant to article 27-J of the public health law; an institutional Provider of mental health or chemical dependence and abuse treatment operating under Article 31 of the New York Mental Hygiene Law and/or approved by the Office of Alcoholism and Substance Abuse Services, or other Provider certified under Article 28 of the New York Public Health Law (or other BENJAMIN 000036 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 36 of 237 7 OHINY_SG_COC_2014 10886 NY SG FP PPO AGE 26 COC 02.14 comparable state law, if applicable). If You receive treatment for chemical dependence or abuse outside of New York State, the Facility must be accredited by the Joint Commission on Accreditation of Healthcare Organizations (“JCAHO”) to provide a chemical abuse treatment program. Grievance: A complaint that You communicate to Us that does not involve a Utilization Review determination. Group: The employer or party that has entered into an Agreement with Us. Habilitation Services: Health care services that help a person keep, learn or improve skills and functioning for daily living. Habilitative Services include the management of limitations and disabilities, including services or programs that help maintain or prevent deterioration in physical, cognitive, or behavioral function. These services consist of physical therapy, occupational therapy and speech therapy. Health Care Professional: An appropriately licensed, registered or certified Physician; osteopath; dentist; optometrist; chiropractor; psychologist; psychiatrist; social worker; podiatrist; physical therapist; occupational therapist; midwife; speech-language pathologist; audiologist; pharmacist certified to administer immunizing agents; or any other licensed, registered or certified Health Care Professional under Title 8 of the Education Law (or other comparable state law, if applicable) that the New York Insurance Law requires to be recognized who charges and bills patients for Covered Services. The Health Care Professional’s services must be rendered within the lawful scope of practice for that type of Provider in order to be covered under this Certificate. Home Health Agency: An organization currently certified or licensed by the State of New York or the state in which it operates and renders home health care services. Hospice Care: Care to provide comfort and support for persons in the last stages of a terminal illness and their families that are provided by a hospice organization certified pursuant to Article 40 of the Public Health Law or under a similar certification process required by the state in which the hospice organization is located. Hospital: A short term, acute, general Hospital, which: is primarily engaged in providing, by or under the continuous supervision of Physicians, to patients, diagnostic services and therapeutic services for diagnosis, treatment and care of injured or sick persons; has organized departments of medicine and major surgery; has a requirement that every patient must be under the care of a Physician or dentist; provides 24-hour nursing service by or under the supervision of a registered professional nurse (R.N.); if located in New York State, has in effect a Hospitalization review plan applicable to all patients which meets at least the standards set forth in section 1861(k) of United States Public Law 89-97 (42 U.S.C. § 1395x(k)); BENJAMIN 000037 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 37 of 237 8 OHINY_SG_COC_2014 10886 NY SG FP PPO AGE 26 COC 02.14 is duly licensed by the agency responsible for licensing such Hospitals; and is not, other than incidentally, a place of rest, a place primarily for the treatment of tuberculosis, a place for the aged, a place for drug addicts, alcoholics, or a place for convalescent, custodial, educational, or rehabilitory care. Hospital does not mean health resorts, spas, or infirmaries at schools or camps. Hospitalization: Care in a Hospital that requires admission as an inpatient and usually requires an overnight stay. Hospital Outpatient Care: Care in a Hospital that usually doesn’t require an overnight stay. In-Network Coinsurance: Your share of the Costs of a Covered Service, calculated as a percent of the Allowed Amount for the Covered Service that You are required to pay to a Participating Provider. In-Network Copayment: A fixed amount You pay directly to a Participating Provider for a Covered Service when You receive the Covered Service. The amount can vary by the type of Covered Service. In-Network Deductible: The amount you owe before We begin to pay for Covered Services received from Participating Providers. The In-Network Deductible applies before any Coinsurance or Copayments are applied. The In-Network Deductible may not apply to all Covered Services. You may also have an In-Network Deductible that applies to a specific Covered Service (for example, a Prescription Drug Deductible) that You owe before We begin to pay for a particular Covered Service. In-Network Out-of-Pocket Limit: The most you pay during a Plan Year in Cost- Sharing before We begin to pay 100% of the Allowed Amount for Covered Services received from Participating Providers. This limit never includes Your Premium, Balance Billing charges or services We do not Cover. Medically Necessary: See Section II - How Your Coverage Works of this Certificate for the definition. Medicare: Title XVIII of the Social Security Act, as amended. Member: The Subscriber and Covered Dependents for whom required Premiums have been paid. Whenever a Member is required to provide a notice pursuant to a Grievance or emergency department visit or admission, “Member” also means the Member’s designee. Non-Participating Provider: A Provider who doesn’t have a contract with Us to provide services to You. You will pay more to see a Non-Participating Provider. Out-of-Network Coinsurance: Your share of the costs of a Covered Service calculated as a percent of the Allowed Amount for the service that You are required to pay to a Non-Participating Provider. BENJAMIN 000038 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 38 of 237 9 OHINY_SG_COC_2014 10886 NY SG FP PPO AGE 26 COC 02.14 Out-of-Network Copayment: A fixed amount You pay directly to a Non-Participating Provider for a Covered Service when You receive the Covered Service. The amount can vary by the type of Covered Service. Out-of-Network Deductible: The amount you owe before We begin to pay for Covered Services received from Non-Participating Providers. The Out-of-Network Deductible applies before any Coinsurance or Copayments are applied. The Out-of-Network Deductible may not apply to all Covered Services. You may also have an Out-of- Network Deductible that applies to a specific Covered Service (for example, a Prescription Drug Deductible) that You owe before We begin to pay for a particular Covered Service. Out-of-Network Out-of-Pocket Limit: The most you pay during a Plan Year in Cost- Sharing before We begin to pay 100% of the Allowed Amount for Covered Services received from Non-Participating Providers. This limit never includes Your Premium, Balance Billing charges or services We do not Cover. You are also responsible for all differences, if any, between the Allowed Amount and the Non-Participating Provider's charge for Out-of-Network services regardless of whether the Out-of-Pocket Limit has been met. Out-of-Pocket Limit: The most You pay during a Plan Year in Cost-Sharing before We begin to pay 100% of the Allowed Amount for Covered Services. This limit never includes Your Premium, Balance Billing charges or the cost of health care services We do not Cover. Participating Provider: A Provider who has a contract with Us to provide services to You. A list of Participating Providers and their locations is available on Our website at www.oxhp.com or upon Your request to Us. The list will be revised from time to time by Us. Physician or Physician Services: Health care services a licensed medical Physician (M.D. - Medical Doctor or D.O. - Doctor of Osteopathic Medicine) provides or coordinates. Plan Year: The 12-month period beginning on the effective date of the Certificate or any anniversary date thereafter, during which the Certificate is in effect. Preauthorization: A decision by Us prior to Your receipt of a Covered Service, procedure, treatment plan, device, or Prescription Drug that the Covered Service, treatment plan, device or Prescription Drug is Medically Necessary. We indicate which Covered Services require Preauthorization in the Schedule of Benefits section of this Certificate. Premium: The amount that must be paid for Your health insurance coverage. Prescription Drugs: A medication, product or device that has been approved by the Food and Drug Administration and that can, under federal or state law, be dispensed only pursuant to a Prescription Order or refill and is on Our Formulary. A Prescription Drug includes a medication that, due to its characteristics, is appropriate for self administration or administration by a non-skilled caregiver. BENJAMIN 000039 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 39 of 237 10 OHINY_SG_COC_2014 10886 NY SG FP PPO AGE 26 COC 02.14 Primary Care Physician: A Participating Physician (M.D. - Medical Doctor or D.O. - Doctor of Osteopathic Medicine) who typically is an internal medicine, family practice or pediatric doctor and who directly provides or coordinates a range of health care services for You. Provider: A Physician (M.D. - Medical Doctor or D.O. - Doctor of Osteopathic Medicine), licensed Health Care Professional or Facility licensed, certified or accredited as required by state law. Rehabilitation Services: Health care services that help a person keep, get back, or improve skills and functioning for daily living that have been lost or impaired because a person was sick, hurt, or disabled. These services consist of physical therapy, occupational therapy, and speech therapy in an inpatient and/or outpatient setting. Schedule of Benefits: The section of this Certificate that describes the Copayments, Deductibles, Coinsurance, Out-of-Pocket Maximums, Preauthorization requirements and other limits on Covered Services. Service Area: The geographical area, designated by Us and approved by the State of New York in which We provide coverage. Our Service Area consists of the following counties: Bronx, Duchess, Kings, Nassau, New York, Orange, Putnam, Queens, Richmond, Rockland, Suffolk, Sullivan, Ulster and Westchester. Skilled Nursing Facility: An institution or a distinct part of an institution that is: currently licensed or approved under state or local law; primarily engaged in providing skilled nursing care and related services as a Skilled Nursing Facility, extended care Facility, or nursing care Facility approved by the Joint Commission on Accreditation of Health Care Organizations or the Bureau of Hospitals of the American Osteopathic Association, or as a Skilled Nursing Facility under Medicare law; or as otherwise determined by Us to meet the standards of any of these authorities. Specialist: A Physician who focuses on a specific area of medicine or a group of patients to diagnose, manage, prevent or treat certain types of symptoms and conditions. Spouse: The person to whom the Subscriber is legally married, including a same sex Spouse and a domestic partner if purchased. Subscriber: The person to whom this Certificate is issued. UCR (Usual, Customary and Reasonable): The cost of a medical service in a geographic area based on what Providers in the area usually charge for the same or similar medical service. Urgent Care: Medical care for an illness, injury or condition serious enough that a reasonable person would seek care right away, but not so severe as to require emergency department care. Urgent Care may be rendered in a Physician's office or Urgent Care Center. Urgent Care Center: A licensed Facility (except Hospitals) that provides Urgent Care. BENJAMIN 000040 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 40 of 237 11 OHINY_SG_COC_2014 10886 NY SG FP PPO AGE 26 COC 02.14 Us, We, Our: Oxford Health Insurance, Inc. and anyone to whom We legally delegate to perform, on Our behalf, under the Certificate. Utilization Review: The review to determine whether services are or were Medically Necessary or experimental or investigational (including treatment for a rare disease or a clinical trial). You, Your: The Member. BENJAMIN 000041 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 41 of 237 12 OHINY_SG_COC_2014 10886 NY SG FP PPO AGE 26 COC 02.14 Section II - How Your Coverage Works 1. Your Coverage under this Certificate. Your employer (referred to as the “Group policyholder”) has purchased a Group health insurance Policy from Us. We will provide the benefits described in this Certificate to members of the Group, that is, to employees of the Group and their Covered Dependents. However, this Certificate is not a contract between You and Us. You should keep this Certificate with Your other important papers so that it is available for Your future reference. 2. Covered Services. You will receive Covered Services under the terms and conditions of this Certificate only when the Covered Service is: Medically Necessary; Provided by a Participating Provider for In-Network Coverage; Listed as a Covered Service; Not in excess of any benefit limitations described in the Schedule of Benefits in Section XV - Schedule of Benefits of this Certificate; and Received while Your Certificate is in force. 3. Participating Providers. To find out if a Provider is a Participating Provider: Check Your Provider directory, available at Your request. Call Customer Service. Visit our website at www.oxhp.com. 4. The Role of Primary Care Physicians. This Certificate does not have a gatekeeper, usually known as a Primary Care Physician (PCP). You do not need a written Referral from a PCP before receiving Specialist care. Freedom Network. Each Member may select a different PCP. Children covered under this Certificate may designate a Participating PCP who specializes in pediatric care. In certain circumstances, You may designate a Specialist as your PCP. See Section II - How Your Coverage Works of this Certificate for more information about designating a Specialist. For purposes of Cost-Sharing, if You seek services from a Primary Care Physician (or a Physician covering for a Primary Care Physician) who has a primary or secondary specialty other than general practice, family practice, internal medicine, pediatrics and OB/GYN, You must pay the specialty office visit Cost-Sharing in the Schedule of Benefits in Section XV - Schedule of Benefits of this Certificate. 5. Services Subject To Preauthorization. Our Preauthorization is required before You receive certain Covered Services. Your Participating Provider is responsible for requesting Preauthorization for in-network services. 6. Medical Management. The benefits available to You under this Certificate are subject to pre-service, concurrent and retrospective reviews to determine when services should be covered by Us. Their purpose is to promote the delivery of BENJAMIN 000042 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 42 of 237 13 OHINY_SG_COC_2014 10886 NY SG FP PPO AGE 26 COC 02.14 cost-effective medical care by reviewing the use of procedures and, where appropriate, the setting or place of service that they are performed. Covered Services must be Medically Necessary for benefits to be provided. 7. Care Must Be Medically Necessary. We Cover benefits described in this Certificate as long as the health care service, procedure, treatment, test, device, Prescription Drug or supply (collectively, “service”) is Medically Necessary. The fact that a Provider has furnished, prescribed, ordered, recommended, or approved the service does not make it Medically Necessary or mean that We have to Cover it. We may base Our decision on a review of: Your medical records; Our medical policies and clinical guidelines; medical opinions of a professional society, peer review committee or other groups of Physicians; reports in peer-reviewed medical literature; reports and guidelines published by nationally-recognized health care organizations that include supporting scientific data; professional standards of safety and effectiveness, which are generally-recognized in the United States for diagnosis, care, or treatment; the opinion of Health Care Professionals in the generally-recognized health specialty involved; and the opinion of the attending Providers, which have credence but do not overrule contrary opinions. Services will be deemed Medically Necessary only if: They are clinically appropriate in terms of type, frequency, extent, site, and duration, and considered effective for Your illness, injury, or disease; They are required for the direct care and treatment or management of that condition; Your condition would be adversely affected if the services were not provided; They are provided in accordance with generally-accepted standards of medical practice; They are not primarily for the convenience of You, Your family, or Your Provider; They are not more costly than an alternative service or sequence of services, that is they are at least as likely to produce equivalent therapeutic or diagnostic results; When setting or place of service is part of the review, services that can be safely provided to You in a lower cost setting will not be Medically Necessary if they are performed in a higher cost setting. For example we will not provide coverage for an inpatient admission for surgery if the surgery could have been performed on an outpatient basis. See Section IX - Grievance, Utilization Review & External Appeals of this Certificate for Your right to an internal appeal and external appeal of Our determination that a service is not Medically Necessary. 8. Important Telephone Numbers and Addresses. BENJAMIN 000043 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 43 of 237 14 OHINY_SG_COC_2014 10886 NY SG FP PPO AGE 26 COC 02.14 CLAIMS Oxford Health Insurance, Inc. P.O. Box 29130 Hot Springs, AR 71903 *Submit claim forms to this address. COMPLAINTS, GRIEVANCES AND UTILIZATION REVIEW APPEALS 1-800 444-6222 and 1-800 201-4911 (After 5:00 p.m) MEDICAL EMERGENCIES AND URGENT CARE Medical Management Coordinator 1-800 444-6222 and 1-800 201-4911 (After 5:00 p.m) CUSTOMER SERVICE 1-800 444-6222 * Customer Service Representatives are available Monday- Friday 8:00 AM to 6:00PM. PREAUTHORIZATION 1-800 444-6222 OUR WEBSITE www.oxhp.com BENJAMIN 000044 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 44 of 237 15 OHINY_SG_COC_2014 10886 NY SG FP PPO AGE 26 COC 02.14 Section III - Access To Care And Transitional Care When Your Provider Leaves the Network If You are in an ongoing course of treatment when Your Provider leaves Our Network, then You may be able to continue to receive Covered Services for the ongoing treatment from the former Participating Provider for up to ninety (90) days from the date Your Provider’s contractual obligation to provide services to You terminates. If You are pregnant and in Your second or third trimester, You may be able to continue care with a former Participating Provider through delivery and any postpartum care directly related to the delivery. In order for You to continue to receive Covered services for up to ninety (90) days or through a pregnancy with a former Participating Provider, the Provider must agree to accept as payment the negotiated fee that was in effect just prior to the termination of our relationship with the Provider. The Provider must also agree to provide Us necessary medical information related to Your care and adhere to our policies and procedures, including those for assuring quality of care, obtaining Preauthorization, Referrals, and a treatment plan approved by Us. If the Provider agrees to these conditions, You will receive the Covered services as if they were being provided by a Participating Provider. You will be responsible only for any applicable in-Network Cost- Sharing. Please note that if the Provider was terminated by Us due to fraud, imminent harm to patients or final disciplinary action by a state board or agency that impairs the Provider’s ability to practice, continued treatment with that Provider is not available. New Members In a Course of Treatment If You are in an ongoing course of treatment with a Non-Participating Provider when Your coverage under this Certificate becomes effective, You may be able to receive Covered Services for the ongoing treatment from the Non-Participating Provider for up to sixty (60) days from the effective date of Your coverage under this Certificate. This course of treatment must be for a life-threatening disease or condition or a degenerative and disabling condition or disease. You may also continue care with a Non- Participating Provider if You are in the second or third trimester of a pregnancy when Your coverage under this Certificate becomes effective. You may continue care through delivery and any post-partum services directly related to the delivery. In order for You to continue to receive Covered services for up to sixty (60) days or through pregnancy, the Non-Participating Provider must agree to accept as payment Our fees for such services. The Provider must also agree to provide Us necessary medical information related to Your care and to adhere to Our policies and procedures including those for assuring quality of care, obtaining Preauthorization, Referrals, and a treatment plan approved by Us. If the Provider agrees to these conditions, You will receive the Covered services as if they were being provided by a Participating Provider. You will be responsible only for any applicable In-Network Cost-Sharing. BENJAMIN 000045 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 45 of 237 16 OHINY_SG_COC_2014 10886 NY SG FP PPO AGE 26 COC 02.14 Section IV - Cost-Sharing Expenses And Allowed Amount 1. Deductible. Except where stated otherwise, You must pay the amount in the Schedule of Benefits in Section XV - Schedule of Benefits of this Certificate for Covered Services during each Plan Year before We provide coverage. If You have other than Individual coverage, the individual Deductible applies to each person covered under this Certificate. Once a person within a family meets the individual Deductible, no further Deductible is required for the person that has meet the individual Deductible. However, after Deductible payments for all persons covered under this Certificate total the family Deductible amount in the Schedule of Benefits in a Plan Year, no further Deductible will be required for any person covered under this Certificate for that Plan Year. Prescription Drug Deductible. Except where stated otherwise, You must pay the amount in the Schedule of Benefits in Section XV - Schedule of Benefits of this Certificate for Covered Prescription Drugs during each Plan Year before We provide coverage. 2. Copayments. Except where stated otherwise, after You have satisfied the annual Deductible as described above, You must pay the Copayments, or fixed amounts, in the Schedule of Benefits in Section XV - Schedule of Benefits of this Certificate for Covered Services. However, when the Allowed Amount for a service is less than the Copayment, You are responsible for the lesser amount. 3. Coinsurance. Except where stated otherwise, after You have satisfied the annual Deductible described above, You must pay a percentage of the Allowed Amount for Covered Services. We will pay the remaining percentage of the Allowed Amount as Your In-Network or Out-of-Network benefit as shown in the Schedule of Benefits in Section XV - Schedule of Benefits of this Certificate. You must also pay any charges of a Non-Participating Provider that are in excess of the Allowed Amount. 4. In-Network Out-of-Pocket Limit. When You have met Your In-Network Out-of- Pocket Limit in payment of In-Network Deductibles, Copayments, and Coinsurance for a Plan Year in the Schedule of Benefits in Section XV - Schedule of Benefits of this Certificate, We will provide coverage for 100% of the Allowed Amount for Covered In-Network Services for the remainder of that Plan Year. If you have other than Individual coverage, the individual In-Network Out-of-Pocket Limit applies to each person covered under this Certificate. Once a person within a family meets the individual In-Network Out-of-Pocket Limit, We will provide coverage for 100% of the Allowed Amount for the rest of that Plan Year for that person. If other than Individual coverage applies, when members of the same family covered under this Certificate have collectively met the family In-Network Out-of-Pocket Limit in payment of In-Network Deductibles, Copayments and Coinsurance for a Plan Year in the Schedule of Benefits, We will provide coverage for 100% of the Allowed Amount for the rest of that Plan Year. BENJAMIN 000046 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 46 of 237 17 OHINY_SG_COC_2014 10886 NY SG FP PPO AGE 26 COC 02.14 Cost-sharing for out-of-network services does not apply towards your In-Network Out-of-Pocket Limit. 5. Out-of-Network Out-of-Pocket Limit. This Certificate has a separate Out-of- Network Out-of-Pocket Limit in the Schedule of Benefits in Section XV - Schedule of Benefits of this Certificate for out-of-network benefits. When You have met Your Out-of-Network Out-of-Pocket Limit in payment of Out-of-Network Deductibles, Copayments, and Coinsurance for a Plan year in the Schedule of Benefits, We will provide coverage for 100% of the Allowed Amount for Covered out-of-network Services for the remainder of that Plan Year. If you have other than Individual coverage, the individual Out-of-Network Out-of-Pocket Limit applies to each person covered under this Certificate. Once a person within a family meets the individual Out-of-Network Out-of-Pocket Limit, We will provide coverage for 100% of the Allowed Amount for the rest of that Plan Year for that person. If other than Individual coverage applies, when members of the same family covered under this Certificate have collectively met the family Out-of-Network Out-of-Pocket Limit in payment of Out-of-Network Deductibles, Copayments and Coinsurance for a Plan Year in the Schedule of Benefits, We will provide coverage for 100% of the Allowed Amount for the rest of that Plan Year. Any charges of a Non- Participating Provider that are in excess of the Allowed Amount do not apply towards Your Out-of-Pocket Limit. 5. Allowed Amount. “Allowed Amount” means the maximum amount we will pay to a Provider for the services or supplies covered under this Certificate, before any applicable Deductible, Copayment, and Coinsurance amounts are subtracted. We determine our Allowed Amount as follows: The Allowed Amount for Participating Providers will be the amount we have negotiated with the Participating Provider. See Section IV Covered Services of the Certificate for the Allowed Amount for an Emergency Condition. Section V - Who Is Covered Who is Covered Under this Certificate. You, the Subscriber to whom this Certificate is issued, are covered under this Certificate. You must live, work, or reside in Our Service Area to be covered under this Contract. If You selected one of the following types of coverage, members of Your family may also be covered. Types of Coverage In addition to Individual coverage, We offer the following types of coverage: BENJAMIN 000047 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 47 of 237 18 OHINY_SG_COC_2014 10886 NY SG FP PPO AGE 26 COC 02.14 Individual and Spouse - If You selected Individual and Spouse coverage, then You and Your Spouse are covered. Parent and Child/Children - If You selected Parent and Child/Children coverage, then You and Your Child or Children, as described below, are covered. Family - If You selected Family coverage, then You and Your Spouse and Your Children, as described below, are covered. Children Covered Under This Certificate If You selected Parent and Child/Children or Family coverage, “Children” covered under this Certificate include Your natural Children, legally adopted Children, step Children, foster children and Children for whom You are the proposed adoptive parent without regard to financial dependence, residency with You, student status or employment. A proposed adopted Child is eligible for coverage on the same basis as a natural Child during any waiting period prior to the finalization of the Child’s adoption. Coverage lasts until the end of the year in which the Child turns 26 years of age. Coverage also includes Children for whom You are a legal guardian if the Children are chiefly dependent upon You for support and You have been appointed the legal guardian by a court order. Grandchildren are not Covered. Any unmarried dependent Child, regardless of age, who is incapable of self-sustaining employment by reason of mental illness, developmental disability, mental retardation (as defined in the Mental Hygiene Law), or physical handicap and who became so incapable prior to attainment of the age at which the Child’s coverage would otherwise terminate and who is chiefly dependent upon You for support and maintenance, will remain covered while Your insurance remains in force and Your Child remains in such condition. You have 31 days from the date of Your Child's attainment of the termination age to submit an application to request that the Child be included in Your coverage and proof of the Child’s incapacity. We have the right to check whether a Child is and continues to qualify under this section. We have the right to request and be furnished with such proof as may be needed to determine eligibility status of a prospective or Covered Subscriber and all other prospective or Covered Members as they pertain to eligibility for coverage under this Certificate at any time. When Coverage Begins Coverage under this Certificate will begin as follows: 1. If You, the Subscriber elect coverage before becoming eligible, or within 30 days of becoming eligible for other than a special enrollment period, coverage begins on the date You become eligible, or on the date determined by Your group. Groups cannot impose waiting periods that exceed 90 days. 2. If You, the Subscriber do not elect coverage upon becoming eligible or within 30 days of becoming eligible for other than a special enrollment period, You must wait until the group’s next open enrollment period to enroll, except as provided below. BENJAMIN 000048 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 48 of 237 19 OHINY_SG_COC_2014 10886 NY SG FP PPO AGE 26 COC 02.14 3. If You, the Subscriber, marry while covered, and We receive notice of such marriage within 30 days thereafter, coverage for Your Spouse starts on the first day of the month following such marriage. If We do not receive notice within 30 days of the marriage, You must wait until the group’s next open enrollment period to add Your Spouse. 4. If You, the Subscriber, have Family or Parent and Child/Children coverage, and have a newborn Child, and We receive notice of such birth within 30 days thereafter, coverage for Your newborn starts at the moment of birth. If You have Individual or Individual and Spouse coverage, You must notify Us of Your desire to switch to Parent and Child/Children or Family coverage and pay any additional premium within 30 days from the date of birth in order for coverage to start at the moment of birth; otherwise Parent and Child/Children or Family coverage begins on the date on which We receive notice. 5. If You, the Subscriber, have Family or Parent and Child/Children coverage, Your adopted newborn Child will be covered from the moment of birth if You notify Us within 30 days of the birth, You take physical custody of the infant as soon as the infant is released from the Hospital after birth and You file a petition pursuant to section 115-c of the New York Domestic Relations Law or other applicable state law within 30 days of the infant’s birth; and provided further that no notice of revocation to the adoption has been filed pursuant to section 115-b of the New York Domestic Relations Law, and consent to the adoption has not been revoked. If You have Individual or Individual and Spouse coverage, You must also notify Us of Your desire to switch to Parent and Child/Children or Family coverage and pay any additional premium within 30 days from the date of birth in order for coverage to start at the moment of birth. Otherwise Parent and Child/Children or Family coverage begins on the date on which We receive notice and the premium payment. However, We will not provide Hospital benefits for the newborn’s initial Hospital stay if one of the infant’s natural parents has coverage for the newborn’s initial Hospital stay. Special Enrollment Periods You, Your Spouse or Child, can also enroll for coverage within 30 days of the loss of coverage in another group health plan if coverage was terminated because You, Your Spouse or Child are no longer eligible for coverage under the group health plan due to: 1. Termination of employment. 2. Termination of the other group health plan. 3. Death of the Spouse. 4. Legal separation, divorce or annulment. 5. Reduction of hours of employment. 6. Employer contributions towards the group health plan were terminated; or BENJAMIN 000049 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 49 of 237 20 OHINY_SG_COC_2014 10886 NY SG FP PPO AGE 26 COC 02.14 7. A Child no longer qualifies for coverage as a Child under the other group health plan. You, Your Spouse or Child can also enroll 30 days from exhaustion of Your COBRA or continuation coverage. We must receive notice and premium payment within 30 days of the loss of coverage. The effective date of Your coverage will depend on when We receive Your application. If Your application is received between the first and fifteenth day of the month, Your coverage will begin on the first day of the following month. If Your application is received between the sixteenth day and the last day of the month, Your coverage will begin on the first day of the second month. In addition, You, Your Spouse or Child, can also enroll for coverage within 60 days of the occurrence of one of the following events: 1. You or Your Spouse or Your Child loses eligibility for Medicaid or a state child health plan. 2. You or Your Spouse or Your Child becomes eligible for Medicaid or a state child health plan. We must receive notice and premium payment within 60 days of one of these events. The effective date of Your coverage will depend on when We receive Your application. If Your application is received between the first and fifteenth day of the month, Your coverage will begin on the first day of the following month. If Your application is received between the sixteenth day and the last day of the month, Your coverage will begin on the first day of the second month. BENJAMIN 000050 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 50 of 237 21 OHINY_SG_COC_2014 10886 NY SG FP PPO AGE 26 COC 02.14 Section VI - Covered Services Preventive Care Please refer to the Schedule of Benefits for Cost-Sharing requirements, day or visit limits, and any Preauthorization or Referral requirements that apply to these benefits. Preventive Care. We Cover the following services for the purpose of promoting good health and early detection of disease. Preventive services are not subject to Cost- Sharing (Copayments, Deductibles, and Coinsurance) when performed by a Participating Provider and provided in accordance with the comprehensive guidelines supported by the Health Resources and Services Administration (“HRSA”), or if the items or services have an “A” or “B” rating from the United States Preventive Services Task Force (“USPSTF”), or if the immunizations are recommended by the Advisory Committee on Immunization Practices (“ACIP”). However, Cost-Sharing may apply to services provided during the same visit as the preventive services. Also, if a preventive service is provided during an office visit wherein the preventive service is not the primary purpose of the visit, the Cost-Sharing amount that would otherwise apply to the office visit will still apply. You may contact Us at the Customer Service number on your ID card or visit Our website at www.oxhp.com for a copy of the comprehensive guidelines supported by HRSA, items or services with an “A” or “B” rating from USPSTF, and immunizations recommended by ACIP. A. Well-Baby and Well-Child Care We Cover well-baby and well-child care which consist of routine physical examinations including vision screenings and hearing screenings, developmental assessment, anticipatory guidance, and laboratory tests ordered at the time of the visit as recommended by the American Academy of Pediatrics. We also Cover preventive care and screenings as provided for in the comprehensive guidelines supported by HRSA and items or services with an “A” or “B” rating from USPSTF. If the schedule of well- child visits referenced above permits one well-child visit per calendar year, We will not deny a well-child visit if 365 days have not passed since the previous well-child visit. Immunizations and boosters as required by ACIP are also Covered. This benefit is provided to Members from birth through attainment of age 19 and is not subject to Copayments, Deductibles or Coinsurance when provided by a Participating Provider. B. Adult Annual Physical Examinations We Cover adult annual physical examinations and preventive care and screenings as provided for in the comprehensive guidelines supported by HRSA and items or services with an “A” or “B” rating from USPSTF. Examples of items or services with an “A” or “B” rating from USPSTF include, but are not limited to, blood pressure screening for adults, cholesterol screening, colorectal cancer screening and diabetes screening. A complete list of the Covered preventive services is available on Our website at www.oxhp.com, or will be mailed to You upon request. BENJAMIN 000051 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 51 of 237 22 OHINY_SG_COC_2014 10886 NY SG FP PPO AGE 26 COC 02.14 You are eligible for a physical examination once every Plan Year, regardless of whether or not 365 days have passed since the previous physical examination visit. Vision screenings do not include refractions. This benefit is not subject to Copayments, Deductibles or Coinsurance when provided in accordance with the comprehensive guidelines supported by HRSA and items or services with an “A” or “B” rating from USPSTF and when provided by a Participating Provider. C. Adult Immunizations We Cover adult immunizations as recommended by ACIP. This benefit is not subject to Copayments, Deductibles or Coinsurance when provided in accordance with the recommendations of ACIP and when provided by a Participating Provider. D. Well-Woman Examinations We Cover well-woman examinations which consist of a routine gynecological examination, breast examination and annual Pap smear, including laboratory and diagnostic services in connection with evaluating the Pap smear. We also Cover preventive care and screenings as provided for in the comprehensive guidelines supported by HRSA and items or services with an “A” or “B” rating from USPSTF. A complete list of the Covered preventive services is available on Our website at www.oxhp.com, or will be mailed to You upon request. This benefit is not subject to Copayments, Deductibles or Coinsurance when provided in accordance with the comprehensive guidelines supported by HRSA and items or services with an “A” or “B” rating from USPSTF and when provided by a Participating Provider. E. Mammograms We Cover mammograms for the screening of breast cancer as follows: one baseline screening mammogram for women age 35 through 39; one baseline screening mammogram annually for women age 40 and over. If a woman of any age has a history of breast cancer or her first degree relative has a history of breast cancer, We Cover mammograms as recommended by her Provider. However, in no event will more than one preventive screening, per Plan Year, be Covered. Mammograms for the screening of breast cancer are not subject to Copayments, Deductibles or Coinsurance when provided in accordance with the comprehensive guidelines supported by HRSA and items or services with an “A” or “B” rating from USPSTF, which may be less frequent than the above schedule, and when provided by a Participating Provider. Diagnostic mammograms (mammograms that are performed in connection with the treatment or follow-up of breast cancer) are unlimited and are Covered whenever they are Medically Necessary. However, diagnostic mammograms may be subject to Copayments, Deductibles or Coinsurance. BENJAMIN 000052 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 52 of 237 23 OHINY_SG_COC_2014 10886 NY SG FP PPO AGE 26 COC 02.14 F. Family Planning & Reproductive Health Services We Cover family planning services which consist of FDA-approved contraceptive methods prescribed by a Provider, not otherwise Covered under the Prescription Drug benefit in Section IV - Covered Services of the Certificate, counseling on use of contraceptives, related topics and sterilization procedures for women. Such services are not subject to Copayments, Deductibles or Coinsurance when provided in accordance with the comprehensive guidelines supported by HRSA and items or services with an “A” or “B” rating from USPSTF and when provided by a Participating Provider. We also Cover vasectomies subject to Copayments, Deductibles or Coinsurance. We do not Cover services related to the reversal of elective sterilizations. G. Bone Mineral Density Measurements or Testing We Cover bone mineral density measurements or tests, and Prescription Drugs and devices approved by the FDA or generic equivalents as approved substitutes. Coverage of Prescription Drugs is subject to Section VI - Covered Services of the Certificate. Bone mineral density measurements or tests, drugs or devices shall include those covered for individuals meeting the criteria under the federal Medicare program and those in accordance with the criteria of the National Institutes of Health. You will also qualify for coverage of bone mineral density measurements and testing if You meet any of the following: Previously diagnosed as having osteoporosis or having a family history of osteoporosis; or With symptoms or conditions indicative of the presence or significant risk of osteoporosis; or On a prescribed drug regimen posing a significant risk of osteoporosis; or With lifestyle factors to a degree as posing a significant risk of osteoporosis; or, With such age, gender, and/or other physiological characteristics which pose a significant risk for osteoporosis. We also Cover bone mineral density measurements or tests, and Prescription Drugs and devices as provided for in the comprehensive guidelines supported by HRSA”) and items or services with an “A” or “B” rating from USPSTF. This benefit is not subject to Copayments, Deductibles or Coinsurance when provided in accordance with the comprehensive guidelines supported by HRSA and items or services with an “A” or “B” rating from USPSTF, which may not include all of the above services such as drugs and devices and when provided by a Participating Provider. H. Screening for Prostate Cancer We Cover an annual standard diagnostic examination including, but not limited to, a digital rectal examination and a prostate specific antigen test for men age 50 and over BENJAMIN 000053 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 53 of 237 24 OHINY_SG_COC_2014 10886 NY SG FP PPO AGE 26 COC 02.14 who are asymptomatic and for men age 40 and over with a family history of prostate cancer or other prostate cancer risk factors. We also Cover standard diagnostic testing including, but not limited to, a digital rectal examination and a prostate-specific antigen test, at any age for men having a prior history of prostate cancer. This benefit is not subject to Copayments, Deductibles or Coinsurance when provided by a Participating Provider. Pre-Hospital Emergency Medical Services and Ambulance Services Please refer to the Schedule of Benefits for Cost-Sharing requirements, day or visit limits, and any Preauthorization or Referral requirements that apply to these benefits. We Cover Pre-Hospital Emergency Medical Services for the treatment of an Emergency Condition when such services are provided by an ambulance service. We also Cover emergency ambulance transportation by a licensed ambulance service (either ground, water or air ambulance) to the nearest Hospital where Emergency Services can be performed. “Pre-Hospital Emergency Medical Services” means the prompt evaluation and treatment of an Emergency Condition and/or transportation to a Hospital. The services must be provided by an ambulance service issued a certificate under the N.Y. Public Health Law. We will, however, only Cover transportation to a Hospital provided by such an ambulance service when a prudent layperson, possessing an average knowledge of medicine and health, could reasonably expect the absence of such transportation to result in: Placing the health of the person afflicted with such condition or, with respect to a pregnant woman, the health of the woman or her unborn child in serious jeopardy, or in the case of a behavioral condition, placing the health of such person or others in serious jeopardy; Serious impairment to such person’s bodily functions; Serious dysfunction of any bodily organ or part of such person; or Serious disfigurement of such person. An ambulance service may not charge or seek reimbursement from You for Pre- Hospital Emergency Medical Services relating to non-airborne transportation to a Hospital except for the collection of any applicable Copayment, Coinsurance, or Deductible. Pre-Hospital Emergency Medical Services and ambulance services for the treatment of an Emergency Condition do not require Preauthorization. Non-Emergency Ambulance Transportation: BENJAMIN 000054 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 54 of 237 25 OHINY_SG_COC_2014 10886 NY SG FP PPO AGE 26 COC 02.14 We Cover non-emergency ambulance transportation by a licensed ambulance service (either ground or air ambulance, as appropriate) between Facilities when the transport is any of the following: From a Non-Participating Hospital to a Participating Hospital. To a Hospital that provides a higher level of care that was not available at the original Hospital. To a more cost-effective acute care Facility. From an acute Facility to a sub-acute setting. See the schedule of benefits in Section XV - Schedule of Benefits of this Certificate for any Preauthorization requirements for non-emergency transportation. Limitations/Terms of Coverage: Benefits do not include travel or transportation expenses unless connected to an Emergency Condition or due to a Facility transfer approved by Us, even though prescribed by a Physician. Non-ambulance transportation such as ambulette, van or taxi cab is not Covered. Coverage for air ambulance related to an Emergency Condition or air ambulance related to non-emergency transportation is provided when Your medical condition is such that transportation by land ambulance is not appropriate; and Your medical condition requires immediate and rapid ambulance transportation that cannot be provided by land ambulance; and one of the following is met: The point of pick-up is inaccessible by land vehicle; or Great distances or other obstacles (for example, heavy traffic) prevent Your timely transfer to the nearest Hospital with appropriate facilities. Emergency Services Please refer to the Schedule of Benefits for Cost-Sharing requirements, day or visit limits, and any Preauthorization or Referral requirements that apply to these benefits. We Cover Emergency Services for the treatment of an Emergency Condition. We define an Emergency Condition to mean: A medical or behavioral condition that manifests itself by Acute symptoms of sufficient severity, including severe pain, such that a prudent layperson, possessing an average knowledge of medicine and health, could reasonably expect the absence of immediate medical attention to result in: Placing the health of the person afflicted with such condition or, with respect to a pregnant woman, the health of the woman or her unborn child in serious jeopardy, or in the case of a behavioral condition, placing the health of such person or others in serious jeopardy; Serious impairment to such person’s bodily functions; Serious dysfunction of any bodily organ or part of such person; or BENJAMIN 000055 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 55 of 237 26 OHINY_SG_COC_2014 10886 NY SG FP PPO AGE 26 COC 02.14 Serious disfigurement of such person. For example, an Emergency Condition may include, but is not limited to, the following conditions: Severe chest pain; Severe or multiple injuries; Severe shortness of breath; Sudden change in mental status (e.g., disorientation); Severe bleeding; Acute pain or conditions requiring immediate attention such as suspected heart attack or appendicitis; Poisonings; or Convulsions. Coverage of Emergency Services for treatment of Your Emergency Condition will be provided regardless of whether the Provider is a Participating Provider. We will also Cover Emergency Services to treat Your Emergency Condition worldwide. However, We will Cover only those Emergency Services and supplies that are Medically Necessary and are performed to treat or stabilize Your Emergency Condition. We define Emergency Services to mean: Evaluation of an Emergency Condition and treatment to keep the condition from getting worse including: A medical screening examination which is within the capability of the emergency department of a Hospital, including ancillary services routinely available to the emergency department to evaluate such Emergency Condition; and Within the capabilities of the staff and Facilities available at the Hospital, such further medical examination and treatment as are required to stabilize the patient. “To stabilize” is to provide such medical treatment of an Emergency Condition as may be necessary to assure, within reasonable medical probability, that no material deterioration of the condition is likely to result from or occur during the transfer of the patient from a Facility, or to deliver a newborn child (including the placenta). Please follow the instructions listed below regardless of whether or not You are in Our Service Area at the time Your Emergency Condition occurs. A. Hospital Emergency Department Visits In the event that You require treatment for an Emergency Condition, seek immediate care at the nearest Hospital emergency department or call 911. Emergency Department Care does not require Preauthorization. However, only Emergency Services for the treatment of an Emergency Condition, as defined above, are Covered in an emergency department. If You are uncertain whether this is the most appropriate place to receive care You can call Us before You seek treatment. Our Medical BENJAMIN 000056 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 56 of 237 27 OHINY_SG_COC_2014 10886 NY SG FP PPO AGE 26 COC 02.14 Management Coordinators are available 24 hours a day, 7 days a week. Your Coordinator will direct You to the emergency department of a Hospital or other appropriate Facility. Follow-up care or routine care provided in a Hospital emergency department is not Covered. You should contact Us to make sure You receive the appropriate follow-up care. B. Emergency Hospital Admissions In the event You are admitted to the Hospital: You or someone on Your behalf must notify Us at the telephone number listed on Your ID card within 48 hours of Your admission, or as soon as is reasonably possible. We Cover inpatient Hospital services at a Non-Participating Hospital at the In-Network Cost-Sharing for as long as Your medical condition prevents Your transfer to a Participating Hospital. Any inpatient Hospital services received from a Non-Participating Hospital after Your medical condition no longer prevents Your transfer to a Participating Hospital will be Covered at the Out-of-Network Cost-Sharing, unless We authorize continued treatment at the Non-Participating Hospital. We Cover inpatient Hospital services at a Non-Participating Hospital for as long as Your medical condition prevents Your transfer to a Participating Hospital. If Your medical condition permits Your transfer to a Participating Hospital We will notify You and arrange the transfer. Any inpatient Hospital services received from a Non-Participating Hospital after we have notified You and arranged for a transfer to a Participating Hospital will not be Covered. See Section IX - Grievance, Utilization Review & External Appeals of the Certificate for Your Appeal rights. C. Payments Relating to Emergency Services Rendered The amount We pay a Non-Participating Provider for Emergency Services will be the greater of: (1) the amount We have negotiated with Participating Providers for the Emergency Service received (and if more than one amount is negotiated, the median of the amounts); (2) 100% of the Allowed Amount for Services provided by a Non- Participating Provider (i.e., the amount We would pay in the absence of any Cost- Sharing that would otherwise apply for services of Non-Participating Providers); or (3) the amount that would be paid under Medicare. The amounts described above exclude any Copayment or Coinsurance that applies to Emergency Services provided by a Participating Provider. You are responsible for any Deductible, Coinsurance or Copayment. Urgent Care Urgent Care is medical care for an illness, injury or condition serious enough that a reasonable person would seek care right away, but not so severe as to require Emergency Department Care. Urgent Care is Covered in or out of Our Service Area. BENJAMIN 000057 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 57 of 237 28 OHINY_SG_COC_2014 10886 NY SG FP PPO AGE 26 COC 02.14 A. In-Network You may obtain Urgent Care from a Participating Physician or a Participating Urgent Care Center. You do not need to contact Us prior to, or after Your visit. B. Out-of-Network You may obtain Urgent Care from a Non-Participating Urgent Care Center or Physician. If Urgent Care results in an Emergency admission please follow the instructions for Emergency Hospital admissions described above. Outpatient and Professional Services (For other than Mental Health and Substance Use ) Please refer to the Schedule of Benefits for Cost-Sharing requirements, day or visit limits, and any Preauthorization or Referral requirements that apply to these benefits. Advanced Imaging Services: We Cover PET scans, MRI, nuclear medicine, and CAT scans. Allergy Testing and Treatment: We Cover testing and evaluations including injections, and scratch and prick tests to determine the existence of an allergy. We also Cover allergy treatment, including desensitization treatments, routine allergy injections and serums. Ambulatory Surgery Center: We Cover surgical procedures performed at Ambulatory Surgical Centers including services and supplies provided by the Center the day the surgery is performed. Chemotherapy: We Cover Chemotherapy in an outpatient Facility or in a Health Care Professional’s office. Orally-administered anti-cancer drugs are Covered under the Prescription Drug section of this Certificate. Chiropractic Services: We Cover chiropractic care when performed by a Doctor of Chiropractic (“Chiropractor”) in connection with the detection or correction by manual or mechanical means of structural imbalance, distortion or subluxation in the human body for the purpose of removing nerve interference and the effects thereof, where such interference is the result of or related to distortion, misalignment or subluxation of the vertebral column. This includes assessment, manipulation and any modalities. Any Medically Necessary laboratory tests will be Covered in accordance with the terms and conditions of this Certificate. Dialysis: We Cover dialysis treatments of an acute or chronic kidney ailment. Habilitation Services: We Cover Habilitation Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care Professional’s office for up to 60 visits per condition per year. Home Health Care: We Cover care provided in Your home by a Home Health Agency certified or licensed by the appropriate state agency. The care must be provided pursuant to Your Physician's written treatment plan and must be in lieu of BENJAMIN 000058 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 58 of 237 29 OHINY_SG_COC_2014 10886 NY SG FP PPO AGE 26 COC 02.14 Hospitalization or confinement in a Skilled Nursing Facility. Home care includes (i) part- time or intermittent nursing care by or under the supervision of a Registered Professional Nurse (RN), (ii) part-time or intermittent services of a home health aide, (iii) physical, occupational, or speech therapy provided by the Home Health Agency, and (iv) medical supplies, drugs, and medications prescribed by a Physician, and laboratory services by or on behalf of the Home Health Agency to the extent such items would have been Covered during a Hospitalization or confinement in a Skilled Nursing Facility. Home Health Care is limited to 40 visits per Calendar year. Each visit by a member of the Home Health Agency is considered one visit. Each visit of up to four hours by a home health aide is one visit. Please note: Any rehabilitation services received under this benefit will not reduce the amount of services available under “Rehabilitation and Habilitation Services”. Interruption of Pregnancy: We Cover therapeutic abortions. We also Cover non- therapeutic abortions in cases of rape, incest or fetal malformation. We Cover elective abortions for one procedure per Member, per Calendar Year. Infertility Treatment: We Cover services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Such Coverage is available as follows: Basic Infertility Services. Basic Infertility Services will be provided to a Member who is an appropriate candidate for infertility treatment. In order to determine eligibility, We will use guidelines established by the American College of Obstetricians and Gynecologists, the American Society for Reproductive Medicine, and the State of New York. However, Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services. Basic Infertility Services consist of: initial evaluation, semen analysis, laboratory evaluation, evaluation of ovulatory function, postcoital test, endometrial biopsy, pelvic ultra sound, hysterosalpingogram, sono-hystogram, testis biopsy, blood tests and medically appropriate treatment of ovulatory dysfunction. Additional tests may be Covered if the tests are determined to be Medically Necessary. Comprehensive Infertility Services. If the Basic Services do not result in increased fertility, We Cover Comprehensive Infertility Services. These services include: ovulation induction and monitoring; pelvic ultra sound; artificial insemination; hysteroscopy; laparoscopy; and laparotomy. Exclusions and Limitations a. In vitro, GIFT and ZIFT procedures. b. Cost for an ovum donor or donor sperm. c. Sperm storage costs. d. Cryopreservation and storage of embryos. e. Ovulation predictor kits. f. Reversal of tubal ligations. Reversal of vasectomies. BENJAMIN 000059 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 59 of 237 30 OHINY_SG_COC_2014 10886 NY SG FP PPO AGE 26 COC 02.14 g. All costs for and relating to surrogate motherhood (maternity services are Covered for Members acting as surrogate mothers). h. Sex change procedures. i. Cloning. j. Medical and surgical procedures that are experimental or investigational unless Our denial is overturned by an External Appeal Agent. k. All services must be provided by Providers who are qualified to provide such services in accordance with the guidelines established and adopted by the American Society for Reproductive Medicine. Infusion Therapy. We Cover infusion therapy which is the administration of drugs using specialized delivery systems which otherwise would have required You to be hospitalized. Drugs or nutrients administered directly into the veins are considered infusion therapy. Drugs taken by mouth or self-injected into the muscles are not considered infusion therapy. The services must be ordered by a Physician or other authorized Health Care Professional and provided in an office or by an agency licensed or certified to provide infusion therapy. Any visits for home infusion therapy count towards Your home health care visit limit. Laboratory Procedures, Diagnostic Testing and Radiology Services: We Cover x- ray, laboratory procedures and diagnostic testing, services and materials, including diagnostic X-rays, X-ray therapy, fluoroscopy, electrocardiograms, electroencephalograms, laboratory tests, and therapeutic radiology services. Maternity and Newborn Care: We Cover services for maternity care provided by a Physician or nurse midwife, nurse practitioner, Hospital or birthing center. We Cover prenatal care (including one visit for genetic testing), postnatal care, delivery, and complications of pregnancy. In order for services of a nurse midwife to be Covered, the nurse midwife must be licensed pursuant to Article 140 of the Education Law, practicing consistent with Section 6951 of the Education Law and affiliated or practicing in conjunction with a Facility licensed pursuant to Article 28 of the Public Health Law. We will not pay for duplicative routine services provided by both a nurse midwife and a Physician. See the Inpatient Services section of Section VI - Covered Services of the Certificate for coverage of inpatient maternity care. We Cover the cost of renting or the purchase of one breast pump per pregnancy for the duration of breast feeding. Medications for Use in the Office: We Cover medications and injectables (excluding self-injectables used by Your Provider in the Provider's office for preventive and therapeutic purposes. Office Visits: We Cover office visits for the diagnosis and treatment of injury, disease and medical conditions. Office visits may include house calls. Outpatient Hospital Services: We Cover Hospital services and supplies as described in the Inpatient Hospital section that can be provided to You while being treated in an outpatient Facility. For example, Covered Services include but are not limited to BENJAMIN 000060 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 60 of 237 31 OHINY_SG_COC_2014 10886 NY SG FP PPO AGE 26 COC 02.14 inhalation therapy, pulmonary rehabilitation, infusion therapy and cardiac rehabilitation. Please remember, unless You are receiving preadmission testing, Hospitals are not Participating Providers for outpatient laboratory procedures and tests. Preadmission Testing: We Cover preadmission testing ordered by Your Physician and performed in Hospital outpatient facilities prior to a scheduled surgery in the same Hospital provided that: the tests are necessary for and consistent with the diagnosis and treatment of the condition for which the surgery is to be performed; reservations for a Hospital bed and operating room were made prior to the performance of the tests; surgery takes place within seven days of the tests; and the patient is physically present at the Hospital for the tests. Rehabilitation Services: We Cover Rehabilitation Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care Professional’s office for up to 60 visits per condition per year. The visit limit applies to all therapies combined. For the purposes of this benefit, "per condition" means the disease or injury causing the need for the therapy. We Cover speech and physical therapy only when: Such therapy is related to the treatment or diagnosis of Your physical illness or injury (in the case of a covered Child, this includes a medically diagnosed congenital defect); It is ordered by a Physician; and You have been Hospitalized or have undergone surgery for such illness or injury. Covered speech, physical and occupational therapy services must begin within six months of the later to occur: The date of the injury or illness that caused the need for the therapy; The date You are discharged from a Hospital where surgical treatment was rendered; or The date outpatient surgical care is rendered. In no event will the therapy continue beyond 365 days after such event. Second Opinions: Second Cancer Opinion. We Cover a second medical opinion by an appropriate Specialist, including but not limited to a Specialist affiliated with a specialty care center, in the event of a positive or negative diagnosis of cancer or a recurrence of cancer or a recommendation of a course of treatment for cancer. You may obtain a second opinion from a Non-participating Provider on an In-Network basis when Your attending Physician provides a written Referral to a Non-Participating Specialist. Second Surgical Opinion. We Cover a second surgical opinion by a qualified Physician on the need for surgery. BENJAMIN 000061 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 61 of 237 32 OHINY_SG_COC_2014 10886 NY SG FP PPO AGE 26 COC 02.14 Required Second Surgical Opinion. We may require a second opinion before We Preauthorize a surgical procedure. There is no cost to You when We request a second opinion. a. The second opinion must be given by a board certified Specialist who personally examines You. b. If the first and second opinions do not agree You may obtain a third opinion. c. The second and third surgical opinion consultants may not perform the surgery on You. Second Opinions in other Cases. There may be other instances when You will disagree with a Provider's recommended course of treatment. In such cases, You may request that we designate another Provider to render a second opinion. If the first and second opinions do not agree, We will designate another Provider to render a third opinion. After completion of the second opinion process, We will Preauthorize Covered Services supported by a majority of the Providers reviewing Your case. Surgical Services: We Cover Physicians' services for surgical procedures, including operating and cutting procedures for the treatment of a sickness or injury, and closed reduction of fractures and dislocations of bones, endoscopies, incisions, or punctures of the skin on an inpatient and outpatient basis, including the services of the surgeon or Specialist, assistant (including a Physician’s assistant or a nurse practitioner), and anesthetist or anesthesiologist, together with preoperative and post-operative care. Benefits are not available for anesthesia services provided as part of a surgical procedure, when rendered by the surgeon or the surgeon’s assistant. Sometimes two or more surgical procedures can be performed during the same operation. If Covered multiple surgical procedures are performed during the same operative session through the same or different incisions, We will pay: For the procedure with the highest Allowed Amount; and 50% of the amount We would otherwise pay for the other procedures. Oral Surgery: We Cover the following limited dental and oral surgical procedures: Oral surgical procedures for jaw bones or surrounding tissue and dental services for the repair or replacement of sound natural teeth that are required due to accidental injury. Replacement is Covered only when repair is not possible. Dental services must be obtained within 12 months of the injury. Oral surgical procedures for jaw bones or surrounding tissue and dental services necessary due to congenital disease or anomaly. Oral surgical procedures required for the correction of a non-dental physiological condition which has resulted in a severe functional impairment. BENJAMIN 000062 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 62 of 237 33 OHINY_SG_COC_2014 10886 NY SG FP PPO AGE 26 COC 02.14 Removal of tumors and cysts requiring pathological examination of the jaws, cheeks, lips, tongue, roof and floor of the mouth. Cysts related to teeth are not Covered. Surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery. Reconstructive Breast Surgery: We Cover breast reconstruction surgery after a mastectomy or partial mastectomy. Coverage includes: all stages of reconstruction of the breast on which the mastectomy or partial mastectomy has been performed; surgery and reconstruction of the other breast to produce a symmetrical appearance; and physical complications of the mastectomy or partial mastectomy, including lymphedemas, in a manner determined by You and Your attending Physician to be appropriate. Implanted breast prostheses following a mastectomy or partial mastectomy are also Covered. Other Reconstructive and Corrective Surgery: We Cover reconstructive and corrective surgery other than reconstructive breast surgery only when: It is performed to correct a congenital birth defect of a covered Child which has resulted in a functional defect; or It is incidental to surgery or follows surgery that was necessitated by trauma, infection or disease of the involved part; or It is otherwise Medically Necessary. Transplants: We Cover only those transplants determined to be nonexperimental and non-investigational. Covered transplants include but are not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome. All transplants must be prescribed by Your Specialist(s). Additionally, all transplants must be performed at Hospitals that We have specifically approved and designated to perform these procedures. We Cover the Hospital and medical expenses, including donor search fees, of the Member-recipient. We Cover transplant services required by You when You serve as an organ donor only if the recipient is a Member. The medical expenses of a non- Member acting as a donor for You are not Covered if the non-Member's expenses will be Covered under another health plan or program. We do not Cover travel expenses, lodging, meals, or other accommodations for donors or guests. We do not Cover donor fees in connection with organ transplant surgery. We do not Cover routine harvesting and storage of stem cells from newborn cord blood. Additional Benefits, Equipment and Devices Please refer to the Schedule of Benefits for Cost-Sharing requirements, day or visit limits, and any Preauthorization or Referral requirements that apply to these benefits. BENJAMIN 000063 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 63 of 237 34 OHINY_SG_COC_2014 10886 NY SG FP PPO AGE 26 COC 02.14 Autism Spectrum Disorder: We Cover the following services when such services are prescribed or ordered by a licensed Physician or a licensed psychologist and are determined by Us to be Medically Necessary for the screening, diagnosis, and treatment of autism spectrum disorder. For purposes of this benefit, “autism spectrum disorder” means any pervasive developmental disorder defined in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders at the time services are rendered, including autistic disorder; Asperger’s disorder; Rett’s disorder; childhood disintegrative disorder; and pervasive developmental disorder not otherwise specified (PDD-NOS). Screening and Diagnosis. We Cover assessments, evaluations, and tests to determine whether someone has autism spectrum disorder. Assistive Communication Devices. We Cover a formal evaluation by a speech- language pathologist to determine the need for an assistive communication device. Based on the formal evaluation, We Cover the rental or purchase of assistive communication devices when ordered or prescribed by a licensed Physician or a licensed psychologist if You are unable to communicate through normal means (i.e., speech or writing) when the evaluation indicates that an assistive communication device is likely to provide You with improved communication. Examples of assistive communication devices include communication boards and speech-generating devices. Coverage is limited to dedicated devices; We will only Cover devices that generally are not useful to a person in the absence of a communication impairment. We will not Cover items, such as, but not limited to, laptops, desktop, or tablet computers. We Cover software and/or applications that enable a laptop, desktop, or tablet computer to function as a speech-generating device. Installation of the program and/or technical support is not separately reimbursable. We will determine whether the device should be purchased or rented. Repair, replacement fitting and adjustments of such devices are Covered when made necessary by normal wear and tear or significant change in Your physical condition. Repair and replacement made necessary because of loss or damage caused by misuse, mistreatment, or theft are not Covered; however, We will Cover one replacement or repair per device type that is necessary due to behavioral issues. Coverage will be provided for the device most appropriate to Your current functional level. We will not provide Coverage for delivery or service charges or for routine maintenance. Behavioral Health Treatment. We Cover counseling and treatment programs that are necessary to develop, maintain, or restore, to the maximum extent practicable, the functioning of an individual. We will provide such Coverage when provided by a licensed Provider. We Cover applied behavior analysis when provided by an applied behavior analysis Provider as defined and described in 11 NYCRR 440, a regulation promulgated by the New York State Department of Financial Services. “Applied behavior analysis” means the design, implementation, and evaluation of environmental modifications, using behavioral stimuli and consequences, to produce socially significant improvement in human behavior, including the use of BENJAMIN 000064 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 64 of 237 35 OHINY_SG_COC_2014 10886 NY SG FP PPO AGE 26 COC 02.14 direct observation, measurement, and functional analysis of the relationship between environment and behavior. The treatment program must describe measurable goals that address the condition and functional impairments for which the intervention is to be applied and include goals from an initial assessment and subsequent interim assessments over the duration of the intervention in objective and measurable terms. Our Coverage of applied behavior analysis services is limited to 680 hours per Member per Calendar Year. Psychiatric and Psychological Care. We Cover direct or consultative services provided by a psychiatrist, psychologist, or a licensed clinical social worker with the experience required by the Insurance Law, licensed in the state in which they are practicing. Therapeutic Care. We Cover therapeutic services necessary to develop, maintain, or restore, to the greatest extent practicable, functioning of the individual when such services are provided by licensed or certified speech therapists, occupational therapists, physical therapists, and social workers to treat autism spectrum disorder and when the services provided by such Providers are otherwise Covered under this Certificate. Except as otherwise prohibited by law, services provided under this paragraph shall be included in any visit maximums applicable to services of such therapists or social workers under this Certificate. Pharmacy Care. We Cover Prescription Drugs to treat autism spectrum disorder that are prescribed by a provider legally authorized to prescribe under Title 8 of the Education Law. Coverage of such Prescription Drugs is subject to all the terms, provisions, and limitations that apply to Prescription Drug Benefits under this Certificate. We will not Cover any services or treatment set forth above when such services or treatment are provided pursuant to an individualized education plan under the Education Law. The provision of services pursuant to an individualized family service plan under Section 2545 of the Public Health Law, an individualized education plan under Article 89 of the Education Law, or an individualized service plan pursuant to regulations of the Office for Persons With Developmental Disabilities shall not affect coverage under the Certificate for services provided on a supplemental basis outside of an educational setting if such services are prescribed by a licensed Physician or licensed psychologist. You are responsible for any applicable Deductible, Copayment, or Coinsurance provisions under this Certificate for similar services. For example, any Deductible, Copayment, or Coinsurance that applies to physical therapy visits generally will also apply to physical therapy services Covered under this benefit; and any Deductible, Copayment, or Coinsurance for Prescription Drugs generally will also apply to Prescription Drugs Covered under this benefit. Any Deductible, Copayment, or Coinsurance that applies to office visits will apply to assistive communication devices Covered under this paragraph. BENJAMIN 000065 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 65 of 237 36 OHINY_SG_COC_2014 10886 NY SG FP PPO AGE 26 COC 02.14 Nothing in this Certificate shall be construed to affect any obligation to provide coverage for otherwise-covered services solely on the basis that the services constitute early intervention program services pursuant to Section 3235-a of the Insurance Law or an individualized service plan pursuant to regulations of the Office for Persons with Developmental Disabilities. Diabetic Equipment, Supplies and Self-Management Education: We Cover diabetic equipment, supplies, and self-management education if recommended or prescribed by a Physician or other licensed Health Care Professional legally authorized to prescribe under Title 8 of the Education Law as described below: Supplies We Cover the following equipment and related supplies for the treatment of diabetes when prescribed by Your Physician or other provider legally authorized to prescribe: Acetone Reagent Strips Acetone Reagent Tablets Alcohol or Peroxide by the pint Alcohol Wipes All insulin preparations Automatic Blood Lance Kit Blood Glucose Kit Blood Glucose Strips (Test or Reagent) Blood Glucose Monitor with or without special features for visually impaired, control solutions, and strips for home blood glucose monitor Cartridges for the visually impaired Diabetes data management systems Disposable insulin and pen cartridges Drawing-up devices for the visually impaired Equipment for use of the Pump Glucose Acetone Reagent Strips Glucose Reagent Strips Glucose Reagent Tape Injection aides Injector (Busher) Automatic Insulin Insulin Cartridge Delivery BENJAMIN 000066 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 66 of 237 37 OHINY_SG_COC_2014 10886 NY SG FP PPO AGE 26 COC 02.14 Insulin infusion devices Insulin Pump Lancets Oral agents such as glucose tablets and gels Glucagon for injection to increase blood glucose concentration Oral anti-diabetic agents used to reduce blood sugar levels Syringe with needle; sterile 1 cc box Urine testing products for glucose and ketones Additional supplies, as the New York State Commissioner of Health shall designate by regulation as appropriate for the treatment of diabetes. Self-Management Education Diabetes self-management education is education designed to educate persons with diabetes as to the proper self-management and treatment of their diabetic condition including information on proper diets. We Cover education on self- management and nutrition when: diabetes is initially diagnosed; a Physician diagnoses a significant change in Your symptoms or condition which necessitates a change in your self-management education; or when a refresher course is necessary. It must be provided in accordance with the following: By a Physician, other health care provider authorized to prescribe under Title 8 of the Education Law, or their staff during an office visit; Upon the referral of Your Physician or other health care provider authorized to prescribe under Title 8 of the Education Law to the following non- Physician, medical educators: certified diabetes nurse educators; certified nutritionists; certified dietitians; and registered dietitians in a group setting when practicable; and Education will also be provided in Your home when Medically Necessary. Limitations The items will only be provided in amounts that are in accordance with the treatment plan developed by the Physician for You. We Cover only basic models of blood glucose monitors unless You have special needs relating to poor vision or blindness. Durable Medical Equipment and Braces: We Cover the rental or purchase of durable medical equipment and braces. Durable Medical Equipment Durable Medical Equipment is equipment which is: designed and intended for repeated use; primarily and customarily used to serve a medical purpose; BENJAMIN 000067 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 67 of 237 38 OHINY_SG_COC_2014 10886 NY SG FP PPO AGE 26 COC 02.14 generally not useful to a person in the absence of disease or injury; and is appropriate for use in the home. Coverage is for standard equipment only. Repairs or replacement are covered when made necessary by normal wear and tear. We do not Cover the cost of repairs or replacement that are the result of misuse or abuse by You. We will determine whether to rent or purchase such equipment. Customized or motorized equipment, or equipment designed for Your comfort or convenience (such as pools, hot tubs, air conditioners, saunas, humidifiers, dehumidifiers, exercise equipment) are not Covered as they do not meet the definition of durable medical equipment. Braces We Cover braces that are worn externally and that temporarily or permanently assist all or part of an external body part function that has been lost or damaged because of an injury, disease or defect. Coverage is for standard equipment only. We Cover replacements when growth or a change in Your medical condition make replacement necessary. We do not Cover the cost of repairs or replacement that are the result of misuse or abuse by You). Hearing Aids: We Cover hearing aids required for the correction of a hearing impairment (a reduction in the ability to perceive sound which may range from slight to complete deafness). Hearing aids are electronic amplifying devices designed to bring sound more effectively into the ear. A hearing aid consists of a microphone, amplifier and receiver. Covered services are available for a hearing aid that is purchased as a result of a written recommendation by a Physician and include the hearing aid and the charges for associated fitting and testing. We Cover a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years. Bone anchored hearing aids are Covered only if You have either of the following: Craniofacial anomalies whose abnormal or absent ear canals preclude the use of a wearable hearing aid; or Hearing loss of sufficient severity that it would not be adequately remedied by a wearable hearing aid. If You meet the criteria for a bone anchored hearing aid, Coverage is provided for one hearing aid per ear during the entire period of time the You are enrolled under this Certificate. Replacements and/or repairs for a bone anchored hearing aid are Covered only for malfunctions. Hospice: Hospice Care is available if Your primary attending Physician has certified that You have six months or less to live. We Cover inpatient Hospice Care in a Hospital or hospice and home care and outpatient services provided by the hospice, including drugs and medical supplies. Coverage is provided for 210 days of Hospice Care. We also Cover five visits for supportive care and guidance for the purpose of helping You BENJAMIN 000068 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 68 of 237 39 OHINY_SG_COC_2014 10886 NY SG FP PPO AGE 26 COC 02.14 and Your immediate family cope with the emotional and social issues related to Your death, either before or after Your death. We Cover Hospice Care only when provided as part of a Hospice Care program certified pursuant to Article 40 of the N.Y. Public Health Law. If care is provided outside New York State, the hospice must be certified under a similar certification process required by the state in which the hospice is located. Coverage is not provided for: funeral arrangements; pastoral, financial, or legal counseling; homemaker, caretaker, or respite care. Medical Supplies: We Cover medical supplies that are required for the treatment of a disease or injury which is Covered under this Certificate. We also Cover maintenance supplies (e.g., ostomy supplies) for conditions Covered under this Certificate. All such supplies must be in the appropriate amount for the treatment or maintenance program in progress. We do not Cover over-the-counter medical supplies. Please see the “Diabetic Supplies, Education and Self-Management” section of this Certificate for a description of diabetic supply Coverage. Prosthetics: External Prosthetic Devices: We Cover prosthetic devices (including wigs) that are worn externally and that temporarily or permanently replace all or part of an external body part that has been lost or damaged because of an injury or disease. We Cover wigs only when You have severe hair loss due to injury or disease or as a side effect of the treatment of a disease (e.g., chemotherapy). We do not Cover wigs made from human hair unless You are allergic to all synthetic wig materials. Dentures or other devices used in connection with the teeth are not Covered unless required due to an accidental injury to sound natural teeth or necessary due to congenital disease or anomaly. Eyeglasses and contact lenses are not Covered under this section of the Certificate and are only covered under the pediatric vision benefit in Section VI - Covered Services of this Certificate. We do not Cover orthotics. For adults, We Cover the cost of only one prosthetic device, per limb, per lifetime. For children, the cost of replacements is also Covered but only if the previous device has been outgrown. Coverage is for standard equipment only. We do not otherwise Cover the cost of repairs or replacement. We also Cover external breast prostheses following a mastectomy, which are not subject to any lifetime limit. Internal Prosthetic Devices: We Cover surgically implanted prosthetic devices and special appliances if they improve or restore the function of an internal body part which has been removed or damaged due to disease or injury. This includes implanted breast prostheses following a mastectomy or partial mastectomy in a manner determined by You and Your attending Physician to be appropriate. Coverage also includes repair and replacement due to normal growth or normal wear and tear. BENJAMIN 000069 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 69 of 237 40 OHINY_SG_COC_2014 10886 NY SG FP PPO AGE 26 COC 02.14 Inpatient Services (For other than Mental Health and Substance Use) Please refer to the Schedule of Benefits for Cost-Sharing requirements, day or visit limits, and any Preauthorization or Referral requirements that apply to these benefits. Hospital Services: We Cover inpatient Hospital services for Acute care or treatment given or ordered by a Health Care Professional for an illness, injury or disease of a severity that must be treated on an inpatient basis including: Semiprivate room and board; General, special, and critical nursing care; Meals and special diets; The use of operating, recovery, and cystoscopic rooms and equipment; The use of intensive care, special care, or cardiac care units and equipment; Diagnostic and therapeutic items, such as drugs and medications, sera, biologicals and vaccines, intravenous preparations and visualizing dyes and administration, but not including those which are not commercially available for purchase and readily obtainable by the Hospital; Dressings and plaster casts; Supplies and the use of equipment in connection with oxygen, anesthesia, physiotherapy, chemotherapy, electrocardiographs, electroencephalographs, X- ray examinations and radiation therapy, laboratory and pathological examinations; Blood and blood products except when participation in a volunteer blood replacement program is available to You; Radiation therapy, inhalation therapy, chemotherapy, pulmonary rehabilitation, infusion therapy and cardiac rehabilitation; Short-term physical, speech and occupational therapy; and Any additional medical services and supplies which are provided while You are a registered bed patient and which are billed by the Hospital. The Cost-Sharing requirements in the Schedule of Benefits apply to a continuous Hospital confinement, which is consecutive days of in-Hospital service received as an inpatient or successive confinements when discharge from and readmission to the Hospital occur within a period of not more than 90 days. Observation Services: We Cover observation services in a Hospital. Observation services are Hospital outpatient services provided to help a Physician decide whether to admit or discharge You. The services include use of a bed and periodic monitoring by nursing or other licensed staff. Inpatient Medical Services: We Cover medical visits by a Health Care Professional on any day of inpatient care Covered under this Certificate. BENJAMIN 000070 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 70 of 237 41 OHINY_SG_COC_2014 10886 NY SG FP PPO AGE 26 COC 02.14 Inpatient Stay for Maternity Care. We Cover inpatient maternity care in a Hospital for the mother, and inpatient newborn care in a Hospital for the infant, for at least 48 hours following a normal delivery and at least 96 hours following a caesarean section delivery, regardless of whether such care is Medically Necessary. The care provided shall include parent education, assistance, and training in breast or bottle-feeding, and the performance of any necessary maternal and newborn clinical assessments. We will also Cover any additional days of such care that We determine are Medically Necessary. In the event the mother elects to leave the Hospital and requests a home care visit before the end of the 48-hour or 96-hour minimum Coverage period, We will Cover a home care visit. The home care visit will be provided within 24 hours after the mother's discharge, or the time of the mother's request, whichever is later. Our Coverage of this home care visit shall be in addition to home health care visits under this Certificate and shall not be subject to any Cost-Sharing amounts in the Schedule of Benefits that apply to home care benefits. Inpatient Stay for Mastectomy Care: We Cover inpatient services for Members undergoing a lymph node dissection, lumpectomy, mastectomy or partial mastectomy for the treatment of breast cancer and any physical complications arising from the mastectomy, including lymphedema, for a period time determined to be medically appropriate by You and Your attending Physician. Autologous Blood Banking Services: We Cover autologous blood banking services only when they are being provided in connection with a scheduled, Covered inpatient procedure for the treatment of a disease or injury. In such instances, We Cover storage fees for a reasonable storage period that is appropriate for having the blood available when it is needed. Rehabilitation Services: We Cover inpatient Rehabilitation Services consisting of physical therapy, speech therapy and occupational therapy for up to one consecutive 60-day period, per condition, per lifetime. For the purposes of this benefit, "per condition" means the disease or injury causing the need for the therapy. We Cover speech and physical therapy only when: 1. such therapy is related to the treatment or diagnosis of Your physical illness or injury (in the case of a covered Child, this includes a medically diagnosed congenital defect); 2. it is ordered by a Physician; and 3. You have been Hospitalized or have undergone surgery for such illness or injury. Covered Services must begin within six months of the later to occur: 1. the date of the injury or illness that caused the need for the therapy; 2. the date You are discharged from a Hospital where surgical treatment was rendered; or 3. the date outpatient surgical care is rendered. BENJAMIN 000071 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 71 of 237 42 OHINY_SG_COC_2014 10886 NY SG FP PPO AGE 26 COC 02.14 Skilled Nursing Facility: We Cover services provided in a Skilled Nursing Facility, including care and treatment in a semi-private room, as described in "Hospital Services" above. Custodial, convalescent or domiciliary care is not Covered (see the “Exclusions and Limitations” section of this Certificate). An admission to a Skilled Nursing Facility must be supported by a treatment plan prepared by Your Provider and approved by Us. We Cover up to 200 days, per Calendar Year, for non-custodial care. End of Life Care: If You are diagnosed with advanced cancer and You have fewer than 60 days to live, We will Cover Acute care provided in a licensed Article 28 facility or Acute care Facility that specializes in the care of terminally ill patients. Your attending Physician and the Facility’s medical director must agree that Your care will be appropriately provided at the Facility. If We disagree with Your admission to the Facility, We have the right to initiate an expedited appeal to an External Appeal Agent. We will Cover and reimburse the Facility for Your care, subject to any applicable limitations in this Certificate until the External Appeal Agent renders a decision in Our favor. We will reimburse Non-Participating Providers for this end of life care as follows: 1. We will reimburse a rate that has been negotiated between Us and the Provider. 2. If there is no negotiated rate, We will reimburse Acute care at the Facility’s current Medicare acute care service rates. 3. Or if it is an alternate level of care, We will reimburse at 75% of the appropriate Medicare rates. Limitations/Terms of Coverage: 1. When You are receiving inpatient care in a Hospital or other Facility as described above, We will not cover additional charges for special duty nurses, charges for private rooms (unless a private room is Medically Necessary), or medications and supplies You take home from the Facility. If You occupy a private room, and the private room is not Medically Necessary, Our coverage will be based on the Facility’s maximum semi-private room charge. You will have to pay the difference between that charge and the charge for the private room. 2. We do not Cover radio, telephone and television expenses, or beauty or barber services. 3. We do not Cover any charges incurred after the day We advise You it is no longer Medically Necessary for you to receive inpatient care, unless Our denial is overturned by an External Appeal Agent. Mental Health Care and Substance Use Services Please refer to the Schedule of Benefits for Cost-Sharing requirements, day or visit limits, and any Preauthorization or Referral requirements that apply to these benefits. Mental Health Care Services BENJAMIN 000072 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 72 of 237 43 OHINY_SG_COC_2014 10886 NY SG FP PPO AGE 26 COC 02.14 Inpatient Services: We Cover inpatient mental health care services relating to the diagnosis and treatment of mental, nervous and emotional disorders comparable to other similar Hospital, medical, and surgical coverage provided under this Certificate. However, Coverage for inpatient services for mental health care is limited to Facilities as defined by New York Mental Hygiene Law § 1.03 subdivision 10. Outpatient Services: We Cover outpatient mental health care services, including but not limited to partial Hospitalization program services and intensive outpatient program services, relating to the diagnosis and treatment of mental, nervous and emotional disorders. Such Coverage is limited to Facilities that have an operating certificate issued pursuant to Article 31 of the New York Mental Hygiene Law; a Facility operated by the Office of Mental Health; services provided by a psychiatrist or psychologist licensed to practice in this state; a licensed clinical social worker who meets the requirements of NY Ins. Law §§ 3221(l)(4)(D), 4303(h)(1); or a professional corporation or a university faculty practice corporation thereof. Limitations/Terms of Coverage: We will not Cover benefits or services deemed to be cosmetic in nature on the grounds that changing or improving an individual’s appearance is justified by the individual’s mental health needs. We will not Cover mental health benefits or services for individuals who are incarcerated, confined or committed to a local correctional facility or prison, or a custodial facility for youth operated by the Office of Children and Family Services. We will not Cover services solely because they are ordered by a court. Substance Use Services Inpatient Services: We Cover inpatient substance use services relating to the diagnosis and treatment of alcoholism and/or substance use and/or dependency. This includes Coverage for detoxification and/or rehabilitation services as a consequence of chemical use and/or substance use. Inpatient substance use services are limited to Facilities in New York which are certified by the Office of Alcoholism and Substance Abuse Services (OASAS), and in other states, to those which are accredited by the Joint Commission as alcoholism, substance abuse or chemical dependence treatment programs. Outpatient Services: We Cover outpatient substance use services relating to the diagnosis and treatment of alcoholism and/or substance use and/or dependency. Such Coverage is limited to facilities in New York State, certified by the Office of Alcoholism and Substance Abuse Services (OASAS) or licensed by OASAS as outpatient clinics or medically supervised ambulatory substance abuse programs or by Physicians who have been granted a waiver pursuant to the Drug Addiction and Treatment Act of 2000 to prescribe Schedule III, IV and V narcotic medications for the treatment of opioid addiction during the acute detoxification stage of treatment or during stages of rehabilitation; and, in other states, to those accredited by the Joint Commission as alcoholism or chemical dependence treatment programs. Coverage is also available in a professional office setting for outpatient substance use services relating to the diagnosis and treatment of alcoholism and/or substance use and/or dependency. BENJAMIN 000073 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 73 of 237 44 OHINY_SG_COC_2014 10886 NY SG FP PPO AGE 26 COC 02.14 We also Cover up to 20 outpatient visits for family counseling. A family member will be deemed to be covered, for the purposes of this provision, so long as that family member (i) identifies himself or herself as a family member of a person suffering from substance use and/or dependency, and (ii) is covered under the same family Certificate that covers the person receiving, or in need of, treatment for substance use, and/or dependence. Our payment for a family member therapy session will be the same amount, regardless of the number of family members who attend the family therapy session. Prescription Drug Coverage Please refer to the Schedule of Benefits for Cost-Sharing requirements, day or visit limits, and any Preauthorization or Referral requirements that apply to these benefits. Covered Outpatient Prescription Drugs We Cover Medically Necessary Outpatient Prescription Drugs that, except as specifically provided otherwise, can be dispensed only pursuant to a prescription and are: Required by law to bear the legend “Caution - Federal Law prohibits dispensing without a prescription”; FDA approved; Ordered by a Provider authorized to prescribe and within the Provider’s scope of practice; Prescribed within the approved FDA administration and dosing guidelines; and Dispensed by a licensed pharmacy. Covered Prescription Drugs include, but are not limited to: Self-injectable/administered Prescription Drugs. Inhalers (with spacers). Topical dental preparations. Pre-natal vitamins, vitamins with fluoride, and single entity vitamins. Osteoporosis drugs and devices approved by the FDA for the treatment of osteoporosis and consistent with the criteria of the federal Medicare program or the National Institutes of Health. Nutritional supplements (formulas) for the therapeutic treatment of phenylketonuria, branched-chain ketonuria, galactosemia and homocystinuria. Non-prescription enteral formulas for home use for which a Physician or other licensed Provider has issued a written order. The written order must state that the enteral formula is Medically Necessary and has been proven effective as a disease-specific treatment regimen for patients whose condition would cause them to become malnourished or suffer from disorders resulting in chronic disability, mental retardation, or death, if left untreated, including but not limited to: inherited BENJAMIN 000074 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 74 of 237 45 OHINY_SG_COC_2014 10886 NY SG FP PPO AGE 26 COC 02.14 diseases of amino acid or organic acid metabolism; Crohn’s disease; gastroesophageal reflux with failure to thrive; gastroesophageal motility such as chronic intestinal pseudo-obstruction; and multiple severe food allergies. Modified solid food products that are low in protein or which contain modified protein to treat certain inherited diseases of amino acid and organic acid metabolism. Prescription Drugs prescribed in conjunction with treatment or services Covered under the Infertility section of this Certificate. Off-Label Cancer drugs, so long as, the Prescription Drug is recognized for the treatment of the specific type of cancer for which it has been prescribed in one of the following reference compendia: the American Hospital Formulary Service-Drug Information; National Comprehensive Cancer Networks Drugs and Biologics Compendium; Thomson Micromedex DrugDex; Elsevier Gold Standard’s Clinical Pharmacology; or other authoritative compendia as identified by the Federal Secretary of Health and Human Services or the Centers for Medicare and Medicaid Services; or recommended by review article or editorial comment in a major peer reviewed professional journal. Orally administered anticancer medication used to kill or slow the growth of cancerous cells. Prescription Drugs for smoking cessation. Contraceptive drugs or devices or generic equivalents approved as substitutes by the FDA. You may request a copy of Our drug formulary. Our drug formulary is also available on Our website at www.oxhp.com. You may also inquire if a specific drug is Covered under this Certificate by contacting us at the number on Your ID card. Refills We Cover Refills of Prescription Drugs only when dispensed at a retail or mail order or Designated pharmacy as ordered by an authorized Provider and only after ¾ of the original Prescription Drug has been used. Benefits for Refills will not be provided beyond one year from the original prescription date. For prescription eye drop medication, We allow for the limited refilling of the prescription prior to the last day of the approved dosage period without regard to any coverage restrictions on early Refill of renewals. To the extent practicable, the quantity of eye drops in the early Refill will be limited to the amount remaining on the dosage that was initially dispensed. Your Cost- Sharing for the limited Refill is the amount that applies to each prescription or Refill as set forth in the Schedule of Benefits in Section XV - Schedule of Benefits of this Certificate. Benefit and Payment Information 1. Cost-Sharing Expenses: You are responsible for paying the costs outlined in the Schedule of Benefits in Section XV - Schedule of Benefits of this Certificate when BENJAMIN 000075 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 75 of 237 46 OHINY_SG_COC_2014 10886 NY SG FP PPO AGE 26 COC 02.14 Covered Prescription Drugs are obtained from a retail or mail order or Designated pharmacy. You have a three tier plan design, which means that Your Out-of-Pocket Expenses will generally be lowest for Prescription Drugs on Tier 1 and highest for Prescription Drugs on Tier 3. Your Out-of-Pocket Expense for Prescription Drugs on Tier 2 will generally be more than for Tier 1 but less than Tier 3. An additional charge may apply when a Prescription Drug on a higher tier is dispensed at Your or Your Provider's request, when a chemically equivalent Prescription Drug is available on a lower tier. You will have to pay the difference between the cost of the Prescription Drug on the higher tier and the cost of the Prescription Drug on the lower tier. The cost difference must be paid in addition to the lower tier Copayment or Coinsurance. You are responsible for paying the full cost (the amount the pharmacy charges You) for any non-Covered Prescription Drug and Our contracted rates (Our Prescription Drug Cost) will not be available to You. 2. Participating Pharmacies: For Prescription Drugs purchased at a retail or mail order or designated Participating Pharmacy, You are responsible for paying the lower of: The applicable Cost-Sharing; or The Participating Pharmacy’s Usual and Customary Charge (which includes a dispensing fee and sales tax) for the Prescription Drug. (Your Cost-Sharing will never exceed the Usual and Customary Charge of the Prescription Drug.) In the event that Our Participating Pharmacies are unable to provide the Covered Prescription Drug, and cannot order the Prescription Drug within a reasonable time, You may, with Our prior written approval, go to a Non-Participating Pharmacy that is able to provide the Prescription Drug. We will pay You the Prescription Drug Cost for such approved Prescription Drug less Your required In- Network Cost-Sharing upon receipt of a complete Prescription Drug claim form. Contact Us by calling the Customer Service number on Your ID card or visit our website at www.oxhp.com to request approval. 3. Non-Participating Pharmacies: We will not pay for any Prescription Drugs that You purchase at a Non-Participating retail or mail order Pharmacy other than as described above. 4. Designated Pharmacies: If You require certain Prescription Drugs including, but not limited to specialty Prescription Drugs, We may direct You to a Designated Pharmacy with whom We have an arrangement to provide those Prescription Drugs. Generally, specialty Prescription Drugs are Prescription Drugs that are approved to treat limited patient populations or conditions; are normally injected, infused or BENJAMIN 000076 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 76 of 237 47 OHINY_SG_COC_2014 10886 NY SG FP PPO AGE 26 COC 02.14 require close monitoring by a Provider; or have limited availability, special dispensing and delivery requirements and/or require additional patient supports. If You are directed to a Designated Pharmacy and You choose not to obtain Your Prescription Drug from a Designated Pharmacy, You will not have Coverage for that Prescription Drug. Following are the therapeutic classes of Prescription Drugs that are included in this program: Age related macular edema Anemia, neutropenia, thrombocytopenia Contraceptives Crohn’s Disease Cystic Fibrosis Cytomegalovirus Endocrine disorders/Neurologic disorders such as infantile spasms Enzyme Deficiencies/Liposomal Storage Disorders Gaucher's Disease Growth Hormone Hemophilia Hepatitis B, Hepatitis C Hereditary Angioedema HIV/AIDS Immune Deficiency Immune Modulator Infertility Iron Overload Iron Toxicity Multiple Sclerosis Oral Oncology Osteoarthritis Osteoporosis Parkinson's Disease Pulmonary Arterial Hypertension Respiratory Condition BENJAMIN 000077 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 77 of 237 48 OHINY_SG_COC_2014 10886 NY SG FP PPO AGE 26 COC 02.14 Rheumatologic and related conditions (Rheumatoid Arthritis, Psoriatic Arthritis,Ankylosing Spondylitis, Juvenile Rheumatoid Arthritis, Psoriasis) Transplant RSV Prevention 5. Mail Order: Certain Prescription Drugs may be ordered through Our mail order supplier. You are responsible for paying the lower of: The applicable Cost-Sharing; or The Prescription Drug Cost for that Prescription Drug. (Your Cost-Sharing will never exceed the Usual and Customary Charge of the Prescription Drug.) To maximize Your benefit, ask Your Physician to write Your Prescription Order or Refill for a 90-day supply, with Refills when appropriate (not a 30-day supply with three Refills). You will be charged the mail order Cost-Sharing for any Prescription Orders or Refills sent to the mail order supplier regardless of the number of days supply written on the Prescription Order or Refill. Prescription Drugs purchased through mail order will be delivered directly to Your home or office. You or Your Provider may obtain a copy of the list of Prescription Drugs available through mail order by visiting Our website at www.oxhp.com or by calling the Customer Service number on Your ID card. The maintenance drug list is updated periodically. Visit Our website or call the Customer Service number on your ID card to find out if a particular drug is on the maintenance list. 6. Tier Status: The tier status of a Prescription Drug may change periodically. Changes will generally be quarterly, but no more than six times per calendar year, based on Our periodic tiering decisions. These changes may occur without prior notice to You. However, if You have a prescription for a drug that is being moved to a higher tier (other than a Brand-Name Drug that becomes available as a Generic as described below) We will notify You. When such changes occur, Your out-of-pocket expense may change. You may access the most up to date tier status on Our website at www.oxhp.com or by calling the Customer Service number on Your ID card. 7. When a Brand-Name Drug Becomes Available As a Generic: When a Brand- Name Drug becomes available as a Generic, the tier placement of the Brand- Name Prescription Drug may change. If this happens, You will pay the Cost- Sharing applicable to the tier to which the Prescription Drug is assigned. Please note, if You are taking a Brand-Name Drug that is being excluded due to a generic becoming available You will receive advance written notice of the Brand-Name Drug exclusion. If coverage is denied, You are entitled to an Appeal as outlined in Section IX - Grievance, Utilization Review & External Appeals of the Certificate. BENJAMIN 000078 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 78 of 237 49 OHINY_SG_COC_2014 10886 NY SG FP PPO AGE 26 COC 02.14 8. Supply Limits: We will pay for no more than a 30-day supply of a Prescription Drug purchased at a retail pharmacy or Designated Pharmacy. You are responsible for one Cost-Sharing amount for up to a 30-day supply. Benefits will be provided for drugs dispensed by a mail order pharmacy in a quantity of up to a 90-day supply. You are responsible for one Cost-Share amount for a 30-day supply up to a maximum of two and a half Cost-Share amounts for a 90-day supply. We will provide benefits that apply to drugs dispensed by a mail order pharmacy to drugs that are purchased from a retail pharmacy when that retail pharmacy has a participation agreement with Us in which it agrees to be bound by the same terms and conditions as a Participating mail order pharmacy. Some Prescription Drugs may be subject to quantity limits based on criteria that We have developed, subject to Our periodic review and modification. The limit may restrict the amount dispensed per Prescription Order or Refill and/or the amount dispensed per month’s supply. You can determine whether a Prescription Drug has been assigned a maximum quantity level for dispensing by accessing Our website at www.oxhp.com or by calling Customer Service at the telephone number on Your ID card. If We deny a request to Cover an amount that exceeds Our quantity level, You are entitled to an Appeal pursuant to Section IX - Grievance, Utilization Review & External Appeals of the Certificate. 9. Cost-Sharing for Orally-Administered Anti-cancer Drugs. Your Cost-Sharing for orally-administered anti-cancer drugs is the lesser of the applicable Prescription Drug Cost-Sharing amount specified in the Schedule of Benefits in Section XV - Schedule of Benefits of this Certificate or the Cost-Sharing amount, if any, that applies to intravenous or injectable chemotherapy agents Covered under Section VI - Covered Services of this Certificate. 10. Half Tablet Program. Certain Prescription Drugs may be designated as eligible for Our voluntary half tablet program. This program provides the opportunity to reduce Your Prescription Drug Out-of-Pocket Expenses by up to 50% by using higher strength tablets and splitting them in half. If You are taking an eligible Prescription Drug, and You would like to participate in this program, please call Your Physician to see if the half tablet program is appropriate for Your condition. If Your Physician agrees, he or she must write a new prescription for Your medication to enable Your participation. You can determine whether a Prescription Drug is eligible for the voluntary half tablet program by accessing Our website at www.oxhp.com or by calling Customer Service at the telephone number on Your ID card. Medical Management This Certificate includes certain features to determine when Prescription Drugs should be Covered, which are described below. As part of these features, Your prescribing Provider may be asked to give more details before We can decide if the Prescription Drug is Medically Necessary. BENJAMIN 000079 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 79 of 237 50 OHINY_SG_COC_2014 10886 NY SG FP PPO AGE 26 COC 02.14 1. Preauthorization. Preauthorization may be needed for certain Prescription Drugs to make sure proper use and guidelines for Prescription Drug coverage are followed. When appropriate, Your Provider will be responsible for obtaining Preauthorization for the Prescription Drug. Should You choose to purchase the Prescription Drug without obtaining Preauthorization, You must pay for the cost of the entire Prescription Drug and submit a claim to Us for reimbursement. For a list of Prescription Drugs that need Preauthorization, please visit our website at www.oxhp.com or call the Customer Service number on Your ID card. The list will be reviewed and updated from time to time. We also reserve the right to require Preauthorization for any new Prescription Drug on the market or of any currently available Prescription Drug which undergoes a change in prescribing protocols and/or indications regardless of the therapeutic classification. Including a Prescription Drug or related item on the list does not promise coverage under Your Plan. Your Provider may check with Us to find out which Prescription Drugs are Covered. 2. Step Therapy. Step therapy is a process in which You may need to use one type of Prescription Drug before We will Cover another as Medically Necessary. We check certain Prescription Drugs to make sure that proper prescribing guidelines are followed. These guidelines help You get high quality and cost effective Prescription Drugs. The Prescription Drugs that require preauthorization under the Step Therapy Program are also included on the preauthorization drug list. Limitations/Terms of Coverage 1. We reserve the right to limit quantities, day supply, early Refill access and/or duration of therapy for certain medications based on Medical Necessity including acceptable medical standards and/or FDA recommended guidelines. 2. If We determine that You may be using a Prescription Drug in a harmful or abusive manner, or with harmful frequency, Your selection of Participating Pharmacies may be limited. If this happens, We may require You to select a single Participating Pharmacy that will provide and coordinate all future pharmacy services. Benefits will be paid only if You use the selected single Participating Pharmacy. If You don’t make a selection within 31 days of the date We notify You, We will select a single Participating Pharmacy for You. 3. Compounded Prescription Drugs will be Covered only when they contain at least one ingredient that is a Covered legend Prescription Drug, are Medically Necessary, and are obtained from a pharmacy that is approved for compounding. All compounded Prescription Drugs require Your Provider to obtain Preauthorization. 4. Various specific and/or generalized “use management” protocols will be used from time-to-time in order to ensure appropriate utilization of medications. Such protocols will be consistent with standard medical/drug treatment guidelines. The primary goal of the protocols is to provide Our Members with a quality-focused BENJAMIN 000080 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 80 of 237 51 OHINY_SG_COC_2014 10886 NY SG FP PPO AGE 26 COC 02.14 drug benefit. In the event a use management protocol is implemented, and You are taking the drug(s) affected by the protocol, You will be notified in advance. 5. Injectable drugs (other than self-administered injectable drugs) and diabetic insulin, oral hypoglycemics, and diabetic supplies are not Covered under this section but are Covered under other sections of this Certificate. 6. We do not Cover charges for the administration or injection of any Prescription Drug. Prescription Drugs given or administered in a Physician’s office are Covered under Section VI - Covered Services of this Certificate. 7. We do not Cover drugs that do not by law require a prescription, except as otherwise provided in this Certificate. 8. We do not Cover Prescription Drugs that have over-the-counter non-prescription equivalents. Non-prescription equivalents are drugs available without a prescription that have the same name/chemical entity as their prescription counterparts. 9. We do not Cover Prescription Drugs to replace those that may have been lost or stolen. 10. We do not Cover Prescription Drugs dispensed to You while in a Hospital, nursing home, other institution, Facility, or if You are a home care patient, except in those cases where the basis of payment by or on behalf of You to the Hospital, nursing home, Home Health Agency or home care services agency, or other institution, does not include services for drugs. 11. Your benefit for insulin, diabetic Prescription Drugs, supplies and equipment is not provided under this section of the Certificate and is Covered under Section VI - Covered Services of the Certificate. 12. We reserve the right to deny benefits as not Medically Necessary or experimental or investigational for any drug prescribed or dispensed in a manner contrary to standard medical practice. If coverage is denied, You are entitled to an Appeal as described in Section VI - Covered Services of this Certificate. 13. A pharmacy need not dispense a prescription order that, in the pharmacist’s professional judgment, should not be filled. 14. We do not Cover nutritional supplements (formulas), non-prescription enteral formulas, and modified food solid products except as described under the Covered Outpatient Prescription Drug Section. General Conditions 1. You must show Your ID card to a retail pharmacy at the time You obtain Your Prescription Drug or You must provide the pharmacy with identifying information that can be verified by Us during regular business hours. You must include Your identification number on the forms provided by the mail order pharmacy from which You make a purchase. BENJAMIN 000081 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 81 of 237 52 OHINY_SG_COC_2014 10886 NY SG FP PPO AGE 26 COC 02.14 2. Drug Utilization, Cost Management and Rebates. We conduct various utilization management activities designed to ensure appropriate Prescription Drug usage, to avoid inappropriate usage, and to encourage the use of cost-effective drugs. Through these efforts, You benefit by obtaining appropriate Prescription Drugs in a cost-effective manner. The cost savings resulting from these activities are reflected in the premiums for Your coverage. We may, from time-to-time, also enter into agreements that result in Us receiving rebates or other funds (“rebates”) directly or indirectly from Prescription Drug manufacturers, Prescription Drug distributors or others. Any rebates are based upon utilization of Prescription Drugs across all of Our business and not solely on any one Member’s utilization of Prescription Drugs. Any rebates received by Us may or may not be applied, in whole or part, to reduce premiums either through an adjustment to claims costs or as an adjustment to the administrative expenses component of Our Prescription Drug premiums. Instead, any such rebates may be retained by Us, in whole or part, in order to fund such activities as new utilization management activities, community benefit activities and increasing reserves for the protection of Members. Rebates will not change or reduce the amount of any Copayment or Coinsurance applicable under Our Prescription Drug coverage. Definitions Terms used is this section are defined as follows. (Other defined terms can be found in the definitions section of this Certificate). Brand-Name Drug: A Prescription Drug that (1) is manufactured and marketed under a trademark or name by a specific drug manufacturer; or (2) that We identify as a Brand- Name Prescription Drug, based on available data resources. All Prescription Drugs identified as a “brand name” by the manufacturer, pharmacy, or Your Physician may not be classified as Brand-Name Drug by Us. Designated Pharmacy: A pharmacy that has entered into an agreement with Us or with an organization contracting on Our behalf, to provide specific Prescription Drugs, including, but not limited to, Specialty Prescription Drugs. The fact that a pharmacy is a Participating Pharmacy does not mean that it is a Designated Pharmacy. Formulary: The list that identifies those Prescription Drugs for which Coverage may be available under this Certificate. This list is subject to Our periodic review and modification (generally quarterly, but no more than six times per calendar year). You may determine to which tier a particular Prescription Drug has been assigned by visiting Our website at www.oxhp.com or by calling the Customer Service number on Your ID card. Generic Drug: A Prescription Drug that (1) is chemically equivalent to a Brand-Name Drug; or (2) that We identify as a Generic Prescription Drug based on available data resources. All Prescription Drugs identified as a “generic” by the manufacturer, pharmacy, or Your Physician may not be classified as a Generic Drug by Us. Non-Participating Pharmacy: A pharmacy that has not entered into an agreement with Us to provide Prescription Drugs to Members. BENJAMIN 000082 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 82 of 237 53 OHINY_SG_COC_2014 10886 NY SG FP PPO AGE 26 COC 02.14 Participating Pharmacy: A pharmacy that has: entered into an agreement with Us or Our designee to provide Prescription Drugs to Members; agreed to accept specified reimbursement rates for dispensing Prescription Drugs; and has been designated by Us as a Participating Pharmacy. A Participating Pharmacy can be either a retail or mail-order pharmacy. Prescription Drug: A medication, product or device that has been approved by the FDA and that can, under federal or state law, be dispensed only pursuant to a Prescription Order or Refill and is on Our Formulary. A Prescription Drug includes a medication that, due to its characteristics, is appropriate for self administration or administration by a non-skilled caregiver. Prescription Drug Cost: The rate We have agreed to pay Our Participating Pharmacies, including a dispensing fee and any sales tax, for a Covered Prescription Drug dispensed at a Participating Pharmacy. If Your Plan includes Coverage at Non- Participating Pharmacies, the Prescription Drug Cost for a Prescription Drug dispensed at a Non-Participating Pharmacy is calculated using the Prescription Drug Cost that applies for that particular Prescription Drug at most Participating Pharmacies. Prescription Order or Refill: The directive to dispense a Prescription Drug issued by a duly licensed health care provider whose scope of practice permits issuing such a directive. Usual and Customary Charge: The usual fee that a pharmacy charges individuals for a Prescription Drug without reference to reimbursement to the pharmacy by third parties as required by Section 6826-a of the Education Law. Wellness Exercise Facility Reimbursement We will partially reimburse the Subscriber and the Subscriber’s Covered Spouse for certain exercise facility fees or membership fees but only if such fees are paid to exercise facilities and which maintain equipment and programs that promote cardiovascular wellness. Memberships in tennis clubs, country clubs, weight loss clinics, spas or any other similar facilities will not be reimbursed. Lifetime memberships are not eligible for reimbursement. Reimbursement is limited to actual work-out visits. We will not provide reimbursement for equipment, clothing, vitamins or other services that may be offered by the facility (massages, yoga, etc.). In order to be eligible for reimbursement, You must: be an active member of the exercise facility, and complete 50 visits in a six-month period. BENJAMIN 000083 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 83 of 237 54 OHINY_SG_COC_2014 10886 NY SG FP PPO AGE 26 COC 02.14 In order to obtain reimbursement, at the end of the six-month period You must: submit a completed reimbursement form. a copy of Your current facility bill which shows the fee paid for Your membership. Once We receive the completed reimbursement form and the bill, You will be reimbursed the lesser of $200 for the Subscriber and $100 for the Subscriber’s Spouse or the actual cost of the membership per six-month period. Pediatric Vision Care Please refer to the Schedule of Benefits for Cost-Sharing requirements, day or visit limits, and any Preauthorization or Referral requirements that apply to these benefits. Pediatric Vision Care: We Cover emergency, preventive and routine vision care for Children up to age 19. Vision Examinations: We Cover vision examinations for the purpose of determining the need for corrective lenses, and if needed, to provide a prescription for corrective lenses. We Cover one vision examination in any twelve (12) month period, unless more frequent examinations are Medically Necessary as evidenced by appropriate documentation. The vision examination may include, but is not limited to: Case history; External examination of the eye or internal examination of the eye; Opthalmoscopic exam; Determination of refractive status; Binocular distance; Tonometry tests for glaucoma; Gross visual fields and color vision testing; and Summary findings and recommendation for corrective lenses. Prescribed Lenses & Frames: We Cover standard prescription lenses or contact lenses once in any twelve (12) month period, unless it is Medically Necessary for You to have new lenses or contact lenses more frequently, as evidenced by appropriate documentation. Prescription lenses may be constructed of either glass or plastic. We also Cover standard frames adequate to hold lenses once in any twelve (12) month period, unless it is Medically Necessary for You to have new frames more frequently, as evidenced by appropriate documentation. Pediatric Dental Care Please refer to the Schedule of Benefits for Cost-Sharing requirements, day or visit limits, and any Preauthorization or Referral requirements that apply to these benefits. BENJAMIN 000084 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 84 of 237 55 OHINY_SG_COC_2014 10886 NY SG FP PPO AGE 26 COC 02.14 Pediatric Dental Care: We Cover the following dental care services for Children up to age 19: Emergency Dental Care: We Cover emergency dental care, which includes emergency treatment required to alleviate pain and suffering caused by dental disease or trauma. Emergency dental care is not subject to Our Preauthorization. Preventive Dental Care: We Cover preventive dental care, that includes procedures which help to prevent oral disease from occurring, including: Prophylaxis (scaling and polishing the teeth at six (6) month intervals; Topical fluoride application at six (6) month intervals where the local water supply is not fluoridated; Sealants on unrestored permanent molar teeth; and Unilateral or bilateral space maintainers for placement in a restored deciduous and/or mixed dentition to maintain space for normally developing permanent teeth. Routine Dental Care: We Cover routine dental care provided in the office of a dentist, including: Dental examinations, visits and consultations once within a six (6) month consecutive period (when primary teeth erupt); X-ray, full mouth x-rays at thirty-six (36) month intervals, bitewing x-rays at six (6) to twelve (12) month intervals, or panoramic x-rays at thirty-six (36) month intervals, and other x-rays if Medically Necessary (once primary teeth erupt); Procedures for simple extractions and other routine dental surgery not requiring Hospitalization, including preoperative care and postoperative care; In-office conscious sedation; Amalgam, composite restorations and stainless steel crowns; and Other restorative materials appropriate for children. Endodontics: We Cover endodontic services, including procedures for treatment of diseased pulp chambers and pulp canals, where Hospitalization is not required. Prosthodontics: We Cover prosthodontic services as follows: Removable complete or partial dentures, including six (6) months follow-up care; and Additional services include insertion of identification slips, repairs, relines and rebases and treatment of cleft palate. Fixed bridges are not Covered unless they are required: For replacement of a single upper anterior (central/lateral incisor or cuspid) in a patient with an otherwise full compliment of natural, functional and/or restored teeth BENJAMIN 000085 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 85 of 237 56 OHINY_SG_COC_2014 10886 NY SG FP PPO AGE 26 COC 02.14 For cleft palate stabilization; or Due to the presence of any neurologic or physiologic condition that would preclude the placement of a removable prosthesis, as demonstrated by medical documentation. Orthodontics: We Cover orthodontics used to help restore oral structures to health and function and to treat serious medical conditions such as: cleft palate and cleft lip; maxillary/mandibular micrognathia (underdeveloped upper or lower jaw); extreme mandibular prognathism; severe asymmetry (craniofacial anomalies); ankylosis of the temporomandibular joint; and other significant skeletal dysplasias. Procedures include but are not limited to: Rapid Palatal Expansion (RPE); Placement of component parts (e.g. brackets, bands); Interceptive orthodontic treatment; Comprehensive orthodontic treatment (during which orthodontic appliances are placed for active treatment and periodically adjusted); Removable appliance therapy; and Orthodontic retention (removal of appliances, construction and placement of retainers). BENJAMIN 000086 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 86 of 237 57 OHINY_SG_COC_2014 10886 NY SG FP PPO AGE 26 COC 02.14 Section - VII Exclusions No Coverage is available under this Certificate for the following: Aviation. We do not Cover services arising out of aviation, other than as a fare-paying passenger on a scheduled or charter flight operated by a scheduled airline. Convalescent and Custodial Care. We do not Cover services related to rest cures, custodial care and transportation. Custodial care means help in transferring, eating, dressing, bathing, toileting and other such related activities. Custodial care does not include Covered services determined to be Medically Necessary. Cosmetic Services. We do not Cover cosmetic services, Prescription Drugs, or surgery except that cosmetic surgery shall not include reconstructive surgery when such service is incidental to or follows surgery resulting from trauma, infection or diseases of the involved part, and reconstructive surgery because of congenital disease or anomaly of a covered Child which has resulted in a functional defect. We also Cover services in connection with reconstructive surgery following a mastectomy, as provided elsewhere in this Certificate. Cosmetic surgery does not include surgery determined to be Medically Necessary. If a claim for a procedure listed in 11 NYCRR 56 (for example, certain plastic surgery and dermatology procedures) is submitted retrospectively and without medical information, any denial will not be subject to the Utilization Review process in Section IX - Grievance, Utilization Review & External Appeals of this Certificate. Coverage Outside of the United States, Canada or Mexico. We do not Cover care or treatment provided outside of the United States, its possessions, Canada or Mexico except for Emergency Services to treat Your Emergency Condition. Dental Services. We do not Cover dental services except for: care or treatment due to accidental injury to sound natural teeth within 12 months of the accident; dental care or treatment necessary due to congenital disease or anomaly; or except as specifically stated in the oral surgery or pediatric dental care section of this Certificate. Experimental or Investigational Treatment. We do not Cover any health care service, procedure, treatment, device, or Prescription Drug that is experimental or investigational. However, We will Cover experimental or investigational treatments, including treatment for Your rare disease or patient costs for Your participation in a clinical trial, when Our denial of services is overturned by an External Appeal Agent certified by the State. However, for clinical trials We will not Cover the costs of any investigational drugs or devices, non-health services required for You to receive the treatment, the costs of managing the research, or costs that would not be Covered under the Certificate for non-investigational treatments. See Section IX - Grievance, Utilization Review & External Appeals of this Certificate for a further explanation of Your Appeal rights. Felony Participation. We do not Cover any illness, treatment or medical condition due to Your participation in a felony, riot or insurrection. This exclusion does not apply to BENJAMIN 000087 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 87 of 237 58 OHINY_SG_COC_2014 10886 NY SG FP PPO AGE 26 COC 02.14 Coverage for services involving injuries suffered by a victim of an act of domestic violence. Foot Care. We do not Cover foot care, in connection with corns, calluses, flat feet, fallen arches, weak feet, chronic foot strain or symptomatic complaints of the feet, except as specifically listed in this Certificate. For foot care related to diabetes, see Section VI - Covered Services of this Certificate. Government Facility. We do not Cover care or treatment provided in a Hospital that is owned or operated by any federal, state or other governmental entity, except as otherwise required by law. Medically Necessary. In general, We will not Cover any health care service, procedure, treatment, device or Prescription Drug that We determine is not Medically Necessary. If an External Appeal Agent certified by the State overturns Our denial, however, We will Cover the procedure, treatment, service, or Prescription Drug for which Coverage has been denied, to the extent that such procedure, treatment, service, or Prescription Drug is otherwise Covered under the terms of this Certificate. Medicare or Other Governmental Program. We do not Cover services if benefits are provided for such services under the federal Medicare program or other governmental program (except Medicaid). Military Service. We do not Cover an illness, treatment or medical condition due to service in the Armed Forces or auxiliary units. No-Fault Automobile Insurance. We do not Cover any benefits to the extent provided for any loss or portion thereof for which mandatory automobile no-fault benefits are recovered or recoverable. This exclusion applies even if You do not make a proper or timely claim for the benefits available to You under a mandatory no-fault policy. Services Separately Billed by Hospital Employees. We do not Cover services rendered and separately billed by employees of Hospitals, laboratories or other institutions. Services Provided by a Family Member. We do not Cover services performed by a member of the Covered person’s immediate family. “Immediate family” shall mean a child, spouse, mother, father, sister, or brother of You or Your spouse. Services With No Charge. We do not Cover services for which no charge is normally made. Services not Listed. We do not Cover services that are not listed in this Certificate as being Covered. Vision Services. We do not Cover the examination or fitting of eyeglasses or contact lenses, except as specifically stated in Section VI - Covered Services of this Certificate. Workers’ Compensation. We do not Cover services if benefits for such services are provided under any state or federal Workers’ Compensation, employers’ liability or occupational disease law. BENJAMIN 000088 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 88 of 237 59 OHINY_SG_COC_2014 10886 NY SG FP PPO AGE 26 COC 02.14 War. We will not Cover an illness, treatment or medical condition due to war, declared or undeclared. BENJAMIN 000089 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 89 of 237 60 OHINY_SG_COC_2014 10886 NY SG FP PPO AGE 26 COC 02.14 Section VIII - Claim Determinations Claims. A claim is a request that benefits or services be provided or paid according to the terms of this Certificate. When You receive services from a Participating Provider you will not need to submit a claim form. However, if You receive services from a Non- Participating Provider either You or the Provider must file a claim form with Us. If the Non-Participating Provider is not willing to file the claim form, You will need to file it with Us. Notice of Claim. Claims for services must include all information designated by Us as necessary to process the claim, including, but not limited to, Member identification number, name, date of birth, date of service, type of service, the charge for each service, procedure code for the service as applicable, diagnosis code, name and address of the Provider making the charge, and supporting medical records, when necessary. A claim that fails to contain all necessary information will not be accepted and must be resubmitted with all necessary information. Claim forms are available from Us by calling the number on your ID card or visiting Our website at www.oxhp.com. Completed claim forms should be sent to the address in Section II - How Your Coverage Works of this Certificate or on Your ID card. Timeframe for Filing Claims. Claims for services must be submitted to Us for payment within 120 days after You receive the services for which payment is being requested. If it is not reasonably possible to submit a claim within the 120 day period, You must submit it as soon as reasonably possible. Claims for Prohibited Referrals. We are not required to pay any claim, bill or other demand or request by a Provider for clinical laboratory services, pharmacy services, radiation therapy services, physical therapy services or x-ray or imaging services furnished pursuant to a referral prohibited by N.Y. Public Health Law § 238-a(1). Claim Determinations. Our claim determination procedure applies to all claims that do not relate to a Medical Necessity or experimental or investigational determination. For example, Our claim determination procedure applies to Referrals and contractual benefit denials. If You disagree with Our claim determination you may submit a Grievance pursuant to Section IX - Grievance, Utilization Review & External Appeals of this Certificate. For a description of the Utilization Review procedures and Appeal process for Medical Necessity or experimental or investigational determinations, see Section IX - Grievance, Utilization Review & External Appeals of this Certificate. A pre-service claim is a request that a service or treatment be approved before it has been received. A post-service claim is a request for a service or treatment that You have already received. Pre-service Claim Determinations. If We have all the information necessary to make a determination regarding a pre- service claim (for example a Referral or a covered benefit determination), We will make BENJAMIN 000090 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 90 of 237 61 OHINY_SG_COC_2014 10886 NY SG FP PPO AGE 26 COC 02.14 a determination and provide notice to You (or Your designee) within 15 days from receipt of the claim. If We need additional information, We will request it within 15 days from receipt of the claim. You will have 45 calendar days to submit the information. If We receive the information within 45 days, We will make a determination and provide notice to You (or Your designee) in writing, within 15 days of Our receipt of the information. If all necessary information is not received within 45 days, We will make a determination within 15 calendar days of the end of the 45 day period. Urgent Pre-service Reviews. With respect to urgent pre-service requests, if We have all information necessary to make a determination, We will make a determination and provide notice to You (or Your designee) by telephone, within 72 hours of receipt of the request. Written notice will follow within three calendar days of the decision. If We need additional information, We will request it within 24 hours. You will then have 48 hours to submit the information. We will make a determination and provide notice to You (or Your designee) by telephone within 48 hours of the earlier of Our receipt of the information or the end of the 48-hour time period. Written notice will follow within three calendar days of the decision. Post-service Claim Determinations. If We have all information necessary to make a determination regarding a post-service claim, We will make a determination and notify You (or Your designee) within 30 calendar days of the receipt of the claim. If We need additional information, We will request it within 30 calendar days. You will then have 45 calendar days to provide the information. We will make a determination and provide notice to You (or Your designee) in writing within 15 calendar days of the earlier of Our receipt of the information or the end of the 45 day period. BENJAMIN 000091 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 91 of 237 62 OHINY_SG_COC_2014 10886 NY SG FP PPO AGE 26 COC 02.14 Section IX - Grievance, Utilization Review & External Appeals GRIEVANCE Grievances. Our Grievance procedure applies to any issue not relating to a Medical Necessity or experimental or investigational determination by Us. For example, it applies to contractual benefit denials or issues or concerns You have regarding Our administrative policies or access to providers. Filing a Grievance. You can contact Us by phone by calling the Customer Service number on Your ID card or in writing to file a Grievance. You may submit an oral Grievance in connection with a denial of a referral or a Covered benefit determination. We may require that You sign a written acknowledgement of Your oral Grievance, prepared by Us. You or Your designee has up to 180 calendar days from when You received the decision You are asking Us to review to file the Grievance. When We receive Your Grievance, We will mail an acknowledgment letter within 15 business days. The acknowledgment letter will include the name, address, and telephone number of the person handling Your Grievance, and indicate what additional information, if any, must be provided. We keep all requests and discussions confidential and We will take no discriminatory action because of Your issue. We have a process for both standard and expedited Grievances, depending on the nature of Your inquiry. Grievance Determination. Qualified personnel will review Your Grievance, or if it is a clinical matter, a licensed, certified or registered Health Care Professional will look into it. We will decide the Grievance and notify You within the following timeframes: Expedited/Urgent Grievances: By phone within the earlier of 48 hours of receipt of the necessary information or 72 hours of receipt of Your Grievance. Written notice will be provided within 72 hours of receipt of Your Grievance. Pre-Service Grievances: (A request for a service or treatment that has not yet been provided.) In writing, within 15 calendar days of receipt of Your Grievance. Post-Service Grievances: (A claim for a service or a treatment that has already been provided.) In writing, within 30 calendar days of receipt of Your Grievance. All Other Grievances: (That are not in relation to a claim or request for service.) In writing, within 30 calendar days of receipt of Your Grievance. BENJAMIN 000092 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 92 of 237 63 OHINY_SG_COC_2014 10886 NY SG FP PPO AGE 26 COC 02.14 Grievance Appeals. If You are not satisfied with the resolution of Your Grievance, You or Your designee may file an Appeal by phone or in writing. You have up to 60 business days from receipt of the Grievance determination to file an Appeal. When We receive Your Appeal, We will mail an acknowledgment letter within 15 business days. The acknowledgement letter will include the name, address, and telephone number of the person handling Your Appeal and indicate what additional information, if any, must be provided. One or more qualified personnel at a higher level than the personnel that rendered the Grievance determination will review it, or if it is a clinical matter, a clinical peer reviewer will look into it. We will decide the Appeal and notify You in writing within the following timeframes: Expedited/Urgent Grievances: The earlier of 2 business days of receipt of the necessary information or 72 hours of receipt of Your Appeal. Pre-Service Grievances: (A request for a service or treatment that has not yet been provided.) 15 calendar days of receipt of Your Appeal. Post-Service Grievances:(A claim for a service or a treatment that has already been provided.) 30 calendar days of receipt of Your Appeal. All Other Grievances: (That are not in relation to a claim or request for service.) 30 calendar days of receipt of Your Appeal. If You remain dissatisfied with Our Appeal determination or at any other time you are dissatisfied, you may: Call the New York State Department of Financial Services at 1-800-342-3736 or write them at: New York State Department of Financial Services Consumer Assistance Unit One Commerce Plaza Albany, NY 12257 www.dfs.ny.gov If You need assistance filing a Grievance or Appeal You may also contact the state independent Consumer Assistance Program at: Community Health Advocates 105 East 22nd Street New York, NY. 10010 Or call toll free: 1-888-614-5400 Or e-mail cha@cssny.org BENJAMIN 000093 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 93 of 237 64 OHINY_SG_COC_2014 10886 NY SG FP PPO AGE 26 COC 02.14 Utilization Review We review health services to determine whether the services are or were Medically Necessary or experimental or investigational ("Medically Necessary"). This process is called Utilization Review (UR). Utilization Review includes all review activities, whether they take place prior to the service being performed (Preauthorization); when the service is being performed (concurrent); or after the service is performed (retrospective). If You have any questions about the Utilization Review process, please call the number on Your ID card. All determinations that services are not Medically Necessary will be made by licensed Physicians or by licensed, certified, registered or credentialed health care professionals who are in the same profession and same or similar specialty as the health care Provider who typically manages Your medical condition or disease or provides the health care service under review. We do not compensate or provide financial incentives to Our employees or reviewers for determining that services are not or were not Medically Necessary. We have developed guidelines and protocols to assist Us in this process. Specific guidelines and protocols are available for Your review upon request. For more information, You can contact Us or visit our website at www.oxhp.com. Preauthorization Reviews If We have all the information necessary to make a determination regarding a Preauthorization review, We will make a determination and provide notice to You (or Your designee) and Your Provider, by telephone and in writing, within three business days of receipt of the request. If We need additional information, We will request it within 3 business days. You or Your Provider will then have 45 calendar days to submit the information. If We receive the requested information within 45 days, We will make a determination and provide notice to You (or Your designee) and Your Provider, by telephone and in writing, within three business days of Our receipt of the information. If all necessary information is not received within 45 days, We will make a determination within 15 calendar days of the end of the 45 day period. Urgent Preauthorization Reviews. With respect to urgent Preauthorization requests, if We have all information necessary to make a determination, We will make a determination and provide notice to You (or Your designee) and Your Provider, by telephone, within 72 hours of receipt of the request. Written notice will follow within one calendar day of the decision. If We need additional information, We will request it within 24 hours. You or Your Provider will then have 48 hours to submit the information. We will make a determination and provide notice to You and Your Provider by telephone and in writing within 48 hours of the earlier of Our receipt of the information or the end of the 48-hour time period. After receiving a request for coverage of home care services following an inpatient Hospital admission, We will make a determination and provide notice to You (or Your designee) and Your Provider, by telephone and in writing, within one business day of receipt of the necessary information. If the day following the request falls on a weekend BENJAMIN 000094 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 94 of 237 65 OHINY_SG_COC_2014 10886 NY SG FP PPO AGE 26 COC 02.14 or holiday, We will make a determination and provide notice to You (or Your designee) and Your Provider within 72 hours of receipt of the necessary information. When We receive a request for home care services and all necessary information prior to Your discharge from an inpatient hospital admission, We will not deny coverage for home care services while Our decision on the request is pending. Concurrent Reviews Utilization review decisions for services during the course of care (concurrent reviews) will be made, and notice provided to You (or Your designee) and Your Provider, by telephone and in writing, within one business day of receipt of all necessary information. If We need additional information, We will request it within one business day. You or Your Provider will then have 45 calendar days to submit the information. We will make a determination and provide notice to You (or Your designee) and Your Provider, by telephone and in writing, within one business of Our receipt of the information or, if We do not receive the information, within 1 business day of the end of the 45-day time period. Urgent Concurrent Reviews. For concurrent reviews that involve an extension of urgent care, if the request for coverage is made at least 24 hours prior to the expiration of a previously approved treatment, We will make a determination and provide notice to You and Your Provider by telephone within 24 hours of receipt of the request. Written notice will be provided within one business day of receipt of the request for coverage if all necessary information was included or three calendar days from the verbal notification if all necessary information was not included. If the request for coverage is not made at least 24 hours prior to the expiration of a previously approved treatment, the Urgent Preauthorization Review timeframes apply. Retrospective Reviews If We have all information necessary to make a determination regarding a retrospective claim, We will make a determination and notify You and Your Provider within 30 calendar days of the receipt of the request. If We need additional information, We will request it within 30 calendar days. You or Your Provider will then have 45 calendar days to provide the information. We will make a determination and provide notice to You and Your Provider in writing within 15 calendar days of the earlier of Our receipt of the information or the end of the 45 day period. Once We have all the information to make a decision, Our failure to make a Utilization review determination within the applicable time frames set forth above will be deemed an adverse determination subject to an internal appeal. Retrospective Review of Preauthorized Services We may only reverse a preauthorized treatment, service or procedure on retrospective review when: The relevant medical information presented to Us upon retrospective review is materially different from the information presented during the Preauthorization review; BENJAMIN 000095 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 95 of 237 66 OHINY_SG_COC_2014 10886 NY SG FP PPO AGE 26 COC 02.14 The relevant medical information presented to Us upon retrospective review existed at the time of the Preauthorization but was withheld or not made available to Us; We were not aware of the existence of such information at the time of the Preauthorization review; and Had We been aware of such information, the treatment, service or procedure being requested would not have been authorized. The determination is made using the same specific standards, criteria or procedures as used during the Preauthorization review. Reconsideration If We did not attempt to consult with Your Provider before making an adverse determination, Your Provider may request reconsideration by the same clinical peer reviewer who made the adverse determination. For Preauthorization and concurrent reviews, the reconsideration will take place within one business day of the request for reconsideration. If the adverse determination is upheld, a notice of adverse determination will be given to You and Your Provider, by telephone and in writing. Utilization Review Internal Appeals You, Your designee, and, in retrospective review cases, Your Provider, may request an internal Appeal of an adverse determination, either by phone, in person, or in writing. You also have the right to Appeal the denial of a Preauthorization request for an out-of- network health service when We determine that the out-of-network health service is not materially different from an available in-network health service. A denial of an out-of- network health service is a service provided by a Non-Participating Provider, but only when the service is not available from a Participating Provider. You are not eligible for a Utilization Review Appeal if the service you request is available from a Participating Provider, even if the Non-Participating Provider has more experience in diagnosing or treating your condition. (Such an Appeal will be treated as a Grievance.) For a Utilization Review Appeal of denial of an Out-of-Network health service, You, or Your designee, must submit: A statement from Your attending Physician, who must be a licensed, board- certified or board-eligible Physician qualified to practice in the specialty area of practice appropriate to treat Your condition, that the requested Out-of-Network health service is materially different from the alternate health service available from a Participating Provider that We approved to treat Your condition; and Two documents from the available medical and scientific evidence that the Out-of- Network service: (a) Is likely to be more clinically beneficial to You than the alternate In-Network service; and (b) that the adverse risk of the Out-of-Network service would likely not be substantially increased over the In-Network health service. BENJAMIN 000096 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 96 of 237 67 OHINY_SG_COC_2014 10886 NY SG FP PPO AGE 26 COC 02.14 You have up to 180 calendar days after You receive notice of the adverse determination to file an Appeal. We will acknowledge Your request for an internal Appeal within 15 calendar days of receipt. This acknowledgment will include the name, address, and phone number of the person handling Your Appeal and, if necessary, inform You of any additional information needed before a decision can be made. A clinical peer reviewer who is a Physician or a Health Care Professional in the same or similar specialty as the Provider who typically manages the disease or condition at issue and who is not subordinate to the clinical peer reviewer who made the initial adverse determination will perform the Appeal. First Level Appeal If Your Appeal relates to a Preauthorization request, We will decide the Appeal within 15 calendar days of receipt of the Appeal request. Written notice of the determination will be provided to You (or Your designee) and where appropriate Your Provider within two business days after the determination is made, but no later than 15 calendar days after receipt of the Appeal request. If Your Appeal relates to a retrospective claim, We will decide the Appeal within 30 calendar days of receipt of the Appeal request. Written notice of the determination will be provided to You (or Your designee) and where appropriate Your Provider within two business days after the determination is made, but no later than 30 calendar days after receipt of the Appeal request. Expedited Appeals. Appeals of reviews of continued or extended health care services, additional services rendered in the course of continued treatment, home health care services following discharge from an inpatient Hospital admission, services in which a Provider requests an immediate review, or any other urgent matter will be handled on an expedited basis. Expedited Appeals are not available for retrospective reviews. For expedited Appeals, Your Provider will have reasonable access to the clinical peer reviewer assigned to the Appeal within one business day of receipt of the request for an Appeal. Your Provider and a clinical peer reviewer may exchange information by telephone or fax. Expedited Appeals will be determined within the lesser of 72 hours from receipt of the Appeal or two business days of receipt of the information necessary to conduct the Appeal. If You are not satisfied with the resolution of Your expedited Appeal, You may file a standard internal Appeal or an external appeal. Our failure to render a determination of Your Appeal within 60 calendar days of receipt of the necessary information for a standard Appeal or within two business days of receipt of the necessary information for an expedited Appeal will be deemed a reversal of the initial adverse determination. Second level Appeal If You disagree with the first level Appeal determination, You or Your designee can file a second level Appeal. You or Your designee can also file an external appeal. The four month timeframe for filing an external appeal begins on receipt of the final adverse BENJAMIN 000097 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 97 of 237 68 OHINY_SG_COC_2014 10886 NY SG FP PPO AGE 26 COC 02.14 determination on the first level of Appeal. By choosing to file a second level Appeal, the time may expire for You to file an external appeal. A second level Appeal must be filed within 45 days of receipt of the final adverse determination on the first level Appeal. We will acknowledge Your request for an internal Appeal within 15 calendar days of receipt. This acknowledgment will include the name, address, and phone number of the person handling Your Appeal and, if necessary, inform You of any additional information needed before a decision can be made. If Your Appeal relates to a Preauthorization request, We will decide the Appeal within 15 calendar days of receipt of the Appeal request. Written notice of the determination will be provided to You (or Your designee) and where appropriate Your Provider within two business days after the determination is made, but no later than 15 calendar days after receipt of the Appeal request. If Your Appeal relates to a retrospective claim, We will decide the Appeal within 30 calendar days of receipt of the Appeal request. Written notice of the determination will be provided to You (or Your designee) and where appropriate Your Provider within two business days after the determination is made, but no later than 30 calendar days after receipt of the Appeal request. If you need Assistance filing an Appeal You may contact the state independent Consumer Assistance Program at: Community Health Advocates 105 East 22nd Street New York, NY. 10010 Or call toll free: 1-888-614-5400 Or e-mail cha@cssny.org External Appeal YOUR RIGHT TO AN EXTERNAL APPEAL In some cases, You have a right to an external appeal of a denial of coverage. Specifically, if We have denied coverage on the basis that a service does not meet Our requirements for Medical Necessity (including appropriateness, health care setting, level of care, or effectiveness of a covered benefit) or is an experimental or investigational treatment (including clinical trials and treatments for rare diseases), or is an out-of- network treatment, You or Your representative may appeal that decision to an External Appeal Agent, an independent third party certified by the State to conduct these appeals. In order for You to be eligible for an external appeal You must meet the following two requirements: The service, procedure, or treatment must otherwise be a Covered Service under the Certificate and BENJAMIN 000098 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 98 of 237 69 OHINY_SG_COC_2014 10886 NY SG FP PPO AGE 26 COC 02.14 In general, You must have received a final adverse determination through the first level of Our internal Appeal process. But, You can file an external appeal even though You have not received a final adverse determination through the first level of Our internal Appeal process if: We agree in writing to waive the internal Appeal. We are not required to agree to Your request to waive the internal Appeal; or You file an external appeal at the same time as You apply for an expedited internal Appeal; or We fail to adhere to Utilization review claim processing requirements (other than a minor violation that is not likely to cause prejudice or harm to You, and We demonstrate that the violation was for good cause or due to matters beyond Our control and the violation occurred during an ongoing, good faith exchange of information between You and Us). YOUR RIGHT TO APPEAL A DETERMINATION THAT A SERVICE IS NOT MEDICALLY NECESSARY If We have denied coverage on the basis that the service does not meet Our requirements for Medical Necessity, You may appeal to an External Appeal Agent if You meet the requirements for an external appeal in I above. YOUR RIGHT TO APPEAL A DETERMINATION THAT A SERVICE IS EXPERIMENTAL OR INVESTIGATIONAL If We have denied coverage on the basis that the service is an experimental or investigational treatment, You must satisfy the two requirements for an external appeal in I above and Your attending Physician must certify that: (1) Your condition or disease is one for which standard health services are ineffective or medically inappropriate; or (2) one for which there does not exist a more beneficial standard service or procedure covered by Us; or (3) one for which there exists a clinical trial or rare disease treatment (as defined by law). In addition, Your attending Physician must have recommended one of the following: A service, procedure or treatment that two (2) documents from available medical and scientific evidence indicate is likely to be more beneficial to You than any standard Covered Service (only certain documents will be considered in support of this recommendation - Your attending Physician should contact the State for current information as to what documents will be considered or acceptable); or A clinical trial for which You are eligible (only certain clinical trials can be considered); or A rare disease treatment for which Your attending Physician certifies that there is no standard treatment that is likely to be more clinically beneficial to You than the requested service, the requested service is likely to benefit You in the treatment of Your rare disease, and such benefit outweighs the risk of the service. In addition, Your attending Physician must certify that Your condition is a rare disease that is BENJAMIN 000099 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 99 of 237 70 OHINY_SG_COC_2014 10886 NY SG FP PPO AGE 26 COC 02.14 currently or was previously subject to a research study by the National Institutes of Health Rare Disease Clinical Research Network or that it affects fewer than 200,000 U.S. residents per year. For purposes of this section, Your attending Physician must be a licensed, board- certified or board eligible Physician qualified to practice in the area appropriate to treat Your condition or disease. In addition, for a rare disease treatment, the attending Physician may not be Your treating Physician. YOUR RIGHT TO APPEAL A DETERMINATION THAT A SERVICE IS OUT-OF- NETWORK If We have denied coverage of an Out-of-Network treatment because it is not materially different than the health service available In-Network, You may appeal to an External Appeal Agent if You meet the two requirements for an external appeal in I above, and You have requested preauthorization for the Out-of-Network treatment. In addition, Your attending Physician must certify that the Out-of-Network service is materially different from the alternate recommended In-Network health service, and based on two (2) documents from available medical and scientific evidence, is likely to be more clinically beneficial than the alternate In-Network treatment and that the adverse risk of the requested health service would likely not be substantially increased over the alternate In-Network health service. For purposes of this section, Your attending Physician must be a licensed, board- certified or board eligible Physician qualified to practice in the specialty area appropriate to treat You for the health service. You do not have a right to an external appeal for a denial of a Referral to an Out-of- Network provider on the basis that a health care provider is available In-Network to provide the particular health service requested by You. THE EXTERNAL APPEAL PROCESS You have four (4) months from receipt of a final adverse determination or from receipt of a waiver of the internal Appeal process to file a written request for an external appeal. If You are filing an external appeal based on Our failure to adhere to claim processing requirements, You have four (4) months from such failure to file a written request for an external appeal. We will provide an external appeal application with the final adverse determination issued through the first level of Our internal Appeal process or Our written waiver of an internal Appeal. You may also request an external appeal application from the New York State Department of Financial Services at 1-800-400-8882. Submit the completed application to the Department of Financial Services at the address indicated on the application. If You meet the criteria for an external appeal, the State will forward the request to a certified External Appeal Agent. You can submit additional documentation with Your external appeal request. If the External Appeal Agent determines that the information You submit represents a material change from the information on which We based Our denial, the External Appeal Agent BENJAMIN 000100 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 100 of 237 71 OHINY_SG_COC_2014 10886 NY SG FP PPO AGE 26 COC 02.14 will share this information with Us in order for Us to exercise Our right to reconsider Our decision. If We choose to exercise this right, We will have three (3) business days to amend or confirm Our decision. Please note that in the case of an expedited appeal (described below), We do not have a right to reconsider Our decision. In general, the External Appeal Agent must make a decision within 30 days of receipt of Your completed application. The External Appeal Agent may request additional information from You, Your Physician, or Us. If the External Appeal Agent requests additional information, it will have five (5) additional business days to make its decision. The External Appeal Agent must notify You in writing of its decision within two (2) business days. If Your attending Physician certifies that a delay in providing the service that has been denied poses an imminent or serious threat to Your health; or if Your attending Physician certifies that the standard external appeal time frame would seriously jeopardize Your life, health or ability to regain maximum function; or if You received emergency services and have not been discharged from a facility and the denial concerns an admission, availability of care, or continued stay, You may request an expedited external appeal. In that case, the External Appeal Agent must make a decision within seventy-two (72) hours of receipt of Your completed application. Immediately after reaching a decision, the External Appeal Agent must try to notify You and Us by telephone or facsimile of that decision. The External Appeal Agent must also notify You in writing of its decision. If the External Appeal Agent overturns Our decision that a service is not Medically Necessary or approves coverage of an experimental or investigational treatment or an Out-of-Network treatment We will provide coverage subject to the other terms and conditions of this Certificate. Please note that if the External Appeal Agent approves coverage of an experimental or investigational treatment that is part of a clinical trial, We will only Cover the costs of services required to provide treatment to You according to the design of the trial. We will not be responsible for the costs of investigational drugs or devices, the costs of non-health care services, the costs of managing research, or costs which would not be Covered under this Certificate for non-experimental or non- investigational treatments provided in the clinical trial. The External Appeal Agent’s decision is binding on both You and Us. The External Appeal Agent’s decision is admissible in any court proceeding. We will charge You a fee of $25 for each external appeal, not to exceed $75 in a single plan year. The external appeal application will explain how to submit the fee. We will waive the fee if We determine that paying the fee would be a hardship to You. If the External Appeal Agent overturns the denial of coverage, the fee will be refunded to You. YOUR RESPONSIBILITIES It is Your RESPONSIBILITY to start the external appeal process. You may start the external appeal process by filing a completed application with the New York State Department of Financial Services. You may appoint a representative to assist You with BENJAMIN 000101 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 101 of 237 72 OHINY_SG_COC_2014 10886 NY SG FP PPO AGE 26 COC 02.14 Your application; however, the Department of Financial Services may contact You and request that You confirm in writing that You have appointed the representative. Under New York State law, Your completed request for external appeal must be filed within four (4) months of either the date upon which You receive a final adverse determination, or the date upon which You receive a written waiver of any internal Appeal, or Our failure to adhere to claim processing requirements. We have no authority to extend this deadline. BENJAMIN 000102 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 102 of 237 73 OHINY_SG_COC_2014 10886 NY SG FP PPO AGE 26 COC 02.14 SECTION X - Coordination of Benefits This section applies when you also have group health coverage with another plan. When You receive a Covered service, We will coordinate benefit payments with any payment made by another plan. The primary plan will pay its full benefits and the other plan may pay secondary benefits, if necessary, to cover some or all of the remaining expenses. This prevents duplicate payments and overpayments. Definitions “Allowable expense” is the necessary, reasonable, and customary item of expense for health care, when the item is covered at least in part under any of the plans involved, except where a statute requires a different definition. When a plan provides benefits in the form of services, the reasonable cash value of each service will be considered as both an allowable expense and a benefit paid. “Plan” is other group health coverage with which We will coordinate benefits. The term “plan” includes: 1. Group health benefits and group blanket or group remittance health benefits coverage, whether insured, self-insured, or self-funded. This includes group HMO and other prepaid group coverage, but does not include blanket school accident coverage or coverages issued to a substantially similar group (e.g., Girl Scouts, Boy Scouts) where the school or organization pays the premiums. 2. Medical benefits coverage, in group and individual automobile “no-fault” and traditional liability “fault” type contracts. 3. Hospital, medical, and surgical benefits coverage of Medicare or a governmental plan offered, required, or provided by law, except Medicaid or any other plan whose benefits are by law excess to any private benefits coverage. “Primary plan” is one whose benefits must be determined without taking the existence of any other plan into consideration. A plan is primary if either: (1) the plan has no order of benefits rules or its rules differ from those required by regulation; or (2) all plans which cover the person use the order of benefits rules required by regulation and under those rules the plan determines its benefits first. More than one plan may be a primary plan (for example, two plans which have no order of benefit determination rules). “Secondary plan” is one which is not a primary plan. If a person is covered by more than one secondary plan, the order of benefit determination rules decide the order in which their benefits are determined in relation to each other. Rules to Determine Order of Payment The first of the rules listed below in paragraphs 1-6 that applies will determine which plan will be primary: 1. If the other plan does not have a provision similar to this one, then the other plan will be primary. BENJAMIN 000103 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 103 of 237 74 OHINY_SG_COC_2014 10886 NY SG FP PPO AGE 26 COC 02.14 2. If the person receiving benefits is the Subscriber and is only covered as a Dependent under the other plan, this Certificate will be primary. 3. If a child is covered under the plans of both parents and the parents are not separated or divorced, the plan of the parent whose birthday falls earlier in the year shall be primary. If both parents have the same birthday, the plan which covered the parent longer will be primary. To determine whose birthday falls earlier in the year, only the month and day are considered. However, if the other plan does not have this birthday rule, but instead has a rule based on the sex of the parent and as a result the plans do not agree on which is primary, then the rule in the other plan will determine which plan is primary. 4. If a child is covered by both parents’ plans, the parents are separated or divorced, and there is no court decree between the parents that establishes financial responsibility for the child’s health care expenses: a. The plan of the parent who has custody will be primary; b. If the parent with custody has remarried, and the child is also covered as a child under the step-parent’s plan, the plan of the parent with custody will pay first, the step-parent's plan will pay second, and the plan of the parent without custody will pay third. c. If a court decree between the parents says which parent is responsible for the child’s health care expenses, then that parent’s plan will be primary if that plan has actual knowledge of the decree. 5. If the person receiving services is covered under one plan as an active employee or member (i.e., not laid-off or retired), or as the spouse or child of such an active employee, and is also covered under another plan as a laid-off or retired employee or as the spouse or child of such a laid-off or retired employee, the plan that covers such person as an active employee or spouse or child of an active employee will be primary. If the other plan does not have this rule, and as a result the plans do not agree on which will be primary, this rule will be ignored. 6. If none of the above rules determine which plan is primary, the plan that covered the person receiving services longer will be primary. Effects of Coordination When this plan is secondary, its benefits will be reduced so that the total benefits paid by the primary plan and this plan during a claim determination period will not exceed Our maximum available benefit for each Covered Service. Also, the amount We pay will not be more than the amount We would pay if We were primary. As each claim is submitted, We will determine Our obligation to pay for allowable expenses based upon all claims that have been submitted up to that point in time during the claim determination period. Right to Receive and Release Necessary Information We may release or receive information that We need to coordinate benefits. We do not need to tell anyone or receive consent to do this. We are not responsible to anyone for BENJAMIN 000104 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 104 of 237 75 OHINY_SG_COC_2014 10886 NY SG FP PPO AGE 26 COC 02.14 releasing or obtaining this information. You must give Us any needed information for coordination purposes, in the time frame requested. Our Right to Recover Overpayment If We made a payment as a primary plan, You agree to pay Us any amount by which We should have reduced Our payment. Also, We may recover any overpayment from the primary plan or the Provider receiving payment and You agree to sign all documents necessary to help Us recover any overpayment. Coordination with “Always Excess,” “Always Secondary,” or “Non-Complying” Plans We will coordinate benefits with plans, whether insured or self-insured, that provide benefits that are stated to be always excess or always secondary or use order of benefit determination rules that are inconsistent with the rules described above in the following manner: 1. If this Certificate is primary, as defined in this section, We will pay benefits first. 2. If this Certificate is secondary, as defined in this section, We will pay only the amount We would pay as the secondary insurer; 3. If We request information from a non-complying plan and do not receive it within 30 days, We will calculate the amount We should pay on the assumption that the non-complying plan and this Certificate provide identical benefits. When the information is received, We will make any necessary adjustments. BENJAMIN 000105 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 105 of 237 76 OHINY_SG_COC_2014 10886 NY SG FP PPO AGE 26 COC 02.14 Section XI - Termination of Coverage Coverage under this Certificate will automatically be terminated on the first of the following to apply. In all cases of termination, unless otherwise noted below, We will provide at least 30 days prior written notice to the Group. 1. The Group, and/or Subscriber, has failed to pay Premiums within 30 days of when Premiums are due. Coverage will terminate as of the last day for which Premiums were paid. 2. The end of month in which the Subscriber ceases to meet the eligibility requirements as defined by the Group. 3. Upon the Subscriber’s death, coverage will terminate unless You have coverage for Dependents. If You have coverage for Dependents, then coverage will terminate as of the last day of the month for which the Premium has been paid. 4. For Spouses in cases of divorce, the date of the divorce. 5. For Children, until the end of the year in which the Child turns 26 years of age. For all other Dependents, the end of month which the Dependent ceases to be eligible. 6. The end of the month during which the Subscriber provides written notice to Us requesting termination of coverage, or on such later date requested for such termination by the notice. 7. If a Subscriber has performed an act that constitutes fraud or made an intentional misrepresentation of material fact in writing on his/her enrollment application, or in order to obtain coverage for a service, coverage will terminate immediately upon written notice of termination delivered by Us to the Subscriber. However, if a Subscriber makes an intentional misrepresentation of material fact in writing on his/her enrollment application we will rescind coverage if the facts misrepresented would have led Us to refuse to issue the coverage. Rescission means that the termination of Your coverage will have a retroactive effect of up to Your enrollment under the Certificate. 8. The date that the Group Policy is terminated. If We terminate and/or decide to stop offering a particular class of group policies, without regard to claims experience or health related status, to which this Certificate belongs, We will provide the Group and Subscribers at least 90 days prior written notice. 9. If We elect to terminate or cease offering all hospital, surgical and medical expense coverage in the small group market, in this state, We will provide written notice to the Group and Subscriber at least 180 days prior to when the coverage will cease. 10. The Group has performed an act or practice that constitutes fraud or made an intentional misrepresentation of material fact under the terms of the coverage. 11. The Group has failed to comply with a material plan provision relating to employer contribution or group participation rules. BENJAMIN 000106 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 106 of 237 77 OHINY_SG_COC_2014 10886 NY SG FP PPO AGE 26 COC 02.14 12. The Group ceases to meet the statutory requirements to be defined as a group for the purposes of obtaining coverage. 13. The date there is no longer any enrollee who lives, resides, or works in Our Service Area. No termination of coverage shall prejudice the right to a claim for benefits which arose prior to such termination. See Section XII - What Happens if You Lose Coverage of this Certificate for Your right to continuation of this coverage and for Your right to conversion to an individual Policy. BENJAMIN 000107 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 107 of 237 78 OHINY_SG_COC_2014 10886 NY SG FP PPO AGE 26 COC 02.14 Section XII - What Happens If You Lose Coverage EXTENSION OF BENEFITS When Your coverage under this Certificate ends, benefits stop. But, if You are totally disabled on the date the Group Policy terminates, or on the date Your coverage under this Certificate terminates, continued benefits may be available for the treatment of the injury or sickness that is the cause of the total disability. For purposes of this section, total disability means You are prevented because of injury or disease from engaging in any work or other gainful activity. Total disability for a minor means that the minor is prevented because of injury or disease from engaging in substantially all of the normal activities of a person of like age and sex who is in good health. When You May Continue Benefits When Your coverage under this Certificate ends, We will provide benefits during a period of total disability for a Hospital stay commencing, or surgery performed, within 31 days from the date Your coverage ends. The Hospital stay or surgery must be for the treatment of the injury, sickness, or pregnancy causing the total disability. If Your coverage ends because You are no longer employed, We will provide benefits during a period of total disability for up to 12 months from the date Your coverage ends for Covered services to treat the injury, sickness, or pregnancy that caused the total disability, unless these services are covered under another group health plan. Termination of Extension of Benefits Extended benefits will end on the earliest of the following: The date You are no longer totally disabled; The date the contractual benefit has been exhausted; 12 months from the date extended benefits began (if Your benefits are extended based on termination of employment); With respect to the 12 month extension of coverage, the date You become eligible for benefits under any group policy providing medical benefits. Limits on Extended Benefits We will not pay extended benefits: For any Member who is not totally disabled on the date coverage under this Certificate ends; Beyond the extent to which We would have paid benefits under this Certificate if coverage had not ended. BENJAMIN 000108 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 108 of 237 79 OHINY_SG_COC_2014 10886 NY SG FP PPO AGE 26 COC 02.14 Continuation of Coverage Under the continuation of coverage provisions of the federal Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA), most employer-sponsored group health plans must offer employees and their families the opportunity for a temporary continuation of health insurance coverage when their coverage would otherwise end. If You are not entitled to temporary continuation of coverage under COBRA, You may be entitled to temporary continuation coverage under the New York Insurance Law as described below. Call or write Your employer to find out if You are entitled to temporary continuation of coverage under COBRA or under the New York Insurance Law. Any period of continuation of coverage will terminate automatically at the end of the period of continuation provided under COBRA or the New York Insurance Law. Pursuant to federal COBRA and state continuation coverage laws, You, the Subscriber, Your Spouse and Your Children may be able to temporarily continue coverage under this Certificate in certain situations when You would otherwise lose coverage, known as qualifying events. 1. If Your coverage ends due to voluntary or involuntary termination of employment or a change in Your employee class (e.g. a reduction in the number of hours of employment) You may continue coverage. Coverage may be continued for You, Your Spouse and any of Your Covered Children. 2. If You are a Covered Spouse, You may continue coverage if Your coverage ends due to: a. Voluntary or involuntary termination of the Covered employee’s employment; b. Reduction in the hours worked by the Covered employee or other change in the employee’s class; c. Divorce or legal separation of the Covered employee; d. Death of the Covered employee; or e. The Covered employee becoming entitled to Medicare. 3. If You are a Covered Child, You may continue coverage if Your coverage ends due to: a. Voluntary or involuntary termination of the Covered employee’s employment; b. Reduction in the hours worked by the Covered employee or other change in the employee’s class; c. Loss of Covered Child status under the plan rules; d. Death of the Covered employee; or e. The Covered employee becoming entitled to Medicare. If You want to continue coverage You must request continuation from Your employer in writing and make the first Premium payment within the 60-day period following the later of: BENJAMIN 000109 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 109 of 237 80 OHINY_SG_COC_2014 10886 NY SG FP PPO AGE 26 COC 02.14 1. The date coverage would otherwise terminate; or 2. The date You are sent notice by first class mail of the right of continuation by the Group policyholder. The policyholder can charge up to 102% of the Group Premium for continued coverage. Continued coverage under this section will terminate at the earliest of the following: 1. The date 36 months after Your coverage would have terminated because of termination of employment; 2. If You are a Covered Spouse or Child the date 36 months after coverage would have terminated due to the death of the employee, divorce or legal separation, the employee’s eligibility for Medicare, or the failure to qualify under the definition of “Children”; 3. The date You become Covered by an insured or uninsured arrangement that provides group hospital, surgical or medical coverage; 4. The date You become entitled to Medicare; 5. The date to which Premiums are paid if You fail to make a timely payment; or 6. The date the Group Policy terminates. However, if the Group Policy is replaced with similar coverage, You have the right to become covered under the new Group Policy for the balance of the period remaining for Your continued coverage. When Your continuation of coverage ends, You may have a right to conversion. See Section XII - What Happens if You Lose Coverage of the Certificate. Supplementary Continuation, Conversion, and Temporary Suspension Rights During Active Duty. If You, the Subscriber are a member of a reserve component of the armed forces of the United States, including the National Guard, You have the right to continuation, conversion, or a temporary suspension of coverage during active duty and reinstatement of coverage at the end of active duty if Your Group does not voluntarily maintain Your coverage and if: 1. Your active duty is extended during a period when the president is authorized to order units of the reserve to active duty, provided that such additional active duty is at the request and for the convenience of the federal government, and 2. You serve no more than four years of active duty. When Your Group does not voluntarily maintain Your coverage during active duty, coverage under this Certificate will be suspended unless You elect to continue coverage in writing within 60 days of being ordered to active duty and You pay the Group policyholder the required Premium payment but not more frequently than on a monthly basis in advance. This right of continuation extends to You and Your eligible Dependents. Continuation of coverage is not available for any person who is eligible to be covered under Medicare; or any person who is covered as an employee, member or dependent under any other insured or uninsured arrangement which provides group BENJAMIN 000110 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 110 of 237 81 OHINY_SG_COC_2014 10886 NY SG FP PPO AGE 26 COC 02.14 hospital, surgical or medical coverage, except for coverage available to active duty members of the uniformed services and their family members. Upon completion of active duty: 1. Your coverage under this Certificate may be resumed as long as You are reemployed or restored to participation in the Group upon return to civilian status. The right of resumption extends to coverage for Your Covered Dependents. For coverage that was suspended while on active duty, coverage under the Group plan will be retroactive to the date on which active duty terminated. 2. If You are not reemployed or restored to participation in Your Group upon return to civilian status, You will be eligible for continuation and conversion as long as You apply to Us for coverage within 31 days of the termination of active duty or discharge from a Hospitalization resulting from active duty as long as the Hospitalization was not in excess of one year. Age 29 Dependent Coverage Extensions Young Adult Option Your Child may be eligible to purchase his or her own individual coverage under Your Group’s policy through the age of 29 if he or she 1) is under the age of 30; 2) is not married; 3) is not insured by or eligible for coverage under an employer-sponsored health benefit plan covering him or her as an employee or member, whether insured or self-insured; 4) lives, works or resides in New York State or Our Service Area; and 5) is not covered by Medicare. The Child may purchase coverage even if he or she is not financially Dependent on his or her parent(s) and does not need to live with his or her parent(s). Your Child may elect this coverage: 1. Within 60 days of the date that his or her coverage would otherwise end due to reaching the maximum age for Dependent coverage, in which case coverage will be retroactive to the date that coverage would otherwise have terminated; 2. Within 60 days of newly meeting the eligibility requirements, in which case coverage will be prospective and start within 30 days of when the Group policyholder or Group policyholder’s designee receives notice and We receive Premium payment; 3. During an annual 30-day open enrollment period, in which case coverage will be prospective and will start within 30 days of when the Group policyholder or Group policyholder’s designee receives notice of election and We receive Premium payment. You or Your Child must pay the Premium rate that applies to individual coverage. Coverage will be the same as the coverage provided under this Certificate. Your Child's children are not eligible for coverage under this option. BENJAMIN 000111 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 111 of 237 82 OHINY_SG_COC_2014 10886 NY SG FP PPO AGE 26 COC 02.14 Conversion Right To New Contract After Termination You have the right to convert to a new Contract if coverage under this Certificate terminates under the circumstances described below. 1. Termination of the Group Policy. If the Group Policy between Us and the Group Policyholder is terminated as set forth in Section XI - Termination of Coverage of this Certificate, and the Group Policyholder has not replaced the coverage for the Group with similar and continuous health care coverage, whether insured or self- insured, You are entitled to purchase a new Contract as direct payment members. 2. If You Are No Longer Covered in a Group. If Your coverage terminates under Section XI - Termination of Coverage of this Certificate because You are no longer a member of a Group, You are entitled to purchase a new Contract as a direct payment member. 3. On the Death of the Subscriber. If coverage terminates under Section XI - Termination of Coverage of this Certificate because of the death of the Subscriber, the Subscriber’s Dependents are entitled to purchase a new Contract as direct payment members. 4. Termination of Your Marriage. If a Spouse’s coverage terminates under Section XI - Termination of Coverage of this Certificate because the Spouse becomes divorced from the Subscriber or the marriage is annulled, that former Spouse is entitled to purchase a new Contract as a direct payment member. 5. Termination of Coverage of a Child. If a Child’s coverage terminates under Section XI - Termination of Coverage of this Certificate because the Child no longer qualifies as a Child, the Child is entitled to purchase a new Contract as a direct payment member. 6. Termination of Your Temporary Continuation of Coverage. If coverage terminates under Section XI - Termination of Coverage of this Certificate because You are no longer eligible for continuation of coverage, You are entitled to purchase a new Contract as a direct payment member. 7. Termination of Your Young Adult Coverage. If a Child’s young adult coverage terminates under Section XI - Termination of Coverage of this Certificate, the Child is entitled to purchase a new Contract as a direct payment member. When to Apply for the New Contract. If You are entitled to purchase a new Contract as described above, You must apply to Us for the new Contract within 60 days after termination of coverage under this Contract. You must also pay the first Premium of the new Contract at the time You apply for coverage. The New Contract. We will offer You an individual direct payment Contract at each level of coverage (i.e., bronze, silver, gold or platinum) that covers all benefits required by state and federal law. You may choose among any of the four Contracts offered by Us. However, the coverage may not be the same as Your current coverage. However, BENJAMIN 000112 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 112 of 237 83 OHINY_SG_COC_2014 10886 NY SG FP PPO AGE 26 COC 02.14 if We determine that You do not reside in New York State, We may issue You or Your family members coverage on a form that we use for conversion in that state. When Conversion is Not Available. We will not issue You an individual direct payment Contract if the issuance of the new Contract will result in overinsurance or duplication of benefits according to the standards We have on file with the Superintendent of the New York State Department of Financial Services. BENJAMIN 000113 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 113 of 237 84 OHINY_SG_COC_2014 10886 NY SG FP PPO AGE 26 COC 02.14 Section XIII - General Provisions 1. Agreements between Us and Participating Providers. Any agreement between Us and Participating Providers may only be terminated by Us or the Providers. This Certificate does not require any Provider to accept a Member as a patient. We do not guarantee a Member’s admission to any Participating Provider or any health benefits program. 2. Assignment. You cannot assign any benefits or monies due under this Certificate to any person, corporation, or other organization. Any assignment by You will be void. Assignment means the transfer to another person or to an organization of Your right to the services provided under this Certificate or your right to collect money from us for those services. However, You may request Us to make payment for services directly to Your Provider instead of You. 3. Changes in This Certificate. We may unilaterally change this Certificate upon renewal, if We give the Group Policyholder 30 days’ prior written notice. 4. Choice of Law. This Certificate shall be governed by the laws of the State of New York. 5. Clerical Error. Clerical error, whether by the Group Policyholder or Us, with respect to this Certificate, or any other documentation issued by Us in connection with this Certificate, or in keeping any record pertaining to the coverage hereunder, will not modify or invalidate coverage otherwise validly in force or continue coverage otherwise validly terminated. 6. Continuation of Benefit Limitations. Some of the benefits under this Certificate may be limited to a specific number of visits, and/or subject to a Deductible. You will not be entitled to any additional benefits if Your coverage status should change during the Year. For example, if Your coverage status changes from covered family member to Subscriber, all benefits previously utilized when you were a covered family member will be applied toward your new status as a Subscriber. 7. Enrollment ERISA. The Group Policyholder will develop and maintain complete and accurate payroll records, as well as any other records of the names, addresses, ages, and social security numbers of all group members covered under this Certificate, and any other information required to confirm their eligibility for coverage. The Group Policyholder will provide Us with this information upon request. The Group Policyholder may also have additional responsibilities as the “plan administrator” as defined by the Employee Retirement Income Security Act of 1974, as amended (“ERISA”). The “plan administrator” is the Group Policyholder, or a third party appointed by the Group Policyholder. We are not the ERISA plan administrator. 8. Entire Agreement. This Certificate, including any endorsements, riders and the attached applications, if any, constitutes the entire Certificate. BENJAMIN 000114 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 114 of 237 85 OHINY_SG_COC_2014 10886 NY SG FP PPO AGE 26 COC 02.14 9. Furnishing Information and Audit. The Group Policyholder and all persons covered under this Certificate will promptly furnish Us with all information and records that We may require from time to time to perform Our obligations under this Certificate. You must provide Us with information over the telephone for reasons like the following: to allow Us to determine the level of care You need; so that We may certify care authorized by Your Physician; or to make decisions regarding the Medical Necessity of Your care. The Group Policyholder will, upon reasonable notice, make available to Us, and We may audit and make copies of, any and all records relating to group enrollment at the Group Policyholder’s New York office. 10. Identification Cards. Identification cards are issued by Us for identification only. Possession of any identification card confers no right to services or benefits under this Certificate. To be entitled to such services or benefits Your Premiums must be paid in full at the time that the services are sought to be received. 11. Incontestability. No statement made by You will be the basis for avoiding or reducing coverage unless it is in writing and signed by You. All statements contained in any such written instrument shall be deemed representations and not warranties. 12. Independent Contractors. Participating Providers are independent contractors. They are not Our agents or employees. We and Our employees are not the agent or employee of any Participating Provider. We are not liable for any claim or demand on account of damages arising out of, or in any manner connected with, any injuries alleged to be suffered by You, Your Covered Spouse or Children while receiving care from any Participating Provider or in any Participating Provider's facility. 13. Material Accessibility. We will give the Group Policyholder, and the Group Policyholder will give You, identification cards, Certificates, riders, and other necessary materials. 14. More Information about Your Health Plan. You can request additional information about Your coverage under this Certificate. Upon Your request, We will provide the following information. A list of the names, business addresses and official positions of Our board of directors, officers and members; and Our most recent annual certified financial statement which includes a balance sheet and a summary of the receipts and disbursements. The information that We provide the State regarding Our consumer complaints. A copy of Our procedures for maintaining confidentiality of Member information. A copy of Our drug formulary. You may also inquire if a specific drug is Covered under this Certificate. BENJAMIN 000115 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 115 of 237 86 OHINY_SG_COC_2014 10886 NY SG FP PPO AGE 26 COC 02.14 A written description of Our quality assurance program. A copy of Our medical policy regarding an experimental or investigational drug, medical device or treatment in clinical trials. Provider affiliations with Participating Hospitals. A copy of Our clinical review criteria, and where appropriate, other clinical information We may consider regarding a specific disease, course of treatment or utilization review guidelines. 15. Notice. Any notice that We give to You under this Certificate will be mailed to Your address as it appears on our records or to the address of the Group Policyholder. You agree to provide Us with notice of any change of Your address. If You have to give Us any notice, it should be sent by U.S. Mail, first class, postage prepaid to: Correspondence Department PO Box 29135 Hot Springs, AR. 71903. 16. Premium Refund. We will give any refund of Premiums, if due, to the Group Policyholder. 17. Recovery of Overpayments. On occasion a payment will be made to You when You are not covered, for a service that is not covered, or which is more than is proper. When this happens We will explain the problem to You and You must return the amount of the overpayment to Us within 60 days after receiving notification from Us. However, We shall not initiate overpayment recovery efforts more than 24 months after the original payment was made unless We have a reasonable belief of fraud or other intentional misconduct. 18. Renewal Date. The renewal date for the Certificate is the anniversary of the effective date of the Group Policy in each Year. This Certificate will automatically renew each year on the renewal date unless otherwise terminated by Us or the Group Policyholder as permitted by the Certificate, or by You upon 30 days’ prior written notice to the Group Policyholder. 19. Right to Develop Guidelines and Administrative Rules. We may develop or adopt standards that describe in more detail when We will make or will not make payments under this Certificate. Examples of the use of the standards are: to determine whether Hospital inpatient care was Medically Necessary; whether surgery was Medically Necessary to treat Your illness or injury; or whether certain services are skilled care. Those standards will not be contrary to the descriptions in this Certificate. If You have a question about the standards that apply to a particular benefit, You may contact Us and We will explain the standards or send You a copy of the standards. We may also develop administrative rules pertaining to enrollment and other administrative matters. We shall have all the powers necessary or appropriate to enable Us to carry out Our duties in connection with the administration of this Certificate. 20. Right to Offset. If We make a claim payment to You or on Your behalf in error or You owe Us any money, You must repay the amount You owe to Us. Except as otherwise required by law, if We owe You a payment for other claims received, We BENJAMIN 000116 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 116 of 237 87 OHINY_SG_COC_2014 10886 NY SG FP PPO AGE 26 COC 02.14 have the right to subtract any amount You owe Us from any payment We owe You. 21. Severability. The unenforceability or invalidity of any provision of the Certificate shall not affect the validity and enforceability of the remainder of the Certificate. 22. Significant Change in Circumstances. If We are unable to arrange for Covered Services as provided under this Certificate as the result of events outside of Our control, We will make a good faith effort to make alternative arrangements. These events would include a major disaster, epidemic, the complete or partial destruction of facilities, riot, civil insurrection, disability of a significant part of Participating Providers' personnel or similar causes. We will make reasonable attempts to arrange for Covered Services. We and Our Participating Providers will not be liable for delay, or failure to provide or arrange for Covered Services if such failure or delay is caused by such an event. 23. Subrogation and Reimbursement. These paragraphs apply when another party (including any insurer) is, or may be found to be, responsible for your injury, illness or other condition and We have provided benefits related to that injury, illness or condition. As permitted by applicable state law, unless preempted by federal law, We may be subrogated to all rights of recovery against any such party (including Your own insurance carrier) for the benefits We have provided to you under this Certificate. Subrogation means that We have the right, independently of you, to proceed directly against the other party to recover the benefits that We have provided. Subject to applicable state law, unless preempted by federal law, We may have a right of reimbursement if you or anyone on your behalf receives payment from any responsible party (including Your own insurance carrier) from any settlement, verdict or insurance proceeds, in connection with an injury, illness, or condition for which We provided benefits. Under New York General Obligations Law 5-335, Our right of recovery does not apply when a settlement is reached between a plaintiff and defendant, unless a statutory right of reimbursement exists. The law also provides that, when entering into a settlement, it is presumed that You did not take any action against Our rights or violate any contract between You and us. The law presumes that the settlement between You and the responsible party does not include compensation for the cost of health care services for which We provided benefits. We request that You notify Us within 30 days of the date when any notice is given to any party, including an insurance company or attorney, of Your intention to pursue or investigate a claim to recover damages or obtain compensation due to injury, illness or condition sustained by You for which we have provided benefits. You must provide all information requested by Us or Our representatives including, but not limited to, completing and submitting any applications or other forms or statements as We may reasonably request. 24. Time to Sue. No action at law or in equity may be maintained against Us prior to the expiration of 60 days after written submission of a claim has been furnished to BENJAMIN 000117 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 117 of 237 88 OHINY_SG_COC_2014 10886 NY SG FP PPO AGE 26 COC 02.14 Us as required in this Certificate. You must start any lawsuit against Us under this Certificate within 3 years from the date the claim was required to be filed. 25. Translation Services. Translation services are available under this Certificate for non-English speaking Members. Please contact us by calling the Customer Service number on Your ID card to access these services. 26. Venue for Legal Action. If a dispute arises under this Certificate, it must be resolved in a court located in the State of New York. You agree not to start a lawsuit against Us in a court anywhere else. You also consent to these courts having personal jurisdiction over You. That means that, when the proper procedures for starting a lawsuit in those courts have been followed, the courts can order You to defend any action We bring against You. 27. Waiver. The waiver by any party of any breach of any provision of the Certificate will not be construed as a waiver of any subsequent breach of the same or any other provision. The failure to exercise any right hereunder will not operate as a waiver of such right. 28. Who May Change This Certificate. The Certificate may not be modified, amended, or changed, except in writing and signed by Our Chief Executive Officer (CEO) or a person designated by the CEO. No employee, agent, or other person is authorized to interpret, amend, modify, or otherwise change the Certificate in a manner that expands or limits the scope of coverage, or the conditions of eligibility, enrollment, or participation, unless in writing and signed by the CEO or person designated by the CEO. 29. Who Receives Payment under This Certificate. Payments under this Certificate for services provided by a Participating Provider will be made directly by Us to the Provider. If You receive services from a Non-Participating Provider, We reserve the right to pay either You or the Provider regardless of whether an assignment has been made. 30. Workers’ Compensation Not Affected. The coverage provided under this Certificate is not in lieu of and does not affect any requirements for coverage by workers’ compensation insurance or law. 31. Your Medical Records and Reports. In order to provide Your coverage under this Certificate, it may be necessary for Us to obtain Your medical records and information from Providers who treated You. Our actions to provide that coverage include processing Your claims, reviewing Grievances, Appeals, or complaints involving Your care, and quality assurance reviews of Your care, whether based on a specific complaint or a routine audit of randomly selected cases. By accepting coverage under this Certificate, You automatically give Us or our designee permission to obtain and use Your medical records for those purposes and You authorize each and every Provider who renders services to You to: Disclose all facts pertaining to Your care, treatment, and physical condition to Us or to a medical, dental, or mental health professional that We may BENJAMIN 000118 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 118 of 237 89 OHINY_SG_COC_2014 10886 NY SG FP PPO AGE 26 COC 02.14 engage to assist Us in reviewing a treatment or claim, or in connection with a complaint or quality of care review; Render reports pertaining to Your care, treatment, and physical condition to Us, or to a medical, dental, or mental health professional that We may engage to assist Us in reviewing a treatment or claim; and Permit copying of Your medical records by Us. We agree to maintain Your medical information in accordance with state and federal confidentiality requirements. However, You automatically give Us permission to share Your information with the New York State Department of Health, quality oversight organizations, and third parties with which We contract to assist Us in administering this Certificate, so long as they also agree to maintain the information in accordance with state and federal confidentiality requirements. BENJAMIN 000119 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 119 of 237 90 OHINY_SG_COC_2014 10886 NY SG FP PPO AGE 26 COC 02.14 Section XIV - Other Covered Services Access to Providers and Changing Providers Sometimes Providers in Our Provider directory are not available. Prior to notifying us of the PCP You selected, You should call the PCP to make sure he or she is still available to take new Subscribers. You may change your PCP by selecting a new Provider from our Roster and either contacting Us at the Customer Service number on your ID card or by accessing our website. This can be done at any time and the change will be effective immediately. Input in Developing Our Policies As a Subscriber You may participate in the development of Our policies by contacting Us at the Customer Service number on your ID card. Your Rights You have the right to obtain complete and current information concerning a diagnosis, treatment and prognosis from a Physician or other Provider in terms You can reasonably understand. When it is not advisable to give such information to You, the information shall be made available to an appropriate person acting on Your behalf. You have the right to refuse treatment to the extent permitted by law and to be informed of the medical consequences of that action. You have the right to formulate advance directives regarding your care. Information Available to You Upon Request When application procedures and minimum qualification requirements for Providers are available to You upon request to Us. Utilization Review The toll-free telephone number of the utilization review agent is available 40 hours a week with an after-hours answering machine. BENJAMIN 000120 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 120 of 237 91 OHINY_SG_COC_2014 10886 NY SG FP PPO AGE 26 COC 02.14 Hemophilia Factor Benefits . The following benefits for hemophilia factor are available only when provided by the specific participating Providers listed below: 1. Prescription Drug Coverage for Factor provided by a Participating Hemophilia Treatment Center We Cover Hemophilia Factor that you self-administer or is administered by a non- skilled caregiver when it would otherwise be covered under your Prescription Drug benefits and it is dispensed by a Participating Hemophilia Treatment Center as part of your written treatment plan. This benefit will be provided in lieu of receiving Factor dispensed by a Designated Pharmacy under your Prescription Drug Coverage benefit. A “Hemophilia Treatment Center” (HTC) means a unique federally funded entity that specializes in comprehensive care for pediatric and adult individuals with inherited bleeding and clotting disorders. An HTC must be a licensed Facility that is also designated as a comprehensive hemophilia diagnostic treatment center receiving a grant under Section 501(a) (2) of the Social Security Act and participates in the 340B Drug Pricing Program. Hemophilia Factor dispensed by an HTC will be Covered under your Chemotherapy benefit. You will be responsible to pay the applicable Chemotherapy cost-share shown in the Schedule of Benefits. 2. Non-Emergent Home Health Care - Assisted Administration of Factor In addition to the Home Health Care Benefits available under Your Certificate, we will Cover non-emergent administration of Hemophilia Factor in Your home when provided by a Participating Home Health Agency certified or licensed by the appropriate state agency. This additional Home Health Care benefit covers both the Factor and the administration services when assisted administration is medically necessary. Coverage will be provided in lieu of receiving medically necessary Covered assisted-administration service from your Physician or another health practitioner in an office or out-patient setting. Any visits for assisted administration of Hemophilia Factor in Your home count towards Your Home Health Care visit limit. The cost-share and definition of a visit in the Home Health Care Benefits shall apply to these additional services. See your Schedule of Benefits and Home Health Care benefit for more information. Please note this benefit only provides Coverage for assisted administration of Factor. It does not Cover Factor that you self-administer or that is administered by a non-skilled caregiver. 3. Preauthorization The benefits covered by this Section require Preauthorization. Your Provider must call Us or Our vendor at the number indicated on Your ID card. After receiving a request for approval, We will review the reasons for Your planned treatment and determine if benefits are available. Criteria will be based on multiple BENJAMIN 000121 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 121 of 237 92 OHINY_SG_COC_2014 10886 NY SG FP PPO AGE 26 COC 02.14 sources including medical policy, clinical guidelines, and pharmacy and therapeutic guidelines. 4. Exclusions and limitations Except as expressly modified by this Section, all of the exclusions and limitations of the Certificate apply to the benefits covered by this Section. 5. Controlling Policy All of the terms, conditions, limitations, and exclusions of Your Certificate shall also apply to this Section except where specifically changed by this Section. BENJAMIN 000122 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 122 of 237 OXFORD HEALTH PLANS 1 OHINY_SG_ONET_RDR_2014 NY SG OON Rider 9.13 Out-of-Network Benefits Rider This Rider amends Your Certificate to provide benefits for Covered Services that are received from Out-of-Network Providers and have not been approved by Us to be covered on an In-Network basis. These benefits are referred to as “Out-of-Network Benefits” and are subject to greater Deductibles, Copayment and Coinsurance amounts than the benefits available if You obtain the same services from Participating Providers. 1. Out-Of-Network Benefits Benefits under this Rider are only available for Medically Necessary services provided by Non-Participating Providers which would have been covered under Your Certificate if they had been provided by a Participating Provider. All services must be furnished by Providers appropriately licensed to provide the particular service being rendered. See the Schedule of Benefits for a list of the services covered out-of-network. 2. Day and Limit Visitations In any case where benefits of the Certificate; Contract; Policy] are limited to a certain number of days or visits, such limits shall apply in the aggregate to services provided pursuant to the Certificate and this Rider. Any days or visits covered pursuant to this Rider will reduce the number of days or visits available under the Certificate and vice versa. 3. Out-of-Network Services Subject To Preauthorization Our Preauthorization is required before You receive certain Covered Out-of- Network services. See the Schedule of Benefits for the services that require Preauthorization. 4. Preauthorization Procedure If You seek coverage for services that require Preauthorization, You must call Us at the number indicated on Your ID card. You must contact Us to request Preauthorization as follows: At least two weeks prior to a planned admission or surgery when Your Physician recommends inpatient Hospitalization. If that is not possible, then during regular business hours prior to the admission. At least two weeks prior to ambulatory surgery or any ambulatory care procedure when a doctor recommends the surgery or procedure be performed in an ambulatory surgical unit of a Hospital or in a free standing Ambulatory Surgical Center. Within the first three months of a pregnancy, or as soon as reasonably possible and again within 48 hours after the actual delivery date if Your Hospital stay is expected to extend beyond 48 hours for a vaginal birth or 96 hours for cesarean birth. BENJAMIN 000123 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 123 of 237 OXFORD HEALTH PLANS 2 OHINY_SG_ONET_RDR_2014 NY SG OON Rider 9.13 Before Air Ambulance services are rendered for a non-Emergency Condition. After receiving a request for approval, We will review the reasons for Your planned treatment and determine if benefits are available. Criteria will be based on multiple sources including medical policy, clinical guidelines, and pharmacy and therapeutic guidelines. 5. Failure to Seek Preauthorization If You fail to seek Our Preauthorization for benefits subject to this section, We will pay an amount $500 less than We would otherwise have paid for the care, or We will pay only 50% of the amount We would otherwise have paid for the care, whichever results in a greater benefit for You. You must pay the remaining charges. We will pay the amount specified above only if We determine the care was Medically Necessary even though You did not seek Our Preauthorization. If We determine that the services were not Medically Necessary, You will be responsible for paying the entire charge for the service. 6. Your Additional Payments for Out-of-Network Benefits When You receive Covered services from a Non-Participating Provider: Cost-Sharing for out-of-network services applies towards Your Out-of- Network Deductible. Any Provider charges that are in excess of the Allowed Amount do not count towards Your Deductible. In addition to the applicable Copayments, Coinsurance, and Deductible described in the Schedule of Benefits, You must also pay the amount, if any, by which the Non-Participating Provider’s actual charge exceeds the Allowed Amount. This means that the total of Our coverage and any amounts You pay under Your applicable Deductible, Copayment and Coinsurance may be less than the Non-Participating Provider’s actual charge. When You receive covered services from a Non-Participating Provider, We will apply nationally-recognized payment rules to the claim submitted for those services. These rules evaluate the claim information and determine the accuracy of the procedure codes and diagnosis codes for the services You received. Sometimes, applying these rules will change the way that We pay for the services. This does not mean that the services were not Medically Necessary. It only means that the claim should have been submitted differently. As an example, Your provider may have billed using several procedure codes when there is a single code that includes all of the separate procedures. We will make one inclusive payment in that case, rather than a separate payment for each billed code. Another example of when We will apply the payment rules to a claim is when You have surgery that involves two surgeons acting as “co-surgeons”. Under the payment rules, the claim from each provider should have a “modifier” on it that identifies it as coming from a co-surgeon. If We receive a claim that does BENJAMIN 000124 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 124 of 237 OXFORD HEALTH PLANS 3 OHINY_SG_ONET_RDR_2014 NY SG OON Rider 9.13 not have the correct modifier, We will change it and make the appropriate payment. 7. Out-of-Network Deductible. This Certificate has a separate Deductible in the Schedule of Benefits that You must pay for Covered out-of-network Services during each Plan Year. If You have other than Individual coverage, the individual Out-of-Network Deductible applies to each person covered under this Certificate. However, after Out-of-Network Deductible payments for any and all persons covered under this Certificate total the family Out-of-Network Deductible amount in the Schedule of Benefits in a Plan Year, no further Out-of-Network Deductible will be required for any person covered under this Certificate for that Plan Year. Any charges of a Non-Participating Provider that are in excess of the Allowed Amount do not apply towards the Deductible. 8. Out-of-Network Out-of-Pocket Limit. This Certificate has a separate Out-of- Network Out-of-Pocket Limit in the Schedule of Benefits in Section XIV - Schedule of Benefits of this Certificate for out-of-network benefits. When You have met Your Out-of-Network Out-of-Pocket Limit in payment of Out-of-Network Deductibles, Copayments, and Coinsurance for a Plan year in the Schedule of Benefits, We will provide coverage for 100% of the Allowed Amount for Covered out-of-network Services for the remainder of that Plan Year. If you have other than Individual coverage, the individual Out-of-Network Out-of-Pocket Limit applies to each person covered under this Certificate. Once a person within a family meets the individual Out-of-Network Out-of-Pocket Limit, We will provide coverage for 100% of the Allowed Amount for the rest of that Plan Year for that person. If other than Individual coverage applies, when members of the same family covered under this Certificate have collectively met the family Out-of-Network Out-of- Pocket Limit in payment of Out-of-Network Deductibles, Copayments and Coinsurance for a Plan Year in the Schedule of Benefits, We will provide coverage for 100% of the Allowed Amount for the rest of that Plan Year. Any charges of a Non-Participating Provider that are in excess of the Allowed Amount do not apply towards Your Out-of-Pocket Limit. 9. Allowed Amount “Allowed Amount” means the maximum amount we will pay to a Provider for the services or supplies covered under this Rider, before any applicable Deductible, Copayment, and Coinsurance amounts are subtracted. We determine our Allowed Amount for Non-Participating Providers as follows: For Facilities, the Allowed Amount will be 140% of the ♦ Medicare amount. If there is no amount as described above, the Allowed Amount will be 50% of the Facility’s charge. For all other Providers, the Allowed Amount will be 140% of the ♦ Medicare amount. BENJAMIN 000125 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 125 of 237 OXFORD HEALTH PLANS 4 OHINY_SG_ONET_RDR_2014 NY SG OON Rider 9.13 If there is no amount as described above, We use an available gap methodology to determine a rate for the service as follows: For services other than Physician-administered pharmaceuticals, we use a gap methodology that uses a relative value scale, which is usually based on the difficulty, time, work, risk and resources of the service. For Physician-administered pharmaceuticals, We use gap methodologies that are similar to the pricing methodology used by the Centers for Medicare and Medicaid Services, and produce fees based on published acquisition costs or average wholesale price for the pharmaceuticals. These methodologies are currently created by RJ Health Systems, Thomson Reuters (published in its Red Book), or Us based on an internally developed pharmaceutical pricing resource if the other methodologies have no pricing data available for a Physician-administered pharmaceutical or special circumstances support an upward adjustment to the other pricing methodology. If there is no amount as described above, the Allowed Amount will be 50% of the Provider’s charge. Our Allowed Amount is not based on UCR and the Non-Participating Provider’s actual charge may exceed Our Allowed Amount. You must pay the difference between Our Allowed Amount and the Non-Participating Provider’s charge. Contact Us at the number on Your ID card or visit our website for information on Your financial responsibility when You receive services from a Non-Participating Provider. We reserve the right to negotiate a lower rate with Non-Participating Providers. Medicare based rates referenced in and applied under this Section shall be updated no less than annually. See Section VI - Covered Services of the Certificate for the Allowed Amount for an Emergency Condition. 10. Filing a Claim For Out of Network Benefits A claim must be filed with Us by You or the Out-of-Network Provider. Claims forms can be obtained from Us by calling the phone number on your identification card or by visiting our website. 11. Exclusions Except as expressly modified by this Rider, all of the exclusions of the Certificate apply to the benefits covered by this Rider. 12. Controlling Certificate BENJAMIN 000126 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 126 of 237 OXFORD HEALTH PLANS 5 OHINY_SG_ONET_RDR_2014 NY SG OON Rider 9.13 All of the terms, conditions, limitations, and exclusions of Your Certificate to which this Rider is attached shall also apply to this Rider except where specifically changed by this Rider. BENJAMIN 000127 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 127 of 237 1 OHINY_SG_SVCAREA_RDR_2014 NY OHI SG NG SVCARE Rider 11.13 RIDER TO EXTEND ELIGIBILITY OUTSIDE THE SERVICE AREA The language in the first paragraph of Section V - Who is Covered of the Certificate that requires you to live, work or reside in the Service Area does not apply to your Plan. This language is deleted and replaced with the following language: Who is Covered Under this Certificate. You, the Subscriber to whom this Certificate is issued, are covered under this Certificate. Your employer must have an office location in Our Service Area. You must live, work, or reside in a state in which we are authorized to deliver a Certificate. This list presently includes New York, New Jersey, Connecticut and other states outside of the New York tri-state area. If would like to confirm if your state is on the list, you may do so by calling the Customer Service number on your ID card. If You selected one of the following types of coverage, members of Your family may also be covered. Types of Coverage In addition to Individual coverage, We offer the following types of coverage: Individual and Spouse - If You selected Individual and Spouse coverage, then You and Your Spouse are covered. Parent and Child/Children - If You selected Parent and Child/Children coverage, then You and Your Child or Children, as described below, are covered. Family - If You selected Family coverage, then You and Your Spouse and Your Children, as described below, are covered. BENJAMIN 000128 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 128 of 237 OXFORD HEALTH PLANS OHI NY Info 1/04 1 OHI NY Info 1/04 OXFORD HEALTH INSURANCE, INC. INFORMATION ABOUT YOUR OXFORD COVERAGE PART I REIMBURSEMENT Overview of Provider Reimbursement Methodologies Generally, Oxford pays Network Providers on a fee-for-service basis. Fee-for-service based payment schedules differ depending on the type of provider, geographic location, or site of service, and may include payment based on each office visit, a hospital day, procedure or service performed, item furnished, course of treatment, or other units of service. A unit of service, such as a hospital day, may include more than a single procedure or item. We may also limit the number of services or procedures that we will pay for during any single office visit or for any single procedure; or for multiple procedures performed at the same time. This practice is known as “bundling” and is used by many third party payers, including the Medicare program. Some providers have agreed to accept variable fee for service payments, payment based on a mutually agreed upon budget, so long as they receive at least a minimum fee. Oxford may make modifications to its fee for service compensation mechanism during the term of your coverage. Oxford does not typically “withhold” a portion of a physician’s contracted fees; which might be paid later depending on the physician’s performance or financial performance of Oxford. (The amount retained is called a “Withhold.”) However, Withholds are among the sanctions that Oxford may implement with respect to physicians who have a demonstrated practice of not following Oxford policies, for example, by improper billing practices, consistently referring Members to providers who are not Network Providers or by failing to obtain required referrals or Precertifications. Oxford may profile Network Providers’ billing, referral, utilization, or other practices, and develop other financial disincentives for providers who do not follow Oxford's policies and procedures during the term of your coverage. Oxford does not generally provide Bonuses or other Incentives to Network Providers. However, Oxford has entered into Incentive Agreements with a few “intermediaries”, such as provider groups and independent practice associations (IPA’s). Incentive Agreements may be based on membership, referrals to specialists or hospitals and other facilities, economic factors, quality factors, member satisfaction factors, or a combination of these and other factors. Incentive Agreements typically, but not always, require the group to meet mutually agreed upon quality measures as a condition of obtaining a bonus based on cost or utilization. Financial incentives or disincentives may also be adopted to promote electronic billing practices or other e-commerce initiatives; or to promote compliance with Oxford utilization management policies. In addition, physicians may be paid at higher rates for certain surgical procedures, if they perform the surgery in their offices, or at ambulatory surgical centers. Oxford may enter into additional Incentive Agreements with providers during the term of your coverage. Network Providers who contract through intermediaries that contract may be subject to Incentives. Oxford’s contracts with intermediaries typically, but not always, limit the nature and scope of the Incentives the group may enter into with Network Providers. Oxford does not pay individual Network Physicians or practitioners on a Capitated basis. However, as described above, Oxford has negotiated a few Capitation Agreements with IPAs. Oxford may enter into additional Capitation Agreements during the term of your coverage or terminate existing Capitation Agreements. Individual practitioners who are paid from funds available under Capitated Agreements with IPAs are generally paid on a fee-for- service basis, but some IPAs may pay individual primary care physicians on a Capitated basis. In addition, practitioners contracting through IPAs may be subject to Incentive Agreements. IPAs with which Oxford contracts may enter into Capitation Agreements with Network Physicians. Intermediaries with which Oxford contracts might enter into or terminate Capitation Agreements or Incentive Agreements with Network Physicians, facilities or practitioners during the term of your coverage. Oxford may audit Network Providers’ billing patterns, licensing compliance, or require documentation that services billed were provided. If the provider cannot demonstrate that services have been provided, or that the services billed are medically necessary and consistent with the services provided, Oxford may seek to recover funds paid to the provider, reduce future payments to the provider, or take other action such as a fee reduction or withhold until the provider has corrected their behavior. A brief description of the compensation mechanisms applicable to different providers as of January 1, 2004 is set forth below. Network Physicians - The compensation mechanisms used for Network Physicians are described in the Overview above. A large majority of Our Network Physicians are reimbursed by Oxford or an BENJAMIN 000129 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 129 of 237 OXFORD HEALTH PLANS OHI NY Info 1/04 2 OHI NY Info 1/04 intermediary on a discounted “fee-for-service” basis. Some Network Physicians have contracted with IPAs or are aligned with other Network Physicians which either: 1) accept compensation based upon a predetermined budget for the cost of Covered Services to Members, or 2) are subject to an Incentive Agreement (Bonus) based on quality and utilization measurements. In addition, some physician groups are eligible to be paid a Bonus based either on the total cost incurred by Oxford for Covered Services rendered to members who select or are assigned to a member of the physician group as their primary care physician, or other utilization measures, such as the total number of days these members (in the aggregate) spend in the hospital or percentage of referrals to certain specialists, hospitals or other facilities. Limited License Practitioners - We reimburse Limited License Practitioners (non-Physician health care professionals) on a fee- for-service basis. Oxford has contracted with a company to manage our physical therapy benefit and certain other therapy benefits. Oxford has also contracted with a company to manage our chiropractic benefit. Oxford may enter into additional Capitation and/or Incentive Agreements with other limited license practitioners during the term of your coverage. Laboratory Services - We have entered into a Capitation agreement with a national laboratory services provider to furnish outpatient laboratory tests for Our Members. Laboratory service providers are reimbursed on a fee-for-service basis, with total payment for laboratory services limited by an agreed upon budget. The company may have a financial incentive to contain the annual aggregate cost of laboratory related services Pharmacy - We have entered into an arrangement with a national pharmacy management company that, in turn, contracts with pharmacies and manufacturers to provide pharmacy products and services to Members. The pharmacies are paid on a fee-for- service basis for both pharmaceuticals and dispensing the prescriptions. The pharmacy management company also provides certain administrative services in connection with administration of Oxford’s pharmacy benefits. If Oxford terminates this contract before expiration of its term, Oxford will pay the pharmacy benefit management company a fee, but this fee is reduced if costs exceed agreed upon targets. Oxford may contract with pharmacies known as “specialty” pharmacies to provide and manage benefits for certain pharmaceuticals, such as infertility drugs. Hospital and Other Ancillary Facilities - Reimbursement to Network Facilities is made on a fee-for-service basis. For inpatient services, payment is generally on the basis of a “per day” rate, or on a case rate for an entire stay based on the diagnosis. In general, Oxford negotiates agreements with individual hospitals or hospital systems. We do not have Capitation agreements with any of Our Network Facilities. However, we have entered into an Incentive Arrangement with an IPA for medical management of subacute facilities. The IPA pays contracting sub-acute facilities on a fee-for-service basis. Certain hospitals are developing their own programs to reduce unnecessary hospital inpatient stays and lengths of stays. Oxford may enter into Capitation and/or Incentive Agreements with hospitals or physicians during the term of your coverage. Radiology Services - Oxford, through an intermediary, has contracted with radiologists who have agreed to be paid on a fee- for-service basis, with total fees limited based on a mutually agreed budget for radiology services. The company may have a financial incentive to contain the annual aggregate cost of imaging services. Non-Participating Providers - Providers that have not entered into contracts with Oxford (directly or indirectly through groups), including providers in the Oxford service area and providers outside the Oxford service area, are paid on a fee for service basis. Oxford has entered into agreements with preferred provider organizations under which certain non-participating providers will provide a discount from their usual charges. Other non- participating providers are paid based on Oxford’s determination, using various industry standards, of the Usual, Customary and Reasonable Charge for the service or as otherwise provided in your summary of benefits. Oxford may seek to impose bundling rules or other limitations on bills received from non-participating providers, but will assure that Members are not charged more than permitted by their benefit plan. Oxford may audit non-participating providers’ billing patterns, licensing compliance, or require documentation that services billed were provided and that the services provided were medically necessary. Any or all of these audits may result in non-payment to the provider for these unusual or fraudulent practices. In some circumstances, this may result in balance billing to the member. If that occurs, please contact Oxford. Effect of Reimbursement Policies - We believe that the implementation of these reimbursement methodologies has produced the results they were designed to accomplish (i.e., access to high quality providers in our service area, and cost- effective delivery of care). Through the application of Our Quality Assurance protocols, We continuously monitor Our Providers to ensure that Our Members have access to the high standards of care to which they are entitled. If a particular reimbursement policy affects a physician’s referral to a particular Network Provider, Our Members have the right to request referral to a different Network Provider. Definitions - In addition to the definitions in your Certificate, Contract, or Handbook (whichever is applicable) the capitalized words in this attachment have the following meaning: Bonus: An incentive payment that is paid to Physicians who have met all contractual requirements to obtain the Bonus. Capitation, Capitated: An agreed upon amount, usually a fixed dollar amount or a percentage of premium, that is paid to or budgeted for the Provider or IPA regardless of the amount of services supplied. Capitation formulas may include adjustments for benefits, age, sex, and other negotiated factors. Usually, the Capitation amounts are paid or allocated on a monthly basis. Incentive Agreements: In general, "Withholds" and "Bonuses" are known as "Incentive Agreements." Incentive Agreements may also include higher than standard fees, or penalties for failure to adhere to Oxford policies, such as making referrals only to Network BENJAMIN 000130 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 130 of 237 OXFORD HEALTH PLANS OHI NY Info 1/04 3 OHI NY Info 1/04 Providers when Network Providers are capable and available to provide necessary services to Members, or based on the provision of services at specific sites of service. Under such agreements, Providers are paid less (some portion of their fee is reduced or withheld) or paid more (such as in the form of a bonus) based on one or more factors that may include (but are not limited to): member satisfaction, quality of care, compliance with Oxford policies, control of costs, and their use of services. IPA: An IPA (independent practice association) is an organization that contracts with physicians and other health care providers. Us, We, Our: When coverage is provided under Oxford’s insurance company, it means Oxford Health Insurance, Inc. In addition, it can also include third parties to whom we delegate responsibility for providing administrative services relating to coverage, such as utilization management. Usual, Customary and Reasonable (UCR) Charge: The amount charged, the amount agreed upon with a non-participating provider, or the amount We determine to be the reasonable charge, for a particular Covered Service. UCR determinations may be based on Medicare fees, industry data regarding charges or costs, or other factors. The basis for determining UCR may be different for different benefit designs. Withhold: Percentage of a physician’s fee that is held back or reserved as an incentive to encourage appropriate and efficient medical treatment or billing. PART II UTILIZATION MANAGEMENT PROGRAM A. PROGRAM OVERVIEW Oxford has developed and implemented Utilization Management programs that are intended to reduce the volume of unnecessary services, direct members to appropriate providers and coordinate services among providers. In general, the utilization management protocols We use are based on industry-standard criteria developed by health care consultants and recognized clinical societies. When We contract with network managers to provide utilization management services, they may use our protocols. In some cases, we review and adopt some or all of the protocols that they develop as our own . Oxford’s Utilization Management Programs are developed and implemented by the Oxford Medical Affairs department, except as described below. Oxford’s Medical Affairs Department is headed by Our Chief Medical Officer, who is a physician, and includes physician Medical Directors, registered nurses, and health practitioner consultants. B. PROTOCOL DEVELOPMENT OVERVIEW In developing our Utilization Review protocols, Oxford typically utilizes guidelines from outside sources, which include external consultants, including but not limited to Milliman & Robertson UM principles. We modify these protocols based on Our experience, medical evidence, and legislative requirements. All such policies are periodically reviewed and updated C. CASE MANAGEMENT Medical Case Management - Medical Case managers work with Providers and Members to assess, plan, coordinate, and evaluate options, settings, services and time frames required to meet a Member’s individual healthcare needs. Medical case management is a clinical goal-directed process requiring communication and coordination of all available resources to promote both quality and cost-effective outcomes. The interventions typically range from simple hospital discharge planning to complex case management in the outpatient setting. Disease Management and Complex Case management - Our Disease Management Services are intended for complex or chronic cases that are likely to result in high utilization of medical services. These cases include but are not limited to, patients with the following conditions required for treatment: • HIV • End Stage Renal Disease • Transplants (organ and bone marrow) • High-risk maternity and high-risk neonates (newborns) • Asthma • Diabetes • Congestive heart failure • Coronary Artery Disease • Rare chronic illnesses During the term of your coverage, Oxford may introduce new disease management programs, contract with other companies to provide disease management, and terminate or modify existing disease management programs. For more information about disease management programs, contact Oxford. Concurrent Review - Concurrent review is the review of care that is in progress for purposes of determining the extent and scope of coverage during a course of treatment. Monitoring the course of treatment through the concurrent review process enables Us to assist with discharge planning from hospital inpatient stays. In addition, it assists us in identifying alternative options of care, such as home care, and when it is appropriate, We can begin case management. We render benefit decisions regarding continuation of stay based on protocol criteria. Discharge Planning - We begin planning for post-Hospitalization care when We are informed of a planned admission. This is one reason that it is essential that your Provider notify Us of your BENJAMIN 000131 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 131 of 237 OXFORD HEALTH PLANS OHI NY Info 1/04 4 OHI NY Info 1/04 potential needs prior to your admission. Planning continues throughout the Hospital stay. Our purpose is to assist with prompt discharge when it is medically appropriate and to explore alternatives to continued Hospitalization. We may contract with other companies to assist Us in discharge planning. Second Opinion Program - We may require members to get a Second Opinion for various inpatient and outpatient procedures. We provide the names of Network Specialists who can offer a Second Opinion. When a Member meets specific medical criteria, We may waive the Second Opinion requirement. Privileging - We have established limitations on the range of services for which Network Providers may be paid. These payment policies may be based, among other things, on the Network Provider’s license and area of specialty. We may establish or change privileging requirements for other services during your enrollment. Review of Utilization Patterns, “Upcoding” and Fraud initiatives - We may conduct reviews of Network Provider utilization practices to assess over- and under-utilization in treatment practices, as well as a physician’s compliance with performance of ‘effectiveness of care’ measures as required by monitoring or regulatory agencies such as the National Committee on Quality Assurance (‘NCQA’), Departments of Health or other agencies. Oxford may establish or change its focus or definition of practice pattern assessment during your enrollment. Oxford may monitor unusual billing, treatment or referral patterns. Such monitoring is expected to enable Us to take action to address potential over- and under-billing by Network Providers. Such actions can include but are not limited to discussion with providers about appropriate billing, treatment and referral, review of medical records by Oxford or external experts, attempts to collect past overpayments, imposition of Withholds, fee reduction or other actions. Where required or appropriate, Oxford refers inappropriate billing or treatment to applicable government authorities. Quantity Level Limits - In conjunction with our pharmacy benefits management company, we have established quantity level limits for coverage of the dosage of certain prescription drugs. We may establish or change quantity level limits during your enrollment. Precertification - Precertification enables Us to review the Medical Necessity of a proposed service or treatment including the determination of a proposed site of care, manage benefit limitations, and whether the service will be performed by Network Providers. Precertification allows Us to notify the Member or the Member’s Provider regarding coverage before the service is provided. In addition, it also allows Us to suggest appropriate and cost effective sites for the proposed service/treatment. We may establish or change precertification requirements during your enrollment. Referral Management - We use referral management to assess how effective our PCPs and Specialists are at providing various services. We record demographic and referral information from each referral and use the data to monitor referral patterns individually and on an aggregate basis. This allows Us to identify patterns of care and quality issues to manage costs and to make improvements in the quality of healthcare delivery. We may establish or change referral processes during your enrollment. Behavioral Health Case Management - Members and PCP’s may call Oxford at 800-201-6991 to obtain a referral for Mental Health and Substance Abuse services. The Behavioral Health Line is staffed by clinical professionals equipped to answer questions regarding Mental Health and Substance Abuse benefits. These professionals can also refer Members to an appropriate Network Provider and they can Precertify these services as necessary. Behavioral health services are subject to concurrent review and discharge planning. D. ADDITIONAL UTILIZATION MANAGEMENT FUNCTIONS Oxford has contracted with certain provider groups and management companies to perform certain utilization management functions. These include: Precertification of Imaging Services: Oxford has contracted with a company to assist Oxford in performing Precertification of imaging services. Payment to Network Providers who contract with the network manager is, in part, dependent on the volume of radiology services provided to Members. The company may have a financial incentive to contain the annual aggregate cost of imaging services. In addition, Network Providers will be paid only for certain imaging procedures, based on their specialty. All denials of precertification for imaging services are made by an Oxford Medical Director and appeals of denials may be made directly to Oxford in accordance with our established appeals process. Review of Orthopedic, Therapy, Subacute Care, and Chiropractic Services: Oxford has contracted with companies to perform review of orthopedic, podiatry, physiatry, therapy, subacute care and chiropractic services. These companies may have a financial incentive to contain the annual aggregate cost of services. Appeals of denials may be made directly to Oxford Informal Subnetwork: Oxford has contracted with IPAs (either on a Capitation or Incentive basis) that have formed informal subnetworks within the Oxford network. Network Providers who participate in an informal subnetwork can ordinarily be expected to refer Members for care to other Network Providers who participate in the same informal subnetwork. IPAs or their affiliates may perform utilization review functions and make coverage or payment recommendations to Us. Our determination of coverage, directly or on appeal, is separate from any such review activities. These IPAs may have a financial incentive to contain the annual aggregate cost of services. Members may however, obtain Covered Services on an In Network basis from other Network Providers. Pharmacy Services: Our pharmacy benefit management company performs review of quantity and dosing guidelines for certain drugs in accordance with policies adopted by Our Pharmacy & Therapeutics Committee. In addition, certain drugs require Precertification. BENJAMIN 000132 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 132 of 237 OXFORD HEALTH PLANS OHI NY Info 1/04 5 OHI NY Info 1/04 Please note: Our utilization management programs, policies, and procedures may change, and the companies with which we contract to perform these services may also change during your enrollment. PART III QUALITY MANAGEMENT Our Quality Management (QM) Program promotes the provision of quality health care and service for all OHP members. Our QM Program identifies and pursues opportunities for improvement of care and service and provides a structure for documentation, tracking and reporting of these activities and identified problem areas across the organization and to the Board of Directors via the QM committee structure. This purpose is accomplished by: • Identifying the scope of care and service provided through a systematic and methodical process focused on areas of care and service relevant to our member population; • Developing clinical guidelines, practice guidelines, and service standards by which performance is measured taking into consideration prudent medical practice and widely accepted guidelines relevant to the clinical area; • Periodically reviewing the medical qualifications of participating providers as required through regulatory mandated as well as various accreditation standards; • Pursuing opportunities to improve access to health care, continuity and coordination of care, and customer service through compilation and analysis of various data including but not limited to: claims payment, member complaint/appeal information, provider practice patterns, and population-based outcome studies. • Resolving identified quality issues, including follow-up on individual circumstances, through peer review processes and implementation of corrective action plans. The QM Program’s goals are to improve and/or maintain quality patient services through ongoing monitoring and assessment of: • Provider compliance with recommended clinical treatment guidelines in the delivery of care through various mechanisms such as the annual HEDIS data collection, ongoing review of provider medical records, analysis of Disease Management outcomes and through other QM studies. • Member and Provider satisfaction. • Mechanisms to avoid adverse impact on quality of care resulting from Our cost-containment programs. • Systematic education and outreach to Our providers and members to facilitate their involvement in quality improvement activities. • Definition and implementation of processes for the adequate oversight of delegated functions. We will periodically evaluate the effectiveness of individual quality improvement initiatives in addition to the effectiveness of the program as a whole. Credentialing/Recredentialing Credentialing Committees: Oxford has Credentialing Committees in each regional office. Each committee is headed by the Regional Medical Director. At regular meetings, the Committee reviews applications and credentials of provider applicants. Credentialing Requirements: In addition to meeting Our facility and records standards, physicians or providers participating in our HMO plans must generally meet the following (depending on specialty) credentialing requirements to be an Oxford Network Physician or Provider: • Current, valid state license to practice; • Current, valid DEA certificate; • Proof of board certification or recent (5 years from completion of training) board eligibility, unless an exception to this requirement has been granted; Admitting privileges at a Network Hospital; unless an exception to this requirement has been granted. We also review information and representations furnished by the physician or provider regarding: physical and mental health status; lack of impairment from chemical dependency or substance abuse; and malpractice history. Providers participating with Our HMO plans are generally recredentialed every three years. We have contracted with a third party vendor that verifies credentialing requirements for Us. Physicians and providers located outside the service areas of our HMO plans, but which are network providers in our PPO plans, are not subject to the same credentialing requirements as providers in HMO plans. Physicians and providers participating in PPO plans may be subject only to credentialing requirements of provider organizations that contract with Oxford. Credentialing requirements and processes may change during your enrollment. Provider Discipline Policies and Procedures Our Provider Discipline Policies and Procedures apply to all Providers affiliated with Us. Problems that may indicate the need for discipline include, but are not limited to: • Quality of care concerns • Noncompliance with utilization, quality or other program guidelines • Unsatisfactory utilization management Depending on the nature and severity of the situation, we may issue a warning, require a corrective action plan, reduce their fees, BENJAMIN 000133 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 133 of 237 OXFORD HEALTH PLANS OHI NY Info 1/04 6 OHI NY Info 1/04 require pre-certification of additional services, reduce or suspend a Provider’s privileges or formally terminate their participation with Us. Disciplinary actions related to quality or utilization issues may be started based on the recommendation of the Vice President for Medical Affairs, Our Medical Director, or any of the Quality Management committees or subcommittees. Disciplinary actions related to administrative issues may be started by referral from any department in the company to the Administrative Management Committee. Disciplinary actions that result in suspension for more than thirty (30) days or termination resulting from a finding of professional misconduct will be reported to the New York Department of Health, Office of Professional Medical Conduct, as required by law. BENJAMIN 000134 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 134 of 237 OXFORD HEALTH PLANS MS-04-151 1 Privacy 10/04 NOTICE TO OXFORD HEALTH PLANS MEMBERS REGARDING OXFORD’S PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN ACCESS THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. Oxford Health Plans LLC (“Oxford”) is committed to maintaining the privacy and confidentiality of your protected health information (PHI). PHI is information about you that is used or disclosed by Oxford to administer your insurance coverage and to pay for the medical treatment you receive. It includes demographic information, such as your name, address, telephone number and Social Security number, and any medical information obtained from you or from providers who submit claims to Oxford related to your medical care. We are required by applicable federal and state laws to maintain the privacy of your PHI. This document serves as the required Notice of Oxford’s privacy practices, our legal duties, and your rights concerning your PHI. Oxford is required to abide by the terms of this Notice unless and until it is amended. This Notice takes effect April 14, 2003, and will remain in effect until such time that it is amended or replaced. Oxford reserves the right to change our privacy practices and the terms of this Notice at any time, provided that applicable law permits such changes. We reserve the right to make the changes in our privacy practices and the new terms of our Notice effective for all PHI that we maintain, including information we created or received prior to any such changes. When Oxford makes a significant change in our privacy practices, we will revise this Notice and send the revised Notice to our health plan subscribers. For additional copies of this Notice, please call our Customer Service Department at the toll-free number on your Oxford ID card, or visit our web site at www.oxfordhealth.com. Q. How does Oxford use or disclose your PHI? A. Oxford may use or disclose your PHI, without your consent or authorization, under the following circumstances: • Treatment: We may disclose your PHI to a healthcare provider who requests it in order to provide you with necessary medical treatment, such as emergency care, X- rays or lab work. A provider might be a doctor, a hospital, a home healthcare agency, etc. • Payment: We may use or disclose your PHI to pay claims submitted by a healthcare provider for treatment provided to you. For example, we may ask a hospital emergency department for details about the treatment you received so that we can accurately pay the hospital for your care. • Healthcare Operations: We may use or disclose your PHI to manage our business. Examples include using it to determine appropriate premiums, to conduct quality improvement activities, to contact you regarding benefits or services that might be of interest to you, and to provide you with preventative health advisories. • Plan Sponsor: We may disclose limited PHI to your health plan sponsor, benefits administrator, or group health plan in order to perform plan administrative functions such as activities related to billing and renewals. • Underwriting: We may receive your PHI for underwriting, premium rating or other activities relating to the creation, renewal or replacement of a contract of health insurance or health benefits. Once an Oxford Member, use and disclosure of your PHI is governed by this Notice. • Marketing: We may use your PHI to contact you with information about health-related benefits and services, treatment alternatives, or appointment reminders. • Research; Death; Organ Donation: In limited circumstances, we may use or disclose your PHI for research purposes or to a coroner, medical examiner, funeral director or an organ procurement center. • Required by Law: We may use or disclose your PHI when we are required to do so by law. For example, upon request, we would disclose PHI to the U.S. Department of Health and Human Services so that this agency can verify Oxford compliance with federal privacy laws. • Health Oversight Activities: We may disclose your PHI to health oversight organizations and agencies as part of accreditation surveys, investigations related to our eligibility for government programs, regulatory audits, and for licensure and disciplinary actions. • Workers’ Compensation: We may disclose your PHI to comply with laws relating to workers’ compensation or other similar programs that provide benefits for work-related injuries or illnesses. • Public Health and Safety: We may disclose your PHI to the extent necessary to avert an imminent threat to your safety or the health or safety of others. We may disclose your PHI to appropriate authorities if we have reasonable belief that you might be a victim of abuse, neglect, domestic violence, or other crimes. • Judicial and Administrative: We may disclose your PHI in response to a court or administrative order, subpoena, discovery request, or other lawful process. • Sale of Business: We may disclose PHI upon sale of all or part of Oxford’s business to another party. • Law Enforcement: We may disclose limited information to law enforcement officials concerning the PHI of a suspect, BENJAMIN 000135 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 135 of 237 OXFORD HEALTH PLANS MS-04-151 2 Privacy 10/04 fugitive, material witness, crime victim or missing person. Under certain circumstances, we may disclose the PHI of an inmate or other person in lawful custody of a law enforcement official or correctional institution. • Military and National Security: Under certain circumstances, we may disclose the PHI of armed forces personnel to military authorities. We may disclose PHI to authorized federal officials when required for national security or intelligence activities. • To Family and Friends: If, in the event of a medical emergency, you are unable to provide any required authorization, we may disclose PHI to a family member, friend or other person to the extent necessary to ensure appropriate medical treatment or to facilitate payment for that treatment. Q. Does Oxford ever need an authorization to use or disclose your PHI? A. Yes. Except for the purposes described above, Oxford cannot use or disclose your PHI without a signed authorization from you. If you provide such an authorization to Oxford, you may revoke it at any time. Your revocation will not affect any use or disclosure of PHI made while the authorization was in place. Q. Can you inspect or receive copies of any PHI in Oxford’s possession? A. Yes. You have the right to inspect or receive copies of your PHI with certain exceptions. You must make a request to Oxford in writing. Oxford reserves the right to charge a reasonable fee for the cost of producing and mailing the PHI. Request forms are available on the Oxford web site or by calling the number listed at the end of this Notice. Q. Can you find out if Oxford disclosed your PHI to a third party? A. Yes. You have the right to receive an accounting of all occasions when Oxford disclosed your PHI for any purpose other than treatment, payment, healthcare operations and certain other instances. Beginning with disclosures made on or after April 14, 2003, we will maintain a record of disclosures for six (6) years. A request for an accounting must be submitted to Oxford in writing. We reserve the right to charge you a reasonable fee for the cost of producing and mailing the information if you request this accounting more than once in a 12-month period. Please note, that Connecticut and New Jersey members will automatically get an abridged accounting whenever they make a request to inspect or receive copies of their PHI. Q. Can you restrict the use or disclosure of your PHI by Oxford? A. Yes. You have the right to request that Oxford place additional restrictions on the use or disclosure of your PHI. We are not required by law to agree to these restrictions. However, if we do agree to the restrictions, we will abide by them except in the event of an emergency. Q. Can you request that Oxford use alternate means to confidentially communicate with you about your PHI or communicate with you at an alternate location? A. Yes. You must inform Oxford, in writing, that confidential communication by alternate means or to an alternate location is required to avoid potential harm to yourself or others. We must accommodate your request if it is reasonable, specifies the alternate communication means or location, and does not interfere with the collection of premiums, the payment of claims, or the administration of your health insurance coverage. Q. Do you have the right to request that Oxford correct, amend, or delete your PHI? A. Yes. You must make your request in writing, and it must explain why the PHI should be corrected, amended, or deleted. Oxford may deny your request if we did not create the PHI in question or for certain other reasons. If we deny your request, we will provide you with a written explanation. You may respond with a statement of disagreement to be added to the information you sought to change. If we accept your request to correct, amend, or delete the PHI, we will make reasonable efforts to inform others of the changes and to include the changes in any future disclosures of that information. Complaints To express concern about a decision Oxford made about access to your PHI, to report a concern that we violated your privacy rights, or to express a complaint about any aspect of Oxford’s privacy practices, please contact the HIPAA Member Rights Unit at the address below. You may also submit a written complaint to the Secretary of the U.S. Department of Health and Human Services at the following address: Office of the Secretary Department of Health and Human Services 200 Independence Avenue, S.W. Washington, D.C. 20201 Telephone: 877-696-6775 Oxford supports your right to protect the privacy of your PHI and will not retaliate against you for filing a complaint with any government regulatory body or with us. If you received this Notice on our web site or by electronic mail (e- mail), you are entitled to receive a written copy of the Notice as well. To request a written copy of the Notice, please call our Customer Service Department at the toll-free number on your Oxford ID card, or call 800-444-6222. You can also contact us by mail at: HIPAA Member Rights Unit Oxford Health Plans 48 Monroe Turnpike Trumbull, CT 06611 BENJAMIN 000136 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 136 of 237 OXFORD HEALTH PLANS MS-04-151 3 Privacy 10/04 All written communications related to this Notice and your rights under HIPAA should be mailed to the HIPAA Member Rights Unit at the address above. Privacy Notice Concerning Financial Information At Oxford Health Plans LLC ("Oxford"), protecting the privacy of the personal information we have about our customers and members is of paramount importance and we take this responsibility very seriously. This information must be and is maintained in a manner that protects the privacy rights of those individuals. This notice describes our policy regarding the confidentiality and disclosure of customer and member personal financial information that Oxford collects in the course of conducting its business. Our policy applies to both current and former customers and members. The Information Oxford Collects We collect non-public, personal financial information about you from the following sources: • Information we receive from you on applications or other forms (such as name, address, social security number and date of birth.) • Information about your transactions with us, our affiliates (companies controlled or owned by Oxford), or others; and • Information we receive from consumer reporting agencies concerning large group customers. The Information Oxford Discloses We do not disclose any non-public, personal financial information about our current and former customers and members to anyone except as permitted by law. For example, we may disclose information to affiliates and other third parties to service or process an insurance transaction; or provide information to insurance regulators or law enforcement authorities upon request. Oxford Security Practices We emphasize the importance of confidentiality through employee training, the implementation of procedures designed to protect the security of our records, and our privacy policy. We restrict access to the personal financial information of our customers and members to those employees who need to know that information to perform their job responsibilities. We maintain physical, electronic, and procedural safeguards that comply with federal and state regulations to guard your non-public, personal financial information. This notice is being provided on behalf of the following Oxford affiliates: Oxford Health Plans LLC Oxford Health Plans (CT), Inc. Oxford Health Plans (NJ), Inc. Oxford Health Plans (NY), Inc. Oxford Health Insurance, Inc. Investors Guaranty Life Insurance Company Oxford Benefit Management, Inc. • you would like a copy of these Notices in Spanish, please contact Oxford Customer Service at the number on the back of your Oxford Member ID card. • If you would like a copy of these Notices in Chinese, please contact Oxford Customer Service at the number on the back of your Oxford Member ID card. • If you would like a copy of these Notices in Korean, please contact Oxford Customer Service at the number on the back of your Oxford Member ID card. BENJAMIN 000137 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 137 of 237 MS-03-420 #6246 R5 ACCESS REQUEST FORM Purpose: This Form is intended for use by an individual to exercise his/her right to access his/her protected health information in Oxford’s designated record sets or the designated record sets of Oxford’s Business Associates. Individual Seeking Access Name: Address: I.D. Number: Telephone: Scope of Access You have the right to inspect and obtain a copy of your protected health information maintained by Oxford and its business associates. You are not, however, entitled to inspect or obtain a copy of any psychotherapy notes we may have or any information we may have compiled in anticipation of or for use in any civil, criminal or administrative action or proceeding. Please specify the records you wish to inspect or obtain copies of: We may charge you to make copies and mail your protected health information. Oxford will notify you in advance of these charges. If you want to pick the copies up at our Trumbull, CT office please check here Signature: Date: Personal Representative If this request is being made by a personal representative on behalf of the individual, please provide a description and any available documentation of authority to act as the individual’s personal representative and sign below. Print name Signature Please send completed form to: HIPAA Member Rights Unit 48 Monroe Turnpike Trumbull, CT 06611 YOU ARE ENTITLED TO A COPY OF THIS REQUEST. BENJAMIN 000138 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 138 of 237 Your Oxford Coverage for all seasons www.oxfordhealth.com BENJAMIN 000139 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 139 of 237 Service Request Summary Search Criteria Type Code Name From To Oxford Rec'd Data Entry Date Closed Date Date Range Usage Include All SR MEMBER 1095319301 Amy Benjamin Unassigned Assigned Opened Closed All CC Return 50 service requests or less for query. Performance Mode <=50 SR# Assignee Requestor Criteria Search Results ---------------------------------------------------------------------------------------------------------------------------------------------- Count Hits 7 ID Date Requestor Opened Closed Stat FA Queue Assignee Claim # Corres # Check # Auth # X 20273324 04/14/2016 NKAJALE 04/21/2016 04/21/2016 C PROVIDER NMAHENDR 5132S24622.01 6105211501 20175994 03/11/2016 PBANER9 03/17/2016 03/17/2016 C PROVIDER KKUMA68 5132S24622 6071102602 19250955 03/16/2015 PCHADBO 03/17/2015 03/17/2015 C OPERATIONS CALDRICH 18006307 12/06/2013 KZAFRA 12/11/2013 12/11/2013 C PROVIDER JSING30 3294114824 3340203385 17996048 12/04/2013 IAGBAY 12/06/2013 12/06/2013 C PROVIDER MSOLANKI 3294114824 3338212045 17541175 07/09/2013 MPUTTA 07/16/2013 07/16/2013 C PHYSIREIMB DCOELHO 3190202873 17492380 06/24/2011 LMOHITHE 07/05/2013 07/05/2013 C PHYSIREIMB DCOELHO 3175231889 Explanation Can we please send memebr determination letter for ETS Z0290747004 dated 2/24/2015? Last Tracking Comments Closing Comments Letter Sent To Member View SR Open SR Clear Close Page 1 of 1Service Request Summary 6/27/2016http://oxfcsaapps.oxhp.com/WEBCSA-SF/servlet/SrSummary?yodaURIPath=http://oxfcsaapps.oxhp.com/WEBCSA-AF/web/controller/ BENJAMIN 000140 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 140 of 237 Communications Events Event ID: Type: Inbound Flag:146543483 PHONE Entered by: On behalf of: Date:LWATS15 LWATS15 Lola Watson 07/11/2014 10:36 AM Comment: OON PROVIDER- GAVE RQST'D BENEFITS W/ AUTH RQ'MNTS Initiator Customer Type MEMBER Code 1095319301 Name Amy Benjamin Other Subject Reason Code Description Subject Type Subject Code Product Name Invalid 8E Explanation of BMEMBER 1095319301 EYPF Amy Benjamin Close Page 1 of 1Communications Event 6/27/2016http://oxfcsaapps.oxhp.com/WEBCSA-SF/servlet/NewCommEvent?EventId=146543483 BENJAMIN 000141 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 141 of 237 Communications Events Event ID: Type: Inbound Flag:146672071 PHONE Entered by: On behalf of: Date:LPAGE10 LPAGE10 Lori Page 07/18/2014 10:39 AM Comment: Initiator Customer Type MEMBER Code 1095319301 Name Amy Benjamin Other Amy S Benjamin Subject Reason Code Description Subject Type Subject Code Product Name Invalid BEN07 Benefit/Coverag MEMBER 1095319301 EYPF Amy Benjamin Close Page 1 of 1Communications Event 6/27/2016http://oxfcsaapps.oxhp.com/WEBCSA-SF/servlet/NewCommEvent?EventId=146672071 BENJAMIN 000142 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 142 of 237 Communications Events Event ID: Type: Inbound Flag:146867570 PHONE Entered by: On behalf of: Date:HMARKUN HMARKUN Heather Markunas 07/29/2014 04:42 PM Comment: John @ Prov calling for fac ben verified Caron Renaissance OON gave ben, effective date and claims address Initiator Customer Type MEMBER Code 1095319301 Name Amy Benjamin Other Subject Reason Code Description Subject Type Subject Code Product Name Invalid BEN07 Benefit/Coverag MEMBER 1095319301 EYPF Amy Benjamin Close Page 1 of 1Communications Event 6/27/2016http://oxfcsaapps.oxhp.com/WEBCSA-SF/servlet/NewCommEvent?EventId=146867570 BENJAMIN 000143 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 143 of 237 THIS IS NOT A BILL 48 Monroe Turnpike Trumbull, CT 06611 OHPI NY INC Please see last page for Appeals Rights E X P L A N A T I O N O F B E N E F I T S ATTENTION: THIS MAILING MAY CONTAIN DOCUMENTATION ON VARIOUS MATTERS Please note : Check(s) associated with your claim(s) will be sent to the subscriber of your family, unless payment is made to the provider. BENJAMIN, AMY 11 COVLEE DRIVE WESTPORT CT 06880 Subscriber Name: BENJAMIN, AMY Subscriber ID #: 10953193*01-10953193*01 11-12-2014 Member Name: BENJAMIN, AMY Provider Name: CARON RENAISSANCE Member ID: 10953193*01 Provider ID: A883799 Patient Acct #: 14614 Claim #: 4304213629 Date of Service CPT Code Description QTY Billed Amt Max Amt Deductible Amt Copay Amt % Co-Ins Amt Adj Code COB Amt Payment Amt 07-24-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 D2 0.00 07-25-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 D2 0.00 07-25-14 80050 GENERAL HEALTH PANEL 1 999.00 0.00 D2 0.00 07-25-14 80101 DRUG SCREEN, SINGLE 1 40.00 0.00 D2 0.00 07-25-14 80101 DRUG SCREEN, SINGLE 1 35.00 0.00 D2 0.00 07-25-14 80101 DRUG SCREEN, SINGLE 1 8.84 0.00 D2 0.00 07-26-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 D2 0.00 REMINDER - Effective January 1, 2007, Quest Diagnostics is no longer a participating laboratory with Oxford Health Plans. To locate a participating laboratory or for more information log in to www.oxfordhealth.com or call 1-800-666-1353. BENJAMIN, AMY 11 COVLEE DRIVE WESTPORT CT 06880 48 Monroe Turnpike, Trumbull, CT 06611 OHPI NY INC BENJAMIN 000158 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 144 of 237 E X P L A N A T I O N O F B E N E F I T S Subscriber Name: BENJAMIN, AMY Subscriber ID #: 10953193*01-10953193*01 11-12-2014 Member Name: BENJAMIN, AMY Provider Name: CARON RENAISSANCE Member ID: 10953193*01 Provider ID: A883799 Patient Acct #: 14614 Claim #: 4304213629 Date of Service CPT Code Description QTY Billed Amt Max Amt Deductible Amt Copay Amt % Co-Ins Amt Adj Code COB Amt Payment Amt 07-27-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 D2 0.00 07-28-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 D2 0.00 07-29-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 D2 0.00 07-30-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 D2 0.00 07-31-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 D2 0.00 08-01-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 D2 0.00 08-02-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 D2 0.00 08-03-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 D2 0.00 08-04-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 D2 0.00 08-05-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 D2 0.00 08-06-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 D2 0.00 08-07-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 D2 0.00 08-07-14 80101 DRUG SCREEN, SINGLE 1 40.00 0.00 D2 0.00 08-07-14 80101 DRUG SCREEN, SINGLE 1 35.00 0.00 D2 0.00 08-08-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 D2 0.00 08-09-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 D2 0.00 08-10-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 D2 0.00 08-11-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 D2 0.00 08-12-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 D2 0.00 08-17-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 D2 0.00 08-17-14 80101 DRUG SCREEN, SINGLE 1 40.00 0.00 D2 0.00 08-17-14 80101 DRUG SCREEN, SINGLE 1 35.00 0.00 D2 0.00 08-18-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 D2 0.00 08-19-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 D2 0.00 08-20-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 D2 0.00 08-21-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 D2 0.00 08-22-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 D2 0.00 08-23-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 D2 0.00 08-24-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 D2 0.00 TOTAL CLAIM: 4304213629 63732.76 0.00 0.00 0.00 0.00 0.00 0.00 Diagnostic Code: 300.00 Diagnostic Desc: ANXIETY STATE, UNSPECIFIED Billed Amt Max Amt Deductible Amt Copay Amt Co-ins Amt COB Amt Payment Amt Claim Payment Summary 63732.76 0.00 0.00 0.00 0.00 0.00 0.00 Check Summary Total Paid . . . . 0.00 Paid To . . . . . . . . . HANLEY CENTER INC Check Date. . . . November 12, 2014 Check Number. . . 12188608 Adjustment Code Descriptions D2 This claim was denied because these services were not authorized in advance. Please refer to your Certificate of Coverage for more information. BENJAMIN 000159 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 145 of 237 % Percent. The portion of the Maximum Amount you are responsible to pay. Please see the coinsurance amount description for additional information. ADJ CODE Adjustment code. The code we assign to describe how we processed this claim line. Generally, the adjustment code shows a correction, adjustment or denial. ANNUAL LIMIT The amount your plan requires you to pay for deductible and out of-pocket maximums during the plan year. BILLED AMT Billed amount. The amount billed by the provider. CLAIM # Claim Number. The number we assign to your claim. The first four digits of a claim number reflect the date the caim was received. (Example: Claim Number 8049234568 - The first digit (8) indicates the year 2008 and the following three digits (049) indicate the day of the year in Julian date format. In this example, the claim was received on the 49th day of the year, or February 18, 2008.) COB AMT Coordination of Benefits. The amount covered by your other health plan when that health plan is your "primary" plan. CPT CODE A five-digit alpha numeric identifier used to define the medical service, supply or drug billed. Unless otherwise noted, the code is assigned by your health care provider. CO-INS AMT Coinsurance amount. The portion of the maximum amount you must pay for covered benefits during the plan year. Please see your Summary of Benefits for the coinsurance amount. Coinsurance (when part of your plan) typically does not apply until after you meet the deductible. COPAY AMT Copayment amount. The amount you are required to pay directly to a Provider for in-network covered benefits at the time of the service. Copayments generally apply when receiving services from participating providers. Please see your Summary of Benefits for the applicable copayment amount. DATE OF SERVICE The date the physician or facility performed the service(s). DEDUCTIBLE AMT Deductible amount. The amount you must pay for covered benefits during the plan year before we begin making payments for covered benefits. Please see your Summary of Benefits for the applicable deductible amount. In most instances, the deductible amount must be met before coinsurance applies. DESCRIPTION A brief explanation of a code used to describe the medical service, supply or medication billed. DIAGNOSIS CODE A three- to five-digit code used to explain the medical diagnosis code billed. Unless otherwise noted, the code is assigned by your health care provider. DIAGNOSIS DESCRIPTION A brief explanation of a code used to describe the medical diagnosis. DEFINITION OF TERMS BE ON THE LOOKOUT FOR FRAUD Fraud hurts everyone through increased insurance premiums and health care costs. Please compare your medical bills to your Explanation of Benefits (EOB) to verify that all services were actually provided. Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation. Please call member services at the phone number on the back of your health plan ID card if you suspect any fraudulent activities. Examples of fraud includethe intentional misrepresentationof any of the following: • The charges for the service, procedure and/or supplies provided. • The type of services, procedures and/or supplies provided. • The dates of services and/or treatments. • The condition treated or the diagnosis made. • The identity of the provider or member. BENJAMIN 000160 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 146 of 237 IN-NETWORK Services provided by a participating health care provider with a referral (if required) or by a non-participating (out-of-network) provider through an approved in-network exception request. MAX AMT Maximum amount. The most that is available to pay for covered benefits under your plan. For a participating provider, it is an agreed upon amount. If your plan has out-of-network benefits, it is the lower of the billed amount, the amount available for payment using the plan’s out-of-network reimbursement rates and rules, or the amount the provider has agreed to accept as payment. Please see your health benefits plan, including your Summary of Benefits for more information. OUT-OF-POCKET MAXIMUM The most you have to pay in deductibles and coinsurance for covered health services during the plan year. Depending on your plan design, the out-of-pocket maximum may also include copayment amounts. Items not covered by your health benefits plan, such as excluded services and penalty amounts, do not count toward the out-of-pocket maximum. For out-of network services, amounts above the out-of-network reimbursement (shown in the maximum amount column) are your responsibility and do not count toward your out-of-pocket maximum. Please see your health benefit plan, including your Summary of Benefits, for details about your plan coverage. OUT-OF-NETWORK Services provided by either a non-participating health care provider or a health care provider who participates in our network when a required referral has not been obtained. PATIENT ACCT # Patient account number. The provider’s account number or invoice number for you or your claim. PATIENT RESP Patient responsibility. The amount you are responsible to pay. This includes items not covered by your health benefits plan, such as excluded services, penalty amounts, deductibles, coinsurance, copayments and for out-of-network services, amounts above the maximum amount. (The patient responsibility shown on this EOB does not take into account any amounts paid at the time of service.) PAYMENT AMT Payment amount. The amount reimbursed under your health benefits plan. QTY Quantity. Refers to the number of times a particular service was performed. REMAINING BALANCE The portion of the annual limit remaining for the current plan year. DEFINITION OF TERMS BENJAMIN 000161 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 147 of 237 BE ON THE LOOKOUT FOR FRAUD Fraud hurts everyone through increased insurance premiums and health care costs. Please compare your medical bills to your Explanation of Benefits (EOB) to verify that all services were actually provided. Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation. Please call member services at the phone number on the back of your health plan ID card if you suspect any fraudulent activities. Examples of fraud includethe intentional misrepresentationof any of the following: • The charges for the service, procedure and/or supplies provided. • The type of services, procedures and/or supplies provided. • The dates of services and/or treatments. • The condition treated or the diagnosis made. • The identity of the provider or member. E X P L A N A T I O N O F B E N E F I T S Availability of Consumer Assistance/Ombudsman Services In addition to the Explanation of Member Appeal Rights attached, there may be other resources available to help you understand the appeals process. For questions about your rights, this notice, or for assistance, you can contact the Employee Benefits Security Administration at 1-866-444-EBSA (3272)or www.askebsa.dol.gov. Additionally, a consumer assistance program may be able to assist you at: Connecticut Office of the Healthcare Advocate P.O. Box 1543 Hartford, CT 06144 Toll-free telephone: 1-866-466-4446 Web site: www.ct.gov/oha E-mail: healthcare.advocate@ct.gov BENJAMIN 000162 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 148 of 237 RIGHTS OF REVIEW AND APPEAL If this claim has or is currently in the process of being appealed, please disregard the Member Appeal Information provided below and follow the instructions that were previously mailed to you. If you would like further clarification or have any questions regarding this Explanation of Benefits (EOB), or if you are not fully satisfied with the resolution of your claim, you may contact Customer Care by calling 1-800-444-6222, or by writing toOxford Correspondence Department, LLC, P.O. Box 29135, Hot Springs, AR 71903. A service associate will investigate and attempt to resolve your concerns at the time of the call. If you remain dissatisfied, you may appeal the determination by following the Appeal Procedures outlined below. If we have requested additional information to process your claim, this information must be submitted toOxford Correspondence Department - Resubmissions, P.O. Box 29133, Hot Springs, AR 71903. The requested information must be submitted within 45 days of the date of your receipt of this notice. Upon receipt of the information, we will elect to take the one-time, 15-day extension that is permitted under the Employment Retirement Income Security Act (ERISA) and will provide you with a written response not later than 15 days from receipt of the information. Failure to submit this information within 45 days will result in an automatic denial of this claim due to lack of information. No further notice will be provided to you. In the event that you fail to follow these procedures in the time frame specified but wish to submit relevant information outside the time frame and/or request an appeal, please follow the appeal procedures outlined below. Failure to comply with appeal process requirements as communicated by Oxford may lead to forfeiture of a consumer’s right to challenge a denial or rejection, even when a request for clarification has been made. Note: A claim is any request by a covered member for certification of a benefit, or payment for a service, as required under the terms of the member’s health plan. A claim is denied when it does not meet the criteria established by your plan. If your claim has been denied in whole or in part and you would like a copy of the criteria used, you must send a written request toOxf rd Disclosure Requests, P.O. Box 29133, Hot Springs, AR 71903. The criteria will be provided to you free of charge. Member Appeal Information You may designate a person (“Designee”) to act on your behalf to appeal this decision. To do so, you must provide us with the designation, in writing, at the time of the appeal. The designation must be signed by you, or by your guardian if you are a minor. First-Level Internal Appeal You or your Designee must submit a request for appeal within180 daysof receipt of this EOB. Unless otherwise specified in the denial description, the appeal must be submitted in writing toOxford Correspondence Department, P.O. Box 29134, Hot Springs, AR 71903,or by calling Customer Care at 1-800-444-6222 and requesting an appeal. The request must include the reason(s) you believe that the claim should not have been denied, your name and member ID number, a copy of this form (or the claim number on this form), and any documentation/ information you would like to submit in support of the appeal. We will provide you with a written response not later than30 daysfrom the Correspondence Department’s (or other department indicated in this correspondence) receipt of your request for a First-Level Appeal. Second-Level Internal Appeal Second-Level appeal rights are available for members of group plans. Individual plans only have one level of internal appeal and if applicable, may be eligible to pursue an external appeal after completion of the First-Level Appeal (see below for more information). If Second-Level Appeal rights are available, you will receive additional information in the First-Level Appeal determination notice. Second-Level Appeal rights allow group members or their Designee to appeal to our Grievance Review Board (GRB) for further consideration. Requests for a Second-Level Appeal must be made within60 business daysof the receipt of the First-Level Appeal determination letter. The request for appeal and any additional information must be submitted toOxfor Grievance Review Board, P.O. Box 29134, Hot Springs, AR 71903. If these rights are available to you, you or your Designee will need to include all information we previously requested (if not already submitted), and any additional facts or information that you believe to be relevant to the issue. The appeal will be resolved not later than30 daysfrom the GRB’s receipt of your request for a Second-Level Appeal. Employee Retirement Income Security Act (ERISA) Rights If we have not approved your claim after all reviews have been completed, group members may have the right to file a civil action under 502(a) of the Employee Retirement Income Security Act. New York State External Appeal Process A denial based upon clinical reasons subject to the Utilization Law of New York, such as (1) lack of medical necessity, (2) experimental/investigational, (3) clinical trial provision, (4) rare disease treatment, or (5) that the out-of-network health service is not materially different from the health services available in-network, may be eligible to be appealed through New York’s external appeal program. You will be notified of your eligibility to pursue an external appeal in the appeal determination notice. You may obtain additional information about the New York external appeals process by calling Customer Care at 1-800-444-6222. TTY/TDD and Language Assistance Notice If you have a hearing impairment and need help, please call our TTY/TDD line at 1-800-201-4875. Please call 1-800-303-6719 for assistance in Chinese, 1-888-201-4746 for assistance in Korean, or the telephone number on your health plan ID card for assistance in English and other languages. NY-14-166 BENJAMIN 000163 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 149 of 237 48 Monroe Turnpike Trumbull, CT 06611 R E M I T T A N C E A D V I C E OHPI NY INC Please see last page for Appeals Rights ATTENTION: THIS MAILING MAY CONTAIN DOCUMENTATION ON VARIOUS MATTERS HANLEY CENTER INC 7789 NW BEACON SQ BLVD BOCA RATON FL 33487 Vendor Name: HANLEY CENTER INC TIN: 592500657 Vendor ID #: P2500657-A883799 Check Number: 12188608 11-12-2014 Member Name: BENJAMIN, AMY Provider Name: CARON RENAISSANCE Member ID: 10953193*01 Provider ID: A883799 Patient Acct #: 14614 Claim #: 4304213629 Serv Date CPT Code Description QTY Billed Amt Max Amt Withhold Amt Deductible Amt Copay/Co-ins Amt Adj Code COB Amt Payment Amt 07-24-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 0.00 D2 0.00 07-25-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 0.00 D2 0.00 07-25-14 80050 GENERAL HEALTH PANEL 1 999.00 0.00 0.00 D2 0.00 07-25-14 80101 DRUG SCREEN, SINGLE 1 40.00 0.00 0.00 D2 0.00 07-25-14 80101 DRUG SCREEN, SINGLE 1 35.00 0.00 0.00 D2 0.00 07-25-14 80101 DRUG SCREEN, SINGLE 1 8.84 0.00 0.00 D2 0.00 07-26-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 0.00 D2 0.00 07-27-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 0.00 D2 0.00 07-28-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 0.00 D2 0.00 07-29-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 0.00 D2 0.00 TOTAL CLAIM: 4304213629 63732.76 0.00 0.00 0.00 0.00 0.00 0.00 HANLEY CENTER INC 7789 NW BEACON SQ BLVD BOCA RATON FL 33487 Why wait for this to arrive in the mail? Save time, money and paper with electronic payments and remittance advice. To sign up or learn more: • Go to OxfordHealth.com • Click on Providers or Facilities • Select Tools & Resources • Select Direct Deposit & Electronic EOBs 48 Monroe Turnpike, Trumbull, CT 06611 OHPI NY INC BENJAMIN 000164 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 150 of 237 R E M I T T A N C E A D V I C E Vendor Name: HANLEY CENTER INC TIN: 592500657 Vendor ID #: P2500657-A883799 Check Number: 12188608 11-12-2014 Member Name: BENJAMIN, AMY Provider Name: CARON RENAISSANCE Member ID: 10953193*01 Provider ID: A883799 Patient Acct #: 14614 Claim #: 4304213629 Serv Date CPT Code Description QTY Billed Amt Max Amt Withhold Amt Deductible Amt Copay/Co-ins Amt Adj Code COB Amt Payment Amt 07-30-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 0.00 D2 0.00 07-31-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 0.00 D2 0.00 08-01-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 0.00 D2 0.00 08-02-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 0.00 D2 0.00 08-03-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 0.00 D2 0.00 08-04-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 0.00 D2 0.00 08-05-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 0.00 D2 0.00 08-06-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 0.00 D2 0.00 08-07-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 0.00 D2 0.00 08-07-14 80101 DRUG SCREEN, SINGLE 1 40.00 0.00 0.00 D2 0.00 08-07-14 80101 DRUG SCREEN, SINGLE 1 35.00 0.00 0.00 D2 0.00 08-08-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 0.00 D2 0.00 08-09-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 0.00 D2 0.00 08-10-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 0.00 D2 0.00 08-11-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 0.00 D2 0.00 08-12-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 0.00 D2 0.00 08-17-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 0.00 D2 0.00 08-17-14 80101 DRUG SCREEN, SINGLE 1 40.00 0.00 0.00 D2 0.00 08-17-14 80101 DRUG SCREEN, SINGLE 1 35.00 0.00 0.00 D2 0.00 08-18-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 0.00 D2 0.00 08-19-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 0.00 D2 0.00 08-20-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 0.00 D2 0.00 08-21-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 0.00 D2 0.00 08-22-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 0.00 D2 0.00 08-23-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 0.00 D2 0.00 08-24-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 0.00 D2 0.00 TOTAL CLAIM: 4304213629 63732.76 0.00 0.00 0.00 0.00 0.00 0.00 Member Name: BENJAMIN, AMY Provider Name: CARON RENAISSANCE Member ID: 10953193*01 Provider ID: A883799 Patient Acct #: 15243 Claim #: 4304213632 Serv Date CPT Code Description QTY Billed Amt Max Amt Withhold Amt Deductible Amt Copay/Co-ins Amt Adj Code COB Amt Payment Amt 08-26-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 0.00 D2 0.00 08-26-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 0.00 D2 0.00 08-27-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 0.00 D2 0.00 08-28-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 0.00 D2 0.00 09-03-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 0.00 D2 0.00 09-03-14 80101 DRUG SCREEN, SINGLE 1 150.00 0.00 0.00 D2 0.00 09-04-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 0.00 D2 0.00 09-05-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 0.00 D2 0.00 09-06-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 0.00 D2 0.00 09-07-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 0.00 D2 0.00 09-08-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 0.00 D2 0.00 09-09-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 0.00 D2 0.00 09-10-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 0.00 D2 0.00 09-11-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 0.00 D2 0.00 09-12-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 0.00 D2 0.00 09-13-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 0.00 D2 0.00 09-14-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 0.00 D2 0.00 09-15-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 0.00 D2 0.00 09-16-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 0.00 D2 0.00 09-16-14 80101 DRUG SCREEN, SINGLE 1 150.00 0.00 0.00 D2 0.00 09-17-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 0.00 D2 0.00 09-18-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 0.00 D2 0.00 09-21-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.00 0.00 0.00 D2 0.00 09-21-14 80101 DRUG SCREEN, SINGLE 1 150.00 0.00 0.00 D2 0.00 TOTAL CLAIM: 4304213632 47324.80 0.00 0.00 0.00 0.00 0.00 0.00 BENJAMIN 000165 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 151 of 237 Great News! Oxford has introduced new auto attendant options on its customer services lines and new dedicated provider support teams to meet your unique needs. Watch for future service enhancements. R E M I T T A N C E A D V I C E Billed Amt Max Amt Withhold Amt Deductible Amt Copay/Co-ins Amt COB Amt Payment Amt Claim Payment Summary 111057.56 0.00 0.00 0.00 0.00 0.00 0.00 Check Summary Total Paid . . . . . . . . 0.00 Check Date. . . . . . . . November 12, 2014 Paid To . . . . . . . . . . . HANLEY CENTER INC Check Number. . . . . 12188608 Adjustment Code Descriptions D2 These services were formally denied because they were not authorized in advance Why wait for this to arrive in the mail? Save time, money and paper with electronic payments and remittance advice. To sign up or learn more: • Go to OxfordHealth.com • Click on Providers or Facilities • Select Tools & Resources • Select Direct Deposit & Electronic EOBs Are you getting all that you can out of oxfordhealth.com? Oxford® is dedicated to helping your practice run smoother. Our website is easy to use and available for you to interact with us at your convenience. Let us give you the VIP tour. Log on as a Provider or Facility on oxfordhealth.com.Go to Tools & Resources > Manage Your Practice > Administrative Ease and register for a webcast training session today. BENJAMIN 000166 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 152 of 237 R E M I T T A N C E A D V I C E OXFORD’S MISSION At Oxford, we recognize the importance of the provider-patient relationship, and know that good care starts with you. We want to complement the care you provide to help asthma patients breathe a little easier help new mothers deliver healthy, full-term babies…help your patients with heart disease and diabetes adopt healthy lifestyles -- to help your patients live longer, healthier and happier lives. OXFORD KEEPS IT SIMPLE At Oxford, we know that being a successful health plan depends on the “simple things”: network, brand, service, product diversity and most importantly, customer satisfaction. We also know that one of the most important questions a Member will ask is “Is my doctor in your plan?” Thanks to you, we’re able to offer our Members access to a network of over 50,000 physicians* and 200 of the area’s finest hospitals. Our commitment to the simple things has allowed us to offer quality healthcare coverage for over a decade. We look forward to your continued participation with Oxford. *The number of physicians available to Members varies by geography and product type. BENJAMIN 000167 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 153 of 237 ADJ CODE Adjustment code. The code we assign to describe how we processed this claim line. Generally, the adjustment code shows a correction, adjustment or denial. BILLED AMT Billed amount. The amount billed by you. CLAIM # Claim Number. The number we assign to your claim. The first four digits of a claim number reflect the date the claim was received. (Example: Claim Number 8049234568 - The first digit (8) indicates the year 2008 and the following three digits (049) indicate the day of the year in Julian date format. In this example, the claim was received on the 49th day of the year, or February 18, 2008.) COB AMT Coordination of Benefits. The amount covered by the member’s other health plan when that health plan is “primary.” CO-INS AMT Coinsurance amount. The portion of the maximum amount the member must pay for covered benefits during the plan year. Coinsurance (when part a member’s plan) typically does not apply until after the member meets the deductible. COPAY AMT Copayment amount. The amount the member is required to pay directly to you for in-network covered benefits at the time of the service. Copayments generally apply when receiving services from participating providers. CPT CODE A five-digit alpha numeric identifier used to define the medical service, supply or drug billed. Unless otherwise noted, the code is assigned by you. DATE RECEIVED The date we received the claim. DEDUCTIBLE AMT Deductible amount. The amount the member must pay for covered benefits during the plan year before we begin making payments for covered benefits. In most instances, the deductible amount must be met before coinsurance applies. DESCRIPTION A brief explanation of a code used to describe the medical service, supply or medication billed. DIAGNOSIS CODE A three- to five-digit code used to explain the medical diagnosis code billed. Unless otherwise noted, the code is assigned by you. DIAGNOSIS DESCRIPTION A brief explanation of a code used to describe the medical diagnosis. MAX AMT Maximum amount. The most that is available to pay for covered benefits under a member’s health benefits plan. For a participating provider, it is an agreed upon amount. If the member’s plan has out-of-network benefits, it is the lower of the billed amount, the amount available for payment using the plan’s out-of-network reimbursement rates and rules, or the amount you have agreed to accept as payment. DEFINITION OF TERMS BE ON THE LOOKOUT FOR FRAUD Fraud can affect members, providers and health plans alike through increased insurance premiums and health care costs. Those who file a claim with intent to defraud, or helps commit fraud against an insurer, is guilty of a crime. Fraud includes intentional misrepresentation of any of the following: • Charges for a service, procedure or supplies • Type of service, procedure or supplies provided • Dates of services or treatments • Medical record of services or treatments provided • Condition treated or diagnosis made • Identity of the provider or member Please contact us at 800-666-1353 if you suspect or are aware of any fraudulent activities. Thank you for doing your part to stop abuse in the health care system. BENJAMIN 000168 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 154 of 237 PATIENT ACCT # Patient account number. Refers to your account number or invoice number for the patient or claim. PAYMENT AMT Payment amount. The amount reimbursed under the member’s health benefits plan. QTY Quantity. Refers to the number of times a particular service was performed. SERV DATE Service date. The date you performed the service(s). VENDOR NAME/ID# Refers to the recipient of payment. This may be you, the individual provider, or the collective provider of services with which you are affiliated (e.g., medical group). WITHHOLD AMT Withhold amount. Refers to a contracted percentage of the fee that is not payable at this time. DEFINITION OF TERMS BENJAMIN 000169 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 155 of 237 Attention Non-contracted Medicare Providers Appeals Process for Non-contracted Medicare Providers Pursuant to federal regulations governing the Medicare Advantage program, non-contracted providers may request reconsideration (appeal) of a Medicare Advantage plan payment denial determination. To appeal a claim denial, submit a written request within 60 calendar days of the remittance notification date and include at a minimum: • A statement indicating factual or legal basis for appeal • A signed Waiver of Liability form (you may obtain a copy on www.uhconline.com) • A copy of the original claim • A copy of the remittance notice showing the claim denial • Any additional information, clinical records or documentation Mail the appeal request to UnitedHealthcare Appeals & Grievances Po Box 6106 Cypress, CA 90630 MS CA 124-0157 Payment Dispute Process for Non-contracted Medicare Providers Pursuant to federal regulations governing the Medicare Advantage program, non-contracted providers may file a payment dispute for a Medicare Advantage plan payment determination. A payment dispute may be filed when the provider disagrees with the amount paid, including issues related to bundling of services. To dispute a claim denial, submit a written request within 120 calendar days of the remittance notification date and include at a minimum: • A statement indicating factual or legal basis for the dispute • A copy of the original claim • A copy of the remittance notice showing the claim payment • Any additional information, clinical records or documentation to support the dispute Mail the payment dispute to Oxford, A UnitedHealthcare Company Attn: Provider Appeals Department PO Box 29136 Hot Springs, AR 71903 For additional information on the Non-contracted Appeal and Dispute processes including a form that may be used to facilitate your request for appeal or dispute, please go to www.uhconline.com. BE ON THE LOOKOUT FOR FRAUD Fraud can affect members, providers and health plans alike through increased insurance premiums and health care costs. Those who file a claim with intent to defraud, or helps commit fraud against an insurer, is guilty of a crime. Fraud includes intentional misrepresentation of any of the following: • Charges for a service, procedure or supplies • Type of service, procedure or supplies provided • Dates of services or treatments • Medical record of services or treatments provided • Condition treated or diagnosis made • Identity of the provider or member Please contact us at 800-666-1353 if you suspect or are aware of any fraudulent activities. Thank you for doing your part to stop abuse in the health care system. R E M I T T A N C E A D V I C E BENJAMIN 000170 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 156 of 237 RIGHTS OF REVIEW AND APPEAL If this claim has or is currently in the process of being appealed, please disregard the Appeals process described below. If you would like further clarification of this Remittance Advice (RA) or are not fully satisfied with the resolution of your claim, you may contact Provider Services at l-800-666-1353 and a Service Associate will investigate and attempt to resolve your concerns at the time of the call. Participating providers may also submit aClaim(s) Review Request Form.to Oxford, A UnitedHealthcare Company, Correspondence Department, P.O. Box 29135, Hot Springs, AR 71903.This form is available on Oxford’s website atwww.oxfordhealth.comLog in as a provider or facility, click on theTools & Resourcestab and then on Forms. If you remain dissatisfied, you may appeal the determination using the procedure listed below. APPEALS FROM PARTICIPATING PROVIDERS CONTRACTED WITH OXFORD You may appeal an adverse claim determination by following the appeal procedures specified in the Provider Reference Manual (PRM). and any subsequent updates. Please be advised that, with the exception of services rendered to New Jersey (NJ) commercial line of business Members after July 11, 2006, which has a different process (described below and in the PRM), you have180 days (6 months)from the date of this determination to send your written request for appeal toOxford, A UnitedHealthcare Company, Attention: Provider Appeals Department, P. O Box 29136, Hot Springs, AR 71903. To be processed, the appeal request must be submitted on theClaim(s) Review Request Form.The form must be completed in its entirety, including the reason(s) you believe the claim should not have been denied, the claim number(s) and any documentation you believe supports your position. Once the review is complete, you will receive Oxford’s written response. If you are not satisfied with Oxford’s decision, you may arbitrate the issue as set forth in your contract with Oxford. ALL PROVIDERS Retrospective Utilization Review Appeal Information for Services Provided to NY Commercial Members: Pursuant to Article 49 of New York Insurance Law, healthcare providers treating a Member in a New York Commercial line of business (LOB) may request a retrospective clinical review if: (1) the review of the procedure was requested only after the services were provided and (2) Oxford denied the service based upon medical necessity or the experimental/investigational exclusion if the Member has a life-threatening or disabling condition. If you have failed to seek a required precertification, a retrospective clinical review is not available. If a retrospective adverse determination is rendered in accordance with the above procedure, you may appeal as described below: Internal Appeal: You must appeal a retrospective adverse determination to Oxford’s Clinical Appeals Department within60 calendar daysof receipt of the retrospective adverse determination. To appeal, you must send an appeal letter, any information requested in the initial retrospective adverse determination and any additional information you would like to submit in support of the appeal to:Clinical Appeals Department, Oxford, A UnitedHealthcare Company, P.O. 29139, Hot Springs AR 71903(Fax 203-459-7351). The Clinical Appeals Department will acknowledge receipt of the appeal and request any information needed to conduct the review within15 business days. The appeal will be resolved within60 calendar daysof receipt of all necessary information. To review the policy used to determine coverage for a request for services, please submit a written request to:Policy Requests and Information, Oxford, A UnitedHealthcare Company, 48 Monroe Turnpike, Trumbull, CT 06611. External Appeal: In general, you may be eligible to file an application for external appeal of a retrospective adverse determination to an independent utilization review organization as provided by the New York Insurance Law, if the Clinical Appeals Department upholds, on medical necessity grounds or the experimental/investigational exclusion, all or part of such a retrospective adverse determination. Determinations based upon the experimental/investigational exclusion (including clinical trials) may be appealed through the external appeal process only if the Member’s condition meets the statutory definition of a “life threatening” or “disabling” condition. To determine eligibility for external review and file an external appeal, youmust file a written application with the New York State Department of Insurance (DOI) within45 daysof receipt of the denial from the Clinical Appeals Department. An application and instructions will be sent with the appeals determination. The DOI will assign the case to a state-licensed external appeal agent who has no affiliation with Oxford. The external appeal agent will issue a standard appeal decision within30 daysof receiving the application and an expedited external appeal decision within three days of receipt of the request. An external appeal agent’s medical necessity decision is binding on all parties, so long as the benefit is available under the Member’s plan. If you have a question concerning a particular member’s LOB, the information may be found on Oxford’s website atwww.oxfordhealth.com or by calling Provider Services at 1-800-666-1353. Claim Appeals for Services Provided to NJ Commercial Members: If you have a dispute relating to the payment of a claim for services that were rendered to a NJ commercial line of business Member on or after July 11, 2006, your dispute may be eligible for a two-step appeal process. Disputes involving medical necessity may not be appealed through this process and must follow the utilization management appeal process. The first step of the claim appeal process allows you to submit a claim appeal through Oxford’s internal appeal process and, if eligible, the second step allows your dispute to be referred to an independent arbitration entity selected by and contracted with the NJ Department of Banking and Insurance (DOBI). Internal Appeal: You must submit an internal appeal to Oxford’s Correspondence Department within90 calendar daysof receipt of an adverse claim determination.The appeal must be submitted on a form created by the DOBI, along with the information required to process your appeal (listed on form). The form is available on Oxford’s web site (www.oxfordhealth.com). The form and the information must be sent to:Oxford, A UnitedHealthcare Company, Attention: Provider Appeals Department, P.O. Box 29136, Hot Springs, AR 71903.The appeal will be resolved within 30 calendar days from the receipt of your appeal submission. If you have a question concerning a particular Member’s line of business, information may be found on Oxford’s web site atwww.oxfordhealth.comor by calling Provider Services at 1-800-666-1353. Arbitration: Disputes may be referred to arbitration when the internal appeal determination is in Oxford’s favor or when we have not made a timely determination on your appeal. To be eligible for the NJ arbitration process, the disputed claim amount must be at least $1,000. While you may aggregate your claims to reach this number, you must initiate the arbitration proceeding on a form created by DOBI on or before the90th calendar dayfollowing your receipt of the determination (or non-determination). The arbitration will be conducted according to the rules of the arbitration entity. Additional information will be provided if any part of the determination is not reversed on appeal. Information is also available on the DOBI web site atwww.state.nj.us/dobi. MS-07-215 BENJAMIN 000171 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 157 of 237 BENJAMIN 000172 20545035 0600 CT Campo Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 158 of 237 THIS IS NOT A BILL 48 Monroe Turnpike Trumbull, CT 06611 OHPI NY INC Please see last page for Appeals Rights E X P L A N A T I O N O F B E N E F I T S ATTENTION: THIS MAILING MAY CONTAIN DOCUMENTATION ON VARIOUS MATTERS Please note : Check(s) associated with your claim(s) will be sent to the subscriber of your family, unless payment is made to the provider. BENJAMIN, AMY 11 COVLEE DRIVE WESTPORT CT 06880 Subscriber Name: BENJAMIN, AMY Subscriber ID #: 10953193*01-10953193*01 11-28-2014 Member Name: BENJAMIN, AMY Provider Name: CARON RENAISSANCE Member ID: 10953193*01 Provider ID: A883799 Patient Acct #: 13815 Claim #: 4304211935 Date of Service CPT Code Description QTY Billed Amt Max Amt Deductible Amt Copay Amt % Co-Ins Amt Adj Code COB Amt Payment Amt 07-30-14 95816 EEG, AWAKE AND DROWSY 1 2000.00 1000.00 30% 300.00 A88P 700.00 07-30-14 90876 PSYCHOPHYSIOLOGICAL THERAPY 1 2000.00 1000.00 30% 300.00 A88P 700.00 REMINDER - Effective January 1, 2007, Quest Diagnostics is no longer a participating laboratory with Oxford Health Plans. To locate a participating laboratory or for more information log in to www.oxfordhealth.com or call 1-800-666-1353. BENJAMIN, AMY 11 COVLEE DRIVE WESTPORT CT 06880 48 Monroe Turnpike, Trumbull, CT 06611 OHPI NY INC BENJAMIN 000173 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 159 of 237 E X P L A N A T I O N O F B E N E F I T S Subscriber Name: BENJAMIN, AMY Subscriber ID #: 10953193*01-10953193*01 11-28-2014 Member Name: BENJAMIN, AMY Provider Name: CARON RENAISSANCE Member ID: 10953193*01 Provider ID: A883799 Patient Acct #: 13815 Claim #: 4304211935 Date of Service CPT Code Description QTY Billed Amt Max Amt Deductible Amt Copay Amt % Co-Ins Amt Adj Code COB Amt Payment Amt TOTAL CLAIM: 4304211935 4000.00 2000.00 0.00 0.00 600.00 0.00 1400.00 Diagnostic Code: 300.00 Diagnostic Desc: ANXIETY STATE, UNSPECIFIED Billed Amt Max Amt Deductible Amt Copay Amt Co-ins Amt COB Amt Payment Amt Claim Payment Summary 4000.00 2000.00 0.00 0.00 600.00 0.00 1400.00 Check Summary Total Paid . . . . 1,400.00 Paid To . . . . . . . . . HANLEY CENTER INC Check Date. . . . November 28, 2014 Check Number. . . 12261044 Adjustment Code Descriptions A88P This claim is for services performed by a non-network health care provider. Your claim has been paid based on the Out-of- Network Reimbursement Amount established by your benefit plan, which provides reimbursement to non-network health care providers or facilities at 50 percent of the provider's billed charges when no Medicare rate or other available rate source applies to the services. You are responsible for amounts above the Out-of-Network Reimbursement Amount shown in the "Max Amt" column, in addition to any deductible and coinsurance amounts reflected above. The amount above the "Max Amt" does not apply to your out-of-pocket maximum. To expedite the review of your correspondence, please include the following information at the top of your introductory letterbefore mailing: 1. Your Oxford Member ID # 2. Includeall relevantClaim #’s you are writing to us about 3. TheDate(s) of Serviceassociated with each claim 4. Please indicate thepurpose of your correspondence 5. If applicable, please include any other related documentation BENJAMIN 000174 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 160 of 237 % Percent. The portion of the Maximum Amount you are responsible to pay. Please see the coinsurance amount description for additional information. ADJ CODE Adjustment code. The code we assign to describe how we processed this claim line. Generally, the adjustment code shows a correction, adjustment or denial. ANNUAL LIMIT The amount your plan requires you to pay for deductible and out of-pocket maximums during the plan year. BILLED AMT Billed amount. The amount billed by the provider. CLAIM # Claim Number. The number we assign to your claim. The first four digits of a claim number reflect the date the caim was received. (Example: Claim Number 8049234568 - The first digit (8) indicates the year 2008 and the following three digits (049) indicate the day of the year in Julian date format. In this example, the claim was received on the 49th day of the year, or February 18, 2008.) COB AMT Coordination of Benefits. The amount covered by your other health plan when that health plan is your "primary" plan. CPT CODE A five-digit alpha numeric identifier used to define the medical service, supply or drug billed. Unless otherwise noted, the code is assigned by your health care provider. CO-INS AMT Coinsurance amount. The portion of the maximum amount you must pay for covered benefits during the plan year. Please see your Summary of Benefits for the coinsurance amount. Coinsurance (when part of your plan) typically does not apply until after you meet the deductible. COPAY AMT Copayment amount. The amount you are required to pay directly to a Provider for in-network covered benefits at the time of the service. Copayments generally apply when receiving services from participating providers. Please see your Summary of Benefits for the applicable copayment amount. DATE OF SERVICE The date the physician or facility performed the service(s). DEDUCTIBLE AMT Deductible amount. The amount you must pay for covered benefits during the plan year before we begin making payments for covered benefits. Please see your Summary of Benefits for the applicable deductible amount. In most instances, the deductible amount must be met before coinsurance applies. DESCRIPTION A brief explanation of a code used to describe the medical service, supply or medication billed. DIAGNOSIS CODE A three- to five-digit code used to explain the medical diagnosis code billed. Unless otherwise noted, the code is assigned by your health care provider. DIAGNOSIS DESCRIPTION A brief explanation of a code used to describe the medical diagnosis. DEFINITION OF TERMS BE ON THE LOOKOUT FOR FRAUD Fraud hurts everyone through increased insurance premiums and health care costs. Please compare your medical bills to your Explanation of Benefits (EOB) to verify that all services were actually provided. Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation. Please call member services at the phone number on the back of your health plan ID card if you suspect any fraudulent activities. Examples of fraud includethe intentional misrepresentationof any of the following: • The charges for the service, procedure and/or supplies provided. • The type of services, procedures and/or supplies provided. • The dates of services and/or treatments. • The condition treated or the diagnosis made. • The identity of the provider or member. BENJAMIN 000175 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 161 of 237 IN-NETWORK Services provided by a participating health care provider with a referral (if required) or by a non-participating (out-of-network) provider through an approved in-network exception request. MAX AMT Maximum amount. The most that is available to pay for covered benefits under your plan. For a participating provider, it is an agreed upon amount. If your plan has out-of-network benefits, it is the lower of the billed amount, the amount available for payment using the plan’s out-of-network reimbursement rates and rules, or the amount the provider has agreed to accept as payment. Please see your health benefits plan, including your Summary of Benefits for more information. OUT-OF-POCKET MAXIMUM The most you have to pay in deductibles and coinsurance for covered health services during the plan year. Depending on your plan design, the out-of-pocket maximum may also include copayment amounts. Items not covered by your health benefits plan, such as excluded services and penalty amounts, do not count toward the out-of-pocket maximum. For out-of network services, amounts above the out-of-network reimbursement (shown in the maximum amount column) are your responsibility and do not count toward your out-of-pocket maximum. Please see your health benefit plan, including your Summary of Benefits, for details about your plan coverage. OUT-OF-NETWORK Services provided by either a non-participating health care provider or a health care provider who participates in our network when a required referral has not been obtained. PATIENT ACCT # Patient account number. The provider’s account number or invoice number for you or your claim. PATIENT RESP Patient responsibility. The amount you are responsible to pay. This includes items not covered by your health benefits plan, such as excluded services, penalty amounts, deductibles, coinsurance, copayments and for out-of-network services, amounts above the maximum amount. (The patient responsibility shown on this EOB does not take into account any amounts paid at the time of service.) PAYMENT AMT Payment amount. The amount reimbursed under your health benefits plan. QTY Quantity. Refers to the number of times a particular service was performed. REMAINING BALANCE The portion of the annual limit remaining for the current plan year. DEFINITION OF TERMS BENJAMIN 000176 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 162 of 237 BE ON THE LOOKOUT FOR FRAUD Fraud hurts everyone through increased insurance premiums and health care costs. Please compare your medical bills to your Explanation of Benefits (EOB) to verify that all services were actually provided. Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation. Please call member services at the phone number on the back of your health plan ID card if you suspect any fraudulent activities. Examples of fraud includethe intentional misrepresentationof any of the following: • The charges for the service, procedure and/or supplies provided. • The type of services, procedures and/or supplies provided. • The dates of services and/or treatments. • The condition treated or the diagnosis made. • The identity of the provider or member. E X P L A N A T I O N O F B E N E F I T S Availability of Consumer Assistance/Ombudsman Services In addition to the Explanation of Member Appeal Rights attached, there may be other resources available to help you understand the appeals process. For questions about your rights, this notice, or for assistance, you can contact the Employee Benefits Security Administration at 1-866-444-EBSA (3272)or www.askebsa.dol.gov. Additionally, a consumer assistance program may be able to assist you at: Connecticut Office of the Healthcare Advocate P.O. Box 1543 Hartford, CT 06144 Toll-free telephone: 1-866-466-4446 Web site: www.ct.gov/oha E-mail: healthcare.advocate@ct.gov BENJAMIN 000177 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 163 of 237 RIGHTS OF REVIEW AND APPEAL If this claim has or is currently in the process of being appealed, please disregard the Member Appeal Information provided below and follow the instructions that were previously mailed to you. If you would like further clarification or have any questions regarding this Explanation of Benefits (EOB), or if you are not fully satisfied with the resolution of your claim, you may contact Customer Care by calling 1-800-444-6222, or by writing toOxford Correspondence Department, LLC, P.O. Box 29135, Hot Springs, AR 71903. A service associate will investigate and attempt to resolve your concerns at the time of the call. If you remain dissatisfied, you may appeal the determination by following the Appeal Procedures outlined below. If we have requested additional information to process your claim, this information must be submitted toOxford Correspondence Department - Resubmissions, P.O. Box 29133, Hot Springs, AR 71903. The requested information must be submitted within 45 days of the date of your receipt of this notice. Upon receipt of the information, we will elect to take the one-time, 15-day extension that is permitted under the Employment Retirement Income Security Act (ERISA) and will provide you with a written response not later than 15 days from receipt of the information. Failure to submit this information within 45 days will result in an automatic denial of this claim due to lack of information. No further notice will be provided to you. In the event that you fail to follow these procedures in the time frame specified but wish to submit relevant information outside the time frame and/or request an appeal, please follow the appeal procedures outlined below. Failure to comply with appeal process requirements as communicated by Oxford may lead to forfeiture of a consumer’s right to challenge a denial or rejection, even when a request for clarification has been made. Note: A claim is any request by a covered member for certification of a benefit, or payment for a service, as required under the terms of the member’s health plan. A claim is denied when it does not meet the criteria established by your plan. If your claim has been denied in whole or in part and you would like a copy of the criteria used, you must send a written request toOxf rd Disclosure Requests, P.O. Box 29133, Hot Springs, AR 71903. The criteria will be provided to you free of charge. Member Appeal Information You may designate a person (“Designee”) to act on your behalf to appeal this decision. To do so, you must provide us with the designation, in writing, at the time of the appeal. The designation must be signed by you, or by your guardian if you are a minor. First-Level Internal Appeal You or your Designee must submit a request for appeal within180 daysof receipt of this EOB. Unless otherwise specified in the denial description, the appeal must be submitted in writing toOxford Correspondence Department, P.O. Box 29134, Hot Springs, AR 71903,or by calling Customer Care at 1-800-444-6222 and requesting an appeal. The request must include the reason(s) you believe that the claim should not have been denied, your name and member ID number, a copy of this form (or the claim number on this form), and any documentation/ information you would like to submit in support of the appeal. We will provide you with a written response not later than30 daysfrom the Correspondence Department’s (or other department indicated in this correspondence) receipt of your request for a First-Level Appeal. Second-Level Internal Appeal Second-Level appeal rights are available for members of group plans. Individual plans only have one level of internal appeal and if applicable, may be eligible to pursue an external appeal after completion of the First-Level Appeal (see below for more information). If Second-Level Appeal rights are available, you will receive additional information in the First-Level Appeal determination notice. Second-Level Appeal rights allow group members or their Designee to appeal to our Grievance Review Board (GRB) for further consideration. Requests for a Second-Level Appeal must be made within60 business daysof the receipt of the First-Level Appeal determination letter. The request for appeal and any additional information must be submitted toOxfor Grievance Review Board, P.O. Box 29134, Hot Springs, AR 71903. If these rights are available to you, you or your Designee will need to include all information we previously requested (if not already submitted), and any additional facts or information that you believe to be relevant to the issue. The appeal will be resolved not later than30 daysfrom the GRB’s receipt of your request for a Second-Level Appeal. Employee Retirement Income Security Act (ERISA) Rights If we have not approved your claim after all reviews have been completed, group members may have the right to file a civil action under 502(a) of the Employee Retirement Income Security Act. New York State External Appeal Process A denial based upon clinical reasons subject to the Utilization Law of New York, such as (1) lack of medical necessity, (2) experimental/investigational, (3) clinical trial provision, (4) rare disease treatment, or (5) that the out-of-network health service is not materially different from the health services available in-network, may be eligible to be appealed through New York’s external appeal program. You will be notified of your eligibility to pursue an external appeal in the appeal determination notice. You may obtain additional information about the New York external appeals process by calling Customer Care at 1-800-444-6222. TTY/TDD and Language Assistance Notice If you have a hearing impairment and need help, please call our TTY/TDD line at 1-800-201-4875. Please call 1-800-303-6719 for assistance in Chinese, 1-888-201-4746 for assistance in Korean, or the telephone number on your health plan ID card for assistance in English and other languages. NY-14-166 BENJAMIN 000178 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 164 of 237 48 Monroe Turnpike Trumbull, CT 06611 R E M I T T A N C E A D V I C E OHPI NY INC Please see last page for Appeals Rights ATTENTION: THIS MAILING MAY CONTAIN DOCUMENTATION ON VARIOUS MATTERS HANLEY CENTER INC 7789 NW BEACON SQ BLVD BOCA RATON FL 33487 Vendor Name: HANLEY CENTER INC TIN: 592500657 Vendor ID #: P2500657-A883799 Check Number: 12261044 11-28-2014 Member Name: BENJAMIN, AMY Provider Name: CARON RENAISSANCE Member ID: 10953193*01 Provider ID: A883799 Patient Acct #: 13815 Claim #: 4304211935 Serv Date CPT Code Description QTY Billed Amt Max Amt Withhold Amt Deductible Amt Copay/Co-ins Amt Adj Code COB Amt Payment Amt 07-30-14 95816 EEG, AWAKE AND DROWSY 1 2000.00 1000.00 0.00 300.00 A88P 700.00 07-30-14 90876 PSYCHOPHYSIOLOGICAL THERAPY 1 2000.00 1000.00 0.00 300.00 A88P 700.00 TOTAL CLAIM: 4304211935 4000.00 2000.00 0.00 0.00 600.00 0.00 1400.00 Billed Amt Max Amt Withhold Amt Deductible Amt Copay/Co-ins Amt COB Amt Payment Amt Claim Payment Summary 4000.00 2000.00 0.00 0.00 600.00 0.00 1400.00 PAY: Authorized Signature (not valid after 180 days) •••••••••• 48 Monroe Turnpike, Trumbull, CT 06611 HANLEY CENTER INC 7789 NW BEACON SQ BLVD BOCA RATON FL 33487 November 28, 2014 JPMorgan Chase Bank, N.A. Syracuse, NY, 13206 50-937 213 2294-09 C12261044C A021309379A 601872294C One Thousand Four Hundred Dollars and No Cents********************************** $1,400.00 12261044 OHPI NY INC Non-negotiable - This is not a check ••••••••••• • Remittance Documentation Image Archive BENJAMIN 000179 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 165 of 237 R E M I T T A N C E A D V I C E Check Summary Total Paid . . . . . . . . 1,400.00 Check Date. . . . . . . . November 28, 2014 Paid To . . . . . . . . . . . HANLEY CENTER INC Check Number. . . . . 12261044 Adjustment Code Descriptions A88P This claim is for services performed by a non-network health care provider. This claim has been paid based on the Out-of-Network Reimbursement Amount established by the member's benefit plan, which provides reimbursement to non-network health care providers or facilities at 50 percent of the provider's billed charges when no Medicare rate or other available rate source applies to the services. The member is responsible for amounts above the Out-of-Network Reimbursement Amount shown in the "Max Amt" column, in addition to any deductible and coinsurance amounts reflected above. P lease E ndorse H ere D O N O T W R IT E O R S T A M P B E LO W T H IS LIN E R E S E R V E D F O R F IN A N C IA L IN S T IT U T IO N U S E X Why wait for this check to arrive in the mail? Save time, money and paper with electronic payments and remittance advice. To sign up or learn more: • Go to OxfordHealth.com • Click on Providers or Facilities • Select Tools & Resources • Select Direct Deposit & Electronic EOBs Are you getting all that you can out of oxfordhealth.com? Oxford® is dedicated to helping your practice run smoother. Our website is easy to use and available for you to interact with us at your convenience. Let us give you the VIP tour. Log on as a Provider or Facility on oxfordhealth.com.Go to Tools & Resources > Manage Your Practice > Administrative Ease and register for a webcast training session today. BENJAMIN 000180 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 166 of 237 ADJ CODE Adjustment code. The code we assign to describe how we processed this claim line. Generally, the adjustment code shows a correction, adjustment or denial. BILLED AMT Billed amount. The amount billed by you. CLAIM # Claim Number. The number we assign to your claim. The first four digits of a claim number reflect the date the claim was received. (Example: Claim Number 8049234568 - The first digit (8) indicates the year 2008 and the following three digits (049) indicate the day of the year in Julian date format. In this example, the claim was received on the 49th day of the year, or February 18, 2008.) COB AMT Coordination of Benefits. The amount covered by the member’s other health plan when that health plan is “primary.” CO-INS AMT Coinsurance amount. The portion of the maximum amount the member must pay for covered benefits during the plan year. Coinsurance (when part a member’s plan) typically does not apply until after the member meets the deductible. COPAY AMT Copayment amount. The amount the member is required to pay directly to you for in-network covered benefits at the time of the service. Copayments generally apply when receiving services from participating providers. CPT CODE A five-digit alpha numeric identifier used to define the medical service, supply or drug billed. Unless otherwise noted, the code is assigned by you. DATE RECEIVED The date we received the claim. DEDUCTIBLE AMT Deductible amount. The amount the member must pay for covered benefits during the plan year before we begin making payments for covered benefits. In most instances, the deductible amount must be met before coinsurance applies. DESCRIPTION A brief explanation of a code used to describe the medical service, supply or medication billed. DIAGNOSIS CODE A three- to five-digit code used to explain the medical diagnosis code billed. Unless otherwise noted, the code is assigned by you. DIAGNOSIS DESCRIPTION A brief explanation of a code used to describe the medical diagnosis. MAX AMT Maximum amount. The most that is available to pay for covered benefits under a member’s health benefits plan. For a participating provider, it is an agreed upon amount. If the member’s plan has out-of-network benefits, it is the lower of the billed amount, the amount available for payment using the plan’s out-of-network reimbursement rates and rules, or the amount you have agreed to accept as payment. DEFINITION OF TERMS BE ON THE LOOKOUT FOR FRAUD Fraud can affect members, providers and health plans alike through increased insurance premiums and health care costs. Those who file a claim with intent to defraud, or helps commit fraud against an insurer, is guilty of a crime. Fraud includes intentional misrepresentation of any of the following: • Charges for a service, procedure or supplies • Type of service, procedure or supplies provided • Dates of services or treatments • Medical record of services or treatments provided • Condition treated or diagnosis made • Identity of the provider or member Please contact us at 800-666-1353 if you suspect or are aware of any fraudulent activities. Thank you for doing your part to stop abuse in the health care system. BENJAMIN 000181 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 167 of 237 PATIENT ACCT # Patient account number. Refers to your account number or invoice number for the patient or claim. PAYMENT AMT Payment amount. The amount reimbursed under the member’s health benefits plan. QTY Quantity. Refers to the number of times a particular service was performed. SERV DATE Service date. The date you performed the service(s). VENDOR NAME/ID# Refers to the recipient of payment. This may be you, the individual provider, or the collective provider of services with which you are affiliated (e.g., medical group). WITHHOLD AMT Withhold amount. Refers to a contracted percentage of the fee that is not payable at this time. DEFINITION OF TERMS BENJAMIN 000182 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 168 of 237 Attention Non-contracted Medicare Providers Appeals Process for Non-contracted Medicare Providers Pursuant to federal regulations governing the Medicare Advantage program, non-contracted providers may request reconsideration (appeal) of a Medicare Advantage plan payment denial determination. To appeal a claim denial, submit a written request within 60 calendar days of the remittance notification date and include at a minimum: • A statement indicating factual or legal basis for appeal • A signed Waiver of Liability form (you may obtain a copy on www.uhconline.com) • A copy of the original claim • A copy of the remittance notice showing the claim denial • Any additional information, clinical records or documentation Mail the appeal request to UnitedHealthcare Appeals & Grievances Po Box 6106 Cypress, CA 90630 MS CA 124-0157 Payment Dispute Process for Non-contracted Medicare Providers Pursuant to federal regulations governing the Medicare Advantage program, non-contracted providers may file a payment dispute for a Medicare Advantage plan payment determination. A payment dispute may be filed when the provider disagrees with the amount paid, including issues related to bundling of services. To dispute a claim denial, submit a written request within 120 calendar days of the remittance notification date and include at a minimum: • A statement indicating factual or legal basis for the dispute • A copy of the original claim • A copy of the remittance notice showing the claim payment • Any additional information, clinical records or documentation to support the dispute Mail the payment dispute to Oxford, A UnitedHealthcare Company Attn: Provider Appeals Department PO Box 29136 Hot Springs, AR 71903 For additional information on the Non-contracted Appeal and Dispute processes including a form that may be used to facilitate your request for appeal or dispute, please go to www.uhconline.com. BE ON THE LOOKOUT FOR FRAUD Fraud can affect members, providers and health plans alike through increased insurance premiums and health care costs. Those who file a claim with intent to defraud, or helps commit fraud against an insurer, is guilty of a crime. Fraud includes intentional misrepresentation of any of the following: • Charges for a service, procedure or supplies • Type of service, procedure or supplies provided • Dates of services or treatments • Medical record of services or treatments provided • Condition treated or diagnosis made • Identity of the provider or member Please contact us at 800-666-1353 if you suspect or are aware of any fraudulent activities. Thank you for doing your part to stop abuse in the health care system. R E M I T T A N C E A D V I C E BENJAMIN 000183 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 169 of 237 RIGHTS OF REVIEW AND APPEAL If this claim has or is currently in the process of being appealed, please disregard the Appeals process described below. If you would like further clarification of this Remittance Advice (RA) or are not fully satisfied with the resolution of your claim, you may contact Provider Services at l-800-666-1353 and a Service Associate will investigate and attempt to resolve your concerns at the time of the call. Participating providers may also submit aClaim(s) Review Request Form.to Oxford, A UnitedHealthcare Company, Correspondence Department, P.O. Box 29135, Hot Springs, AR 71903.This form is available on Oxford’s website atwww.oxfordhealth.comLog in as a provider or facility, click on theTools & Resourcestab and then on Forms. If you remain dissatisfied, you may appeal the determination using the procedure listed below. APPEALS FROM PARTICIPATING PROVIDERS CONTRACTED WITH OXFORD You may appeal an adverse claim determination by following the appeal procedures specified in the Provider Reference Manual (PRM). and any subsequent updates. Please be advised that, with the exception of services rendered to New Jersey (NJ) commercial line of business Members after July 11, 2006, which has a different process (described below and in the PRM), you have180 days (6 months)from the date of this determination to send your written request for appeal toOxford, A UnitedHealthcare Company, Attention: Provider Appeals Department, P. O Box 29136, Hot Springs, AR 71903. To be processed, the appeal request must be submitted on theClaim(s) Review Request Form.The form must be completed in its entirety, including the reason(s) you believe the claim should not have been denied, the claim number(s) and any documentation you believe supports your position. Once the review is complete, you will receive Oxford’s written response. If you are not satisfied with Oxford’s decision, you may arbitrate the issue as set forth in your contract with Oxford. ALL PROVIDERS Retrospective Utilization Review Appeal Information for Services Provided to NY Commercial Members: Pursuant to Article 49 of New York Insurance Law, healthcare providers treating a Member in a New York Commercial line of business (LOB) may request a retrospective clinical review if: (1) the review of the procedure was requested only after the services were provided and (2) Oxford denied the service based upon medical necessity or the experimental/investigational exclusion if the Member has a life-threatening or disabling condition. If you have failed to seek a required precertification, a retrospective clinical review is not available. If a retrospective adverse determination is rendered in accordance with the above procedure, you may appeal as described below: Internal Appeal: You must appeal a retrospective adverse determination to Oxford’s Clinical Appeals Department within60 calendar daysof receipt of the retrospective adverse determination. To appeal, you must send an appeal letter, any information requested in the initial retrospective adverse determination and any additional information you would like to submit in support of the appeal to:Clinical Appeals Department, Oxford, A UnitedHealthcare Company, P.O. 29139, Hot Springs AR 71903(Fax 203-459-7351). The Clinical Appeals Department will acknowledge receipt of the appeal and request any information needed to conduct the review within15 business days. The appeal will be resolved within60 calendar daysof receipt of all necessary information. To review the policy used to determine coverage for a request for services, please submit a written request to:Policy Requests and Information, Oxford, A UnitedHealthcare Company, 48 Monroe Turnpike, Trumbull, CT 06611. External Appeal: In general, you may be eligible to file an application for external appeal of a retrospective adverse determination to an independent utilization review organization as provided by the New York Insurance Law, if the Clinical Appeals Department upholds, on medical necessity grounds or the experimental/investigational exclusion, all or part of such a retrospective adverse determination. Determinations based upon the experimental/investigational exclusion (including clinical trials) may be appealed through the external appeal process only if the Member’s condition meets the statutory definition of a “life threatening” or “disabling” condition. To determine eligibility for external review and file an external appeal, youmust file a written application with the New York State Department of Insurance (DOI) within45 daysof receipt of the denial from the Clinical Appeals Department. An application and instructions will be sent with the appeals determination. The DOI will assign the case to a state-licensed external appeal agent who has no affiliation with Oxford. The external appeal agent will issue a standard appeal decision within30 daysof receiving the application and an expedited external appeal decision within three days of receipt of the request. An external appeal agent’s medical necessity decision is binding on all parties, so long as the benefit is available under the Member’s plan. If you have a question concerning a particular member’s LOB, the information may be found on Oxford’s website atwww.oxfordhealth.com or by calling Provider Services at 1-800-666-1353. Claim Appeals for Services Provided to NJ Commercial Members: If you have a dispute relating to the payment of a claim for services that were rendered to a NJ commercial line of business Member on or after July 11, 2006, your dispute may be eligible for a two-step appeal process. Disputes involving medical necessity may not be appealed through this process and must follow the utilization management appeal process. The first step of the claim appeal process allows you to submit a claim appeal through Oxford’s internal appeal process and, if eligible, the second step allows your dispute to be referred to an independent arbitration entity selected by and contracted with the NJ Department of Banking and Insurance (DOBI). Internal Appeal: You must submit an internal appeal to Oxford’s Correspondence Department within90 calendar daysof receipt of an adverse claim determination.The appeal must be submitted on a form created by the DOBI, along with the information required to process your appeal (listed on form). The form is available on Oxford’s web site (www.oxfordhealth.com). The form and the information must be sent to:Oxford, A UnitedHealthcare Company, Attention: Provider Appeals Department, P.O. Box 29136, Hot Springs, AR 71903.The appeal will be resolved within 30 calendar days from the receipt of your appeal submission. If you have a question concerning a particular Member’s line of business, information may be found on Oxford’s web site atwww.oxfordhealth.comor by calling Provider Services at 1-800-666-1353. Arbitration: Disputes may be referred to arbitration when the internal appeal determination is in Oxford’s favor or when we have not made a timely determination on your appeal. To be eligible for the NJ arbitration process, the disputed claim amount must be at least $1,000. While you may aggregate your claims to reach this number, you must initiate the arbitration proceeding on a form created by DOBI on or before the90th calendar dayfollowing your receipt of the determination (or non-determination). The arbitration will be conducted according to the rules of the arbitration entity. Additional information will be provided if any part of the determination is not reversed on appeal. Information is also available on the DOBI web site atwww.state.nj.us/dobi. MS-07-215 BENJAMIN 000184 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 170 of 237 THIS IS NOT A BILL 48 Monroe Turnpike Trumbull, CT 06611 OHPI NY INC Please see last page for Appeals Rights E X P L A N A T I O N O F B E N E F I T S ATTENTION: THIS MAILING MAY CONTAIN DOCUMENTATION ON VARIOUS MATTERS Please note : Check(s) associated with your claim(s) will be sent to the subscriber of your family, unless payment is made to the provider. BENJAMIN, AMY 11 COVLEE DRIVE WESTPORT CT 06880 Subscriber Name: BENJAMIN, AMY Subscriber ID #: 10953193*01-10953193*01 12-30-2014 Member Name: BENJAMIN, AMY Provider Name: CARON RENAISSANCE Member ID: 10953193*01 Provider ID: A883799 Patient Acct #: 13815 Claim #: 4304211935.01 Date of Service CPT Code Description QTY Billed Amt Max Amt Deductible Amt Copay Amt % Co-Ins Amt Adj Code COB Amt Payment Amt 07-30-14 95816 EEG, AWAKE AND DROWSY 1 2000.00 1000.00 30% 300.00 A88P 700.00 07-30-14 90876 PSYCHOPHYSIOLOGICAL THERAPY 1 2000.00 1000.00 30% 300.00 A88P 700.00 TOTAL CLAIM: 4304211935.01 4000.00 2000.00 0.00 0.00 600.00 0.00 1400.00 Diagnostic Code: 300.00 Diagnostic Desc: ANXIETY STATE, UNSPECIFIED REMINDER - Effective January 1, 2007, Quest Diagnostics is no longer a participating laboratory with Oxford Health Plans. To locate a participating laboratory or for more information log in to www.oxfordhealth.com or call 1-800-666-1353. BENJAMIN, AMY 11 COVLEE DRIVE WESTPORT CT 06880 48 Monroe Turnpike, Trumbull, CT 06611 OHPI NY INC BENJAMIN 000185 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 171 of 237 E X P L A N A T I O N O F B E N E F I T S Summary Year: 01-MAR-14 To: 28-FEB-15 Individual Limits Family Limits Annual Limit Year to Date Remaining Balance Annual Limit Year to Date Remaining Balance In Network Out Of Pocket 3000.00 837.05 2162.95 6000.00 4092.05 1907.95 Out Of Network Deductible 2000.00 2000.00 0.00 4000.00 4000.00 0.00 Out Of Network Out Of Pocket 5000.00 4062.99 937.01 10000.00 9708.21 291.79 Billed Amt Max Amt Deductible Amt Copay Amt Co-ins Amt COB Amt Payment Amt Claim Payment Summary 4000.00 2000.00 0.00 0.00 600.00 0.00 1400.00 Check Summary Total Paid . . . . 1,400.00 Paid To . . . . . . . . . AMY BENJAMIN Check Date. . . . December 30, 2014 Check Number. . . 12404847 Adjustment Code Descriptions A88P This claim is for services performed by a non-network health care provider. Your claim has been paid based on the Out-of- Network Reimbursement Amount established by your benefit plan, which provides reimbursement to non-network health care providers or facilities at 50 percent of the provider's billed charges when no Medicare rate or other available rate source applies to the services. You are responsible for amounts above the Out-of-Network Reimbursement Amount shown in the "Max Amt" column, in addition to any deductible and coinsurance amounts reflected above. The amount above the "Max Amt" does not apply to your out-of-pocket maximum. To expedite the review of your correspondence, please include the following information at the top of your introductory letterbefore mailing: 1. Your Oxford Member ID # 2. Includeall relevantClaim #’s you are writing to us about 3. TheDate(s) of Serviceassociated with each claim 4. Please indicate thepurpose of your correspondence 5. If applicable, please include any other related documentation THE BASICS: WE’VE GOT YOU COVERED At Oxford, we want to help you understand the benefits, programs and services available to you so that you can use them effectively. And we know that good care starts with your physician. Here are some of the basics that you can rely on from your Oxford coverage: ♦ Network of over 50,000 physicians* and over 200 of the area’s finest hospitals; ♦ Area’s first credentialed network of complementary and alternative medicine practitioners; ♦ Annual physical at no charge for most plans; ♦ No charge for routine preventive in-network pediatric care; ♦ 24-hour access to registered nurses for healthcare guidance through Oxford On-Call®; and ♦ Access to your choice of OB/GYN without a referral. *The number of physicians available to you varies by geography and product type. MS-13-197 BENJAMIN 000186 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 172 of 237 % Percent. The portion of the Maximum Amount you are responsible to pay. Please see the coinsurance amount description for additional information. ADJ CODE Adjustment code. The code we assign to describe how we processed this claim line. Generally, the adjustment code shows a correction, adjustment or denial. ANNUAL LIMIT The amount your plan requires you to pay for deductible and out of-pocket maximums during the plan year. BILLED AMT Billed amount. The amount billed by the provider. CLAIM # Claim Number. The number we assign to your claim. The first four digits of a claim number reflect the date the caim was received. (Example: Claim Number 8049234568 - The first digit (8) indicates the year 2008 and the following three digits (049) indicate the day of the year in Julian date format. In this example, the claim was received on the 49th day of the year, or February 18, 2008.) COB AMT Coordination of Benefits. The amount covered by your other health plan when that health plan is your "primary" plan. CPT CODE A five-digit alpha numeric identifier used to define the medical service, supply or drug billed. Unless otherwise noted, the code is assigned by your health care provider. CO-INS AMT Coinsurance amount. The portion of the maximum amount you must pay for covered benefits during the plan year. Please see your Summary of Benefits for the coinsurance amount. Coinsurance (when part of your plan) typically does not apply until after you meet the deductible. COPAY AMT Copayment amount. The amount you are required to pay directly to a Provider for in-network covered benefits at the time of the service. Copayments generally apply when receiving services from participating providers. Please see your Summary of Benefits for the applicable copayment amount. DATE OF SERVICE The date the physician or facility performed the service(s). DEDUCTIBLE AMT Deductible amount. The amount you must pay for covered benefits during the plan year before we begin making payments for covered benefits. Please see your Summary of Benefits for the applicable deductible amount. In most instances, the deductible amount must be met before coinsurance applies. DESCRIPTION A brief explanation of a code used to describe the medical service, supply or medication billed. DIAGNOSIS CODE A three- to five-digit code used to explain the medical diagnosis code billed. Unless otherwise noted, the code is assigned by your health care provider. DIAGNOSIS DESCRIPTION A brief explanation of a code used to describe the medical diagnosis. DEFINITION OF TERMS BE ON THE LOOKOUT FOR FRAUD Fraud hurts everyone through increased insurance premiums and health care costs. Please compare your medical bills to your Explanation of Benefits (EOB) to verify that all services were actually provided. Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation. Please call member services at the phone number on the back of your health plan ID card if you suspect any fraudulent activities. Examples of fraud includethe intentional misrepresentationof any of the following: • The charges for the service, procedure and/or supplies provided. • The type of services, procedures and/or supplies provided. • The dates of services and/or treatments. • The condition treated or the diagnosis made. • The identity of the provider or member. BENJAMIN 000187 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 173 of 237 IN-NETWORK Services provided by a participating health care provider with a referral (if required) or by a non-participating (out-of-network) provider through an approved in-network exception request. MAX AMT Maximum amount. The most that is available to pay for covered benefits under your plan. For a participating provider, it is an agreed upon amount. If your plan has out-of-network benefits, it is the lower of the billed amount, the amount available for payment using the plan’s out-of-network reimbursement rates and rules, or the amount the provider has agreed to accept as payment. Please see your health benefits plan, including your Summary of Benefits for more information. OUT-OF-POCKET MAXIMUM The most you have to pay in deductibles and coinsurance for covered health services during the plan year. Depending on your plan design, the out-of-pocket maximum may also include copayment amounts. Items not covered by your health benefits plan, such as excluded services and penalty amounts, do not count toward the out-of-pocket maximum. For out-of network services, amounts above the out-of-network reimbursement (shown in the maximum amount column) are your responsibility and do not count toward your out-of-pocket maximum. Please see your health benefit plan, including your Summary of Benefits, for details about your plan coverage. OUT-OF-NETWORK Services provided by either a non-participating health care provider or a health care provider who participates in our network when a required referral has not been obtained. PATIENT ACCT # Patient account number. The provider’s account number or invoice number for you or your claim. PATIENT RESP Patient responsibility. The amount you are responsible to pay. This includes items not covered by your health benefits plan, such as excluded services, penalty amounts, deductibles, coinsurance, copayments and for out-of-network services, amounts above the maximum amount. (The patient responsibility shown on this EOB does not take into account any amounts paid at the time of service.) PAYMENT AMT Payment amount. The amount reimbursed under your health benefits plan. QTY Quantity. Refers to the number of times a particular service was performed. REMAINING BALANCE The portion of the annual limit remaining for the current plan year. DEFINITION OF TERMS BENJAMIN 000188 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 174 of 237 BE ON THE LOOKOUT FOR FRAUD Fraud hurts everyone through increased insurance premiums and health care costs. Please compare your medical bills to your Explanation of Benefits (EOB) to verify that all services were actually provided. Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation. Please call member services at the phone number on the back of your health plan ID card if you suspect any fraudulent activities. Examples of fraud includethe intentional misrepresentationof any of the following: • The charges for the service, procedure and/or supplies provided. • The type of services, procedures and/or supplies provided. • The dates of services and/or treatments. • The condition treated or the diagnosis made. • The identity of the provider or member. E X P L A N A T I O N O F B E N E F I T S Availability of Consumer Assistance/Ombudsman Services In addition to the Explanation of Member Appeal Rights attached, there may be other resources available to help you understand the appeals process. For questions about your rights, this notice, or for assistance, you can contact the Employee Benefits Security Administration at 1-866-444-EBSA (3272)or www.askebsa.dol.gov. Additionally, a consumer assistance program may be able to assist you at: Connecticut Office of the Healthcare Advocate P.O. Box 1543 Hartford, CT 06144 Toll-free telephone: 1-866-466-4446 Web site: www.ct.gov/oha E-mail: healthcare.advocate@ct.gov BENJAMIN 000189 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 175 of 237 RIGHTS OF REVIEW AND APPEAL If this claim has or is currently in the process of being appealed, please disregard the Member Appeal Information provided below and follow the instructions that were previously mailed to you. If you would like further clarification or have any questions regarding this Explanation of Benefits (EOB), or if you are not fully satisfied with the resolution of your claim, you may contact Customer Care by calling 1-800-444-6222, or by writing toOxford Correspondence Department, LLC, P.O. Box 29135, Hot Springs, AR 71903. A service associate will investigate and attempt to resolve your concerns at the time of the call. If you remain dissatisfied, you may appeal the determination by following the Appeal Procedures outlined below. If we have requested additional information to process your claim, this information must be submitted toOxford Correspondence Department - Resubmissions, P.O. Box 29133, Hot Springs, AR 71903. The requested information must be submitted within 45 days of the date of your receipt of this notice. Upon receipt of the information, we will elect to take the one-time, 15-day extension that is permitted under the Employment Retirement Income Security Act (ERISA) and will provide you with a written response not later than 15 days from receipt of the information. Failure to submit this information within 45 days will result in an automatic denial of this claim due to lack of information. No further notice will be provided to you. In the event that you fail to follow these procedures in the time frame specified but wish to submit relevant information outside the time frame and/or request an appeal, please follow the appeal procedures outlined below. Failure to comply with appeal process requirements as communicated by Oxford may lead to forfeiture of a consumer’s right to challenge a denial or rejection, even when a request for clarification has been made. Note: A claim is any request by a covered member for certification of a benefit, or payment for a service, as required under the terms of the member’s health plan. A claim is denied when it does not meet the criteria established by your plan. If your claim has been denied in whole or in part and you would like a copy of the criteria used, you must send a written request toOxf rd Disclosure Requests, P.O. Box 29133, Hot Springs, AR 71903. The criteria will be provided to you free of charge. Member Appeal Information You may designate a person (“Designee”) to act on your behalf to appeal this decision. To do so, you must provide us with the designation, in writing, at the time of the appeal. The designation must be signed by you, or by your guardian if you are a minor. First-Level Internal Appeal You or your Designee must submit a request for appeal within180 daysof receipt of this EOB. Unless otherwise specified in the denial description, the appeal must be submitted in writing toOxford Correspondence Department, P.O. Box 29134, Hot Springs, AR 71903,or by calling Customer Care at 1-800-444-6222 and requesting an appeal. The request must include the reason(s) you believe that the claim should not have been denied, your name and member ID number, a copy of this form (or the claim number on this form), and any documentation/ information you would like to submit in support of the appeal. We will provide you with a written response not later than30 daysfrom the Correspondence Department’s (or other department indicated in this correspondence) receipt of your request for a First-Level Appeal. Second-Level Internal Appeal Second-Level appeal rights are available for members of group plans. Individual plans only have one level of internal appeal and if applicable, may be eligible to pursue an external appeal after completion of the First-Level Appeal (see below for more information). If Second-Level Appeal rights are available, you will receive additional information in the First-Level Appeal determination notice. Second-Level Appeal rights allow group members or their Designee to appeal to our Grievance Review Board (GRB) for further consideration. Requests for a Second-Level Appeal must be made within60 business daysof the receipt of the First-Level Appeal determination letter. The request for appeal and any additional information must be submitted toOxfor Grievance Review Board, P.O. Box 29134, Hot Springs, AR 71903. If these rights are available to you, you or your Designee will need to include all information we previously requested (if not already submitted), and any additional facts or information that you believe to be relevant to the issue. The appeal will be resolved not later than30 daysfrom the GRB’s receipt of your request for a Second-Level Appeal. Employee Retirement Income Security Act (ERISA) Rights If we have not approved your claim after all reviews have been completed, group members may have the right to file a civil action under 502(a) of the Employee Retirement Income Security Act. New York State External Appeal Process A denial based upon clinical reasons subject to the Utilization Law of New York, such as (1) lack of medical necessity, (2) experimental/investigational, (3) clinical trial provision, (4) rare disease treatment, or (5) that the out-of-network health service is not materially different from the health services available in-network, may be eligible to be appealed through New York’s external appeal program. You will be notified of your eligibility to pursue an external appeal in the appeal determination notice. You may obtain additional information about the New York external appeals process by calling Customer Care at 1-800-444-6222. TTY/TDD and Language Assistance Notice If you have a hearing impairment and need help, please call our TTY/TDD line at 1-800-201-4875. Please call 1-800-303-6719 for assistance in Chinese, 1-888-201-4746 for assistance in Korean, or the telephone number on your health plan ID card for assistance in English and other languages. NY-14-166 BENJAMIN 000190 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 176 of 237 The attached reimbursement check has been issued in response to a request for reimbursement from you or your health care provider. If this service was provided by a non-network physician or facility, payment is being made directly to you. As a result, you are responsible for paying the provider the full amount of the check, in addition to any applicable copay, deductible, coinsurance or other cost-share amount listed on the Check Summary Statement. Oxford Claims Department Have more questions about your claim? Visit www.oxfordhealth.com for all your claim and benefit information 48 Monroe Turnpike Trumbull, CT 06611 Check Summary Statement This is not a bill. Do not pay. This is to notify you that we processed your claim. Please note: As the subscriber, you will receive all check(s) associated with any claim for you and/or your dependent(s), unless payment is made to the provider. AMY BENJAMIN 11 COVLEE DRIVE WESTPORT CT 06880 Subscriber Information Subscriber Name: AMY BENJAMIN Subscriber ID: 10953193 Check #: 12404847 Check Amount: $1,400.00 Claim # Member Name Service Date(s) Payment Amount 4304211935.01 BENJAMIN, AMY 10953193*01 07-30-2014 $1400.00 4358212764 BENJAMIN, ALAN 10953193*02 12-10-2014 $0.00 PAY: Authorized Signature (not valid after 180 days) •••••••••• 48 Monroe Turnpike, Trumbull, CT 06611 AMY BENJAMIN 11 COVLEE DRIVE WESTPORT CT 06880 December 30, 2014 JPMorgan Chase Bank, N.A. Syracuse, NY, 13206 50-937 213 2294-09 C12404847C A021309379A 601872294C One Thousand Four Hundred Dollars and No Cents********************************** $1,400.00 12404847 OHPI NY INC Non-negotiable - This is not a check ••••••••••• • Remittance Documentation Image Archive BENJAMIN 000191 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 177 of 237 Total: $1,400.00 P lease E ndorse H ere D O N O T W R IT E O R S T A M P B E LO W T H IS LIN E R E S E R V E D F O R F IN A N C IA L IN S T IT U T IO N U S E X BENJAMIN 000192 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 178 of 237 Check Summary Statement This is not a bill. Do not pay. This is to notify you that we processed your claim. Please note: As the subscriber, you will receive all check(s) associated with any claim for you and/or your dependent(s), unless payment is made to the provider. Oxford Claims Department 48 Monroe Turnpike Trumbull, CT 06611 Have more questions about your claim? Visit www.oxfordhealth.com for all your claim and benefit information Claim Payment Summary Detailed claim information is located on member's Explanation Of Benefits Billed Amount Max Amount Deductible Amount Copay Amount Co-ins Amount COB Amount Payment Amount Claim Payment Summary $4175.00 $2000.00 $0.00 $0.00 $600.00 $0.00 $1400.00 Subscriber Information Subscriber Name: AMY BENJAMIN Subscriber ID: 10953193 Check #: 12404847 Check Amount: $1,400.00 BENJAMIN 000193 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 179 of 237 BENJAMIN 000194 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 180 of 237 BENJAMIN 000195 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 181 of 237 BENJAMIN 000196 -,,-., ' ·' ':-.":' ' .... ···- -----::_.o·_:..:...;:::..::,;;: "'' ''--' ·-·..:: ··:....·::..:·_ ... - - -·-... ___ _._ 'c-.. -.--o: .-.. ·"""·""''"""'""· .-.-.... -.'"':--.. ----: -co::~'"'---~:-:'-co·:.-.o-: ~--- c.-.:.-.--o:-.-. :o-:~.--~.""0~ .. -.:--. ·.:--.-.. -.:--. ~::.--o .. , :=::.:::..:::=:..: -· ....... :::...::-:..:::-::::: --- -- ·:o·:::.=::: =:: ,-.:-::::=:--:.=:::,-,::= .. =::::: :o=:-,-o=::::::t:.=:·;,-,:;:o_ .. --- ,-,~=='---'=-...:=: "'"- ····--· . -·- .-.-.,..,-i~i----o~:.-.:-.:- ---~ ,:-.. -. :-.·.~:.-.o-:,·:- :· .. - .. - .. ---; ~---' =-----="'::.-.--:'-"" --oc.-. . -.:-. ~ .-::-.-::'::~c-.. -., :-.-::,:.-.:-:~ .·.:-- :...~ ·--·-=---C-.:··- -- --·~:·:: .. ":::::--. - '~"''"~=--~ ' .. ----------· . -----·····- ._._, ,._. -·-··- - ..• :00:.....::: .• :.:~ -- ""'::;:""-:= ::::.::::: _____ o:::::::::::::::::: .• -= ::0'---'=---- . :: :.,_:::;::,_- :....::::::. ··- -------- -··- .. --- ::_:: o;;:_: :...:;_·. __ : ::;,_;:, :_:::::...:~:_::_:._;: :_;:::_:: _ _;:...: --------- ........ -- - --- .. . :..: ·:...=:..::..·::..:·:.· -- ~~--=---=-=-:: :::::::: :-.,-,.-. . . ···- -,: ::::::,___; :o,;, :.::::=·-::c . :: ·..:: ::::·_ :·::..::::· ~:--:: ___;,;:; ::·_ ::: ""''---'""'::..:: ;_, ''---' ==:8.i2 .. .... . --::,.-.:=. __ -,_----.. . ----:-:-.:.--' :-.:- :-. -------- -... ·. · .. · .. ·, : .. -- -- -· - - - .. -----· ....... -- . -·· - ·· · ~ h~ :;.=:~:~'"""'~ ---~ ~h~ 0:.=:~:;::::;! ::'. :;:=;:~:;~ ----=~ c~: - -::·.·-:-:::-:::: -- -:--~:.- .-.:-::- .--:.-,;:-"o-:-.:.-.. -.. --: :-.,,, .. -.;:,_-- ... - ---· .. --- :::::; =2f::::::,_.8:,,_,, __ -·· -· co. :-o-::-.:.-.: :.-•• -. --: :·.:---•. -.: :-.: .--:.---; ........ -·:-·=·-·.: ,_._. :.c.:-·;-··...::: ''-' -· ,__.__,._. "-: :.;...::. ·co.-:::.-.::-:,.--, :::::::-:-:;-·;:o ,----::-- ·::;=:;:::;::;:o-· ;:o---·-··::::::o..:::: -··- ;:o;-_; - - .. .. - :-.c.-.":.--:.-.c:-... ::" ,___, .. ,___ .. ·- :--.. -.:-:-.:~-: :.- .-.. -.--- -. ·.·..::....·::"-''-" ._ .. _,_,_,, ····----- --· ·-· -------···· -············· ..... :"0:::-.;:,~::~o=:: .-.: ~~='="' ,--~.=::~-=-- :::..-::'~~-=- ~--- :;:_::;-.:--:-::, ::~,;:;:_ ,--~.=:::-··· , __ _ - ··-·...:...:·.:· ''--''-''"- ._. ''-'''-''- '-'-= ";:__: ''-''"-'' :_: '"-'::_::_: ::_:; =---"" :::-~:-.. ---; .-.:--. ,:-.. -.. -:-:::-:-o ~--_,,.,.._ ::-:.-. :-.:--.-.::::-:.-.:' .-.: .--:~.-- .... ----: :~:=:::; :...:.::-::::'--.: """''''--"'-'"''· ::..::::.; ~===·-· ::..::_...;:-.::-:.:; :~- ,;_.:_ . .:::=:::.,_.,: :c:::: ::::::::..::.;::: ........ . .. .. _ -- -'" -'" .,___ :u:: payment ~or the fisted rnedica5 services o: suppi:es. , ne prov;der oi care s:..:::.:•l''"Hti:er wiii not atternp1 i.O coiiect from the e.ny henefi;;=, p;::;yab~e direct!y to the provider of care. ;:=;he Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 182 of 237 BENJAMIN 000197 ------- '"--"-"~=::::: Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 183 of 237 BENJAMIN 000198 20545035 0600 mtormat;o.-; as shown on it-:e !ace hereof :s true. accurate and tornpteie. 2 !f [L3tient QGcup:eri R pr:vate room or requ:red pr:vate nurs:ng for rnea:cai necessity. any required cen:1icatrons are on THE:. or Feder;::;! :egutations. are on fire. ~e::;:_~:~e::: ':;:; Federal Law .and r-ieg:;tat:ons {.:12 ~SC 1 935t. 42 CFR 424.::5. 10 :...:SC HJ7i U:n:.HJbji' 1086.32 CFR •99) ::1 :d <:1ny oth2r app5:ca.bte contract regulations. rs on ft5e. confonnance wi;:h the C:vit Right;;:. Act of 1964 f'S amended Records adequ.a.!e!y oescr·ibing services 't-.dii be rnaSn!ained and necessat-y 7. For fv18iJ•GaJ8 PtH'"DOses· ::me pauen:: has :ndlca.ted that other hearth :nsurance or a state medica! ass:sta:nce £:Heney ':viti pay part of i'.:"iedicare med:cat ar1d non-rneti:ca! :niorrnat:on ", .... ,.....,d;ng "!a~eriai fact are subject to prosecution under appiicable Federa: ._, 9 For TRtCARE Pu;:.:;oses. (a} r ne :nlorrnation on the face o: n::s cia:m :s true. accurate and of the patu~nt; -·--~· ---~~--------~ I'-' The pni:eni has •euresenied thai :Jy a reported res=dent:at .addrE-ss S;ater-nent iDD Fcrrn i25i · ... ;;;;;;, Gr :he physician '1as certified ;c) , ne pa:::em or r:e p.:wem: s DCHem or gu.::ra:an nas respo;;QE:HJ o:recuy w m::o pruvide(s request io :dent:fy art t1eatih ·nsmance coverage. ana that ail such coverage is :~eri!l'ied on ,rr:e lace or payments io iRtCARE-de>erm:nea henefns: ie) , ne benei;c;a.:;r s cast sh;,::.re has not C-ee: vo~:n:::u uy ·::::::'::::::seoi or se:-..:ices are at!ocated in the charges inctuded :n rh;s bit' :s n::.t an employee or memoer of tr:e :._m:forrneo Ser-..I:ces. For purposes u, contract surgeons or otr-;er personal serv:ce cont:acts. S:<,-;;iariy. members of the Uniformed Services not on c;ctive dut-y' ;;;; 8r;.seo on 4::::: LH1i!50 ~;ares Cooe: ~::l';i'-~•CC(a)(i ){)}a:: pro"'··""'"' pari:cipatinq :n r-./iedica.re must arso.part.icipa.te in TRiC.t:.RE lor inpatient nospitai ser-vices provided pursuant to ac''l1;Ssions to {h) ;; TRtCARE benefits are ::o be paid jn a pan:iclpaiing status th::; submitter of ih:s daim agrees to subm;t this eta:,.,... to the suppiies tisted on tr--.e ct~:sm form_ The prov:der of care'""'" o:::.•_.:_.o:::,_-- ii'ie TRiCARE-deterTnined reasonable cnarge ever-, .f :t ~s !ess pald by TRiC.ARE cornb:ned ~vlth the cost-share amount and ded,_;cHbie amount if any, pa:d by or on behaif of the pa!:eni as ;,;.ny benefits payab1e d;;eciiy to the prov:der of care. :f the prov:der o'f care ls a pan!c!patlng provrder Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 184 of 237 THIS IS NOT A BILL 48 Monroe Turnpike Trumbull, CT 06611 OHPI NY INC Please see last page for Appeals Rights E X P L A N A T I O N O F B E N E F I T S ATTENTION: THIS MAILING MAY CONTAIN DOCUMENTATION ON VARIOUS MATTERS Please note : Check(s) associated with your claim(s) will be sent to the subscriber of your family, unless payment is made to the provider. BENJAMIN, AMY 11 COVLEE DRIVE WESTPORT CT 06880 Subscriber Name: BENJAMIN, AMY Subscriber ID #: 10953193*01-10953193*01 11-12-2014 Member Name: BENJAMIN, AMY Provider Name: CARON RENAISSANCE Member ID: 10953193*01 Provider ID: A883799 Patient Acct #: 15243 Claim #: 4304213632 Date of Service CPT Code Description QTY Billed Amt Max Amt Deductible Amt Copay Amt % Co-Ins Amt Adj Code COB Amt Payment Amt 08-26-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 D2 0.00 08-26-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 D2 0.00 08-27-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 D2 0.00 08-28-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 D2 0.00 09-03-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 D2 0.00 09-03-14 80101 DRUG SCREEN, SINGLE 1 150.00 0.00 D2 0.00 09-04-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 D2 0.00 REMINDER - Effective January 1, 2007, Quest Diagnostics is no longer a participating laboratory with Oxford Health Plans. To locate a participating laboratory or for more information log in to www.oxfordhealth.com or call 1-800-666-1353. BENJAMIN, AMY 11 COVLEE DRIVE WESTPORT CT 06880 48 Monroe Turnpike, Trumbull, CT 06611 OHPI NY INC BENJAMIN 000199 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 185 of 237 E X P L A N A T I O N O F B E N E F I T S Subscriber Name: BENJAMIN, AMY Subscriber ID #: 10953193*01-10953193*01 11-12-2014 Member Name: BENJAMIN, AMY Provider Name: CARON RENAISSANCE Member ID: 10953193*01 Provider ID: A883799 Patient Acct #: 15243 Claim #: 4304213632 Date of Service CPT Code Description QTY Billed Amt Max Amt Deductible Amt Copay Amt % Co-Ins Amt Adj Code COB Amt Payment Amt 09-05-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 D2 0.00 09-06-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 D2 0.00 09-07-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 D2 0.00 09-08-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 D2 0.00 09-09-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 D2 0.00 09-10-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 D2 0.00 09-11-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 D2 0.00 09-12-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 D2 0.00 09-13-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 D2 0.00 09-14-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 D2 0.00 09-15-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 D2 0.00 09-16-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 D2 0.00 09-16-14 80101 DRUG SCREEN, SINGLE 1 150.00 0.00 D2 0.00 09-17-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 D2 0.00 09-18-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 D2 0.00 09-21-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.00 0.00 D2 0.00 09-21-14 80101 DRUG SCREEN, SINGLE 1 150.00 0.00 D2 0.00 TOTAL CLAIM: 4304213632 47324.80 0.00 0.00 0.00 0.00 0.00 0.00 Diagnostic Code: 300.00 Diagnostic Desc: ANXIETY STATE, UNSPECIFIED Billed Amt Max Amt Deductible Amt Copay Amt Co-ins Amt COB Amt Payment Amt Claim Payment Summary 47324.80 0.00 0.00 0.00 0.00 0.00 0.00 Check Summary Total Paid . . . . 0.00 Paid To . . . . . . . . . HANLEY CENTER INC Check Date. . . . November 12, 2014 Check Number. . . 12188608 Adjustment Code Descriptions D2 This claim was denied because these services were not authorized in advance. Please refer to your Certificate of Coverage for more information. To expedite the review of your correspondence, please include the following information at the top of your introductory letterbefore mailing: 1. Your Oxford Member ID # 2. Includeall relevantClaim #’s you are writing to us about 3. TheDate(s) of Serviceassociated with each claim 4. Please indicate thepurpose of your correspondence 5. If applicable, please include any other related documentation BENJAMIN 000200 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 186 of 237 % Percent. The portion of the Maximum Amount you are responsible to pay. Please see the coinsurance amount description for additional information. ADJ CODE Adjustment code. The code we assign to describe how we processed this claim line. Generally, the adjustment code shows a correction, adjustment or denial. ANNUAL LIMIT The amount your plan requires you to pay for deductible and out of-pocket maximums during the plan year. BILLED AMT Billed amount. The amount billed by the provider. CLAIM # Claim Number. The number we assign to your claim. The first four digits of a claim number reflect the date the caim was received. (Example: Claim Number 8049234568 - The first digit (8) indicates the year 2008 and the following three digits (049) indicate the day of the year in Julian date format. In this example, the claim was received on the 49th day of the year, or February 18, 2008.) COB AMT Coordination of Benefits. The amount covered by your other health plan when that health plan is your "primary" plan. CPT CODE A five-digit alpha numeric identifier used to define the medical service, supply or drug billed. Unless otherwise noted, the code is assigned by your health care provider. CO-INS AMT Coinsurance amount. The portion of the maximum amount you must pay for covered benefits during the plan year. Please see your Summary of Benefits for the coinsurance amount. Coinsurance (when part of your plan) typically does not apply until after you meet the deductible. COPAY AMT Copayment amount. The amount you are required to pay directly to a Provider for in-network covered benefits at the time of the service. Copayments generally apply when receiving services from participating providers. Please see your Summary of Benefits for the applicable copayment amount. DATE OF SERVICE The date the physician or facility performed the service(s). DEDUCTIBLE AMT Deductible amount. The amount you must pay for covered benefits during the plan year before we begin making payments for covered benefits. Please see your Summary of Benefits for the applicable deductible amount. In most instances, the deductible amount must be met before coinsurance applies. DESCRIPTION A brief explanation of a code used to describe the medical service, supply or medication billed. DIAGNOSIS CODE A three- to five-digit code used to explain the medical diagnosis code billed. Unless otherwise noted, the code is assigned by your health care provider. DIAGNOSIS DESCRIPTION A brief explanation of a code used to describe the medical diagnosis. DEFINITION OF TERMS BE ON THE LOOKOUT FOR FRAUD Fraud hurts everyone through increased insurance premiums and health care costs. Please compare your medical bills to your Explanation of Benefits (EOB) to verify that all services were actually provided. Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation. Please call member services at the phone number on the back of your health plan ID card if you suspect any fraudulent activities. Examples of fraud includethe intentional misrepresentationof any of the following: • The charges for the service, procedure and/or supplies provided. • The type of services, procedures and/or supplies provided. • The dates of services and/or treatments. • The condition treated or the diagnosis made. • The identity of the provider or member. BENJAMIN 000201 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 187 of 237 IN-NETWORK Services provided by a participating health care provider with a referral (if required) or by a non-participating (out-of-network) provider through an approved in-network exception request. MAX AMT Maximum amount. The most that is available to pay for covered benefits under your plan. For a participating provider, it is an agreed upon amount. If your plan has out-of-network benefits, it is the lower of the billed amount, the amount available for payment using the plan’s out-of-network reimbursement rates and rules, or the amount the provider has agreed to accept as payment. Please see your health benefits plan, including your Summary of Benefits for more information. OUT-OF-POCKET MAXIMUM The most you have to pay in deductibles and coinsurance for covered health services during the plan year. Depending on your plan design, the out-of-pocket maximum may also include copayment amounts. Items not covered by your health benefits plan, such as excluded services and penalty amounts, do not count toward the out-of-pocket maximum. For out-of network services, amounts above the out-of-network reimbursement (shown in the maximum amount column) are your responsibility and do not count toward your out-of-pocket maximum. Please see your health benefit plan, including your Summary of Benefits, for details about your plan coverage. OUT-OF-NETWORK Services provided by either a non-participating health care provider or a health care provider who participates in our network when a required referral has not been obtained. PATIENT ACCT # Patient account number. The provider’s account number or invoice number for you or your claim. PATIENT RESP Patient responsibility. The amount you are responsible to pay. This includes items not covered by your health benefits plan, such as excluded services, penalty amounts, deductibles, coinsurance, copayments and for out-of-network services, amounts above the maximum amount. (The patient responsibility shown on this EOB does not take into account any amounts paid at the time of service.) PAYMENT AMT Payment amount. The amount reimbursed under your health benefits plan. QTY Quantity. Refers to the number of times a particular service was performed. REMAINING BALANCE The portion of the annual limit remaining for the current plan year. DEFINITION OF TERMS BENJAMIN 000202 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 188 of 237 BE ON THE LOOKOUT FOR FRAUD Fraud hurts everyone through increased insurance premiums and health care costs. Please compare your medical bills to your Explanation of Benefits (EOB) to verify that all services were actually provided. Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation. Please call member services at the phone number on the back of your health plan ID card if you suspect any fraudulent activities. Examples of fraud includethe intentional misrepresentationof any of the following: • The charges for the service, procedure and/or supplies provided. • The type of services, procedures and/or supplies provided. • The dates of services and/or treatments. • The condition treated or the diagnosis made. • The identity of the provider or member. E X P L A N A T I O N O F B E N E F I T S Availability of Consumer Assistance/Ombudsman Services In addition to the Explanation of Member Appeal Rights attached, there may be other resources available to help you understand the appeals process. For questions about your rights, this notice, or for assistance, you can contact the Employee Benefits Security Administration at 1-866-444-EBSA (3272)or www.askebsa.dol.gov. Additionally, a consumer assistance program may be able to assist you at: Connecticut Office of the Healthcare Advocate P.O. Box 1543 Hartford, CT 06144 Toll-free telephone: 1-866-466-4446 Web site: www.ct.gov/oha E-mail: healthcare.advocate@ct.gov BENJAMIN 000203 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 189 of 237 RIGHTS OF REVIEW AND APPEAL If this claim has or is currently in the process of being appealed, please disregard the Member Appeal Information provided below and follow the instructions that were previously mailed to you. If you would like further clarification or have any questions regarding this Explanation of Benefits (EOB), or if you are not fully satisfied with the resolution of your claim, you may contact Customer Care by calling 1-800-444-6222, or by writing toOxford Correspondence Department, LLC, P.O. Box 29135, Hot Springs, AR 71903. A service associate will investigate and attempt to resolve your concerns at the time of the call. If you remain dissatisfied, you may appeal the determination by following the Appeal Procedures outlined below. If we have requested additional information to process your claim, this information must be submitted toOxford Correspondence Department - Resubmissions, P.O. Box 29133, Hot Springs, AR 71903. The requested information must be submitted within 45 days of the date of your receipt of this notice. Upon receipt of the information, we will elect to take the one-time, 15-day extension that is permitted under the Employment Retirement Income Security Act (ERISA) and will provide you with a written response not later than 15 days from receipt of the information. Failure to submit this information within 45 days will result in an automatic denial of this claim due to lack of information. No further notice will be provided to you. In the event that you fail to follow these procedures in the time frame specified but wish to submit relevant information outside the time frame and/or request an appeal, please follow the appeal procedures outlined below. Failure to comply with appeal process requirements as communicated by Oxford may lead to forfeiture of a consumer’s right to challenge a denial or rejection, even when a request for clarification has been made. Note: A claim is any request by a covered member for certification of a benefit, or payment for a service, as required under the terms of the member’s health plan. A claim is denied when it does not meet the criteria established by your plan. If your claim has been denied in whole or in part and you would like a copy of the criteria used, you must send a written request toOxf rd Disclosure Requests, P.O. Box 29133, Hot Springs, AR 71903. The criteria will be provided to you free of charge. Member Appeal Information You may designate a person (“Designee”) to act on your behalf to appeal this decision. To do so, you must provide us with the designation, in writing, at the time of the appeal. The designation must be signed by you, or by your guardian if you are a minor. First-Level Internal Appeal You or your Designee must submit a request for appeal within180 daysof receipt of this EOB. Unless otherwise specified in the denial description, the appeal must be submitted in writing toOxford Correspondence Department, P.O. Box 29134, Hot Springs, AR 71903,or by calling Customer Care at 1-800-444-6222 and requesting an appeal. The request must include the reason(s) you believe that the claim should not have been denied, your name and member ID number, a copy of this form (or the claim number on this form), and any documentation/ information you would like to submit in support of the appeal. We will provide you with a written response not later than30 daysfrom the Correspondence Department’s (or other department indicated in this correspondence) receipt of your request for a First-Level Appeal. Second-Level Internal Appeal Second-Level appeal rights are available for members of group plans. Individual plans only have one level of internal appeal and if applicable, may be eligible to pursue an external appeal after completion of the First-Level Appeal (see below for more information). If Second-Level Appeal rights are available, you will receive additional information in the First-Level Appeal determination notice. Second-Level Appeal rights allow group members or their Designee to appeal to our Grievance Review Board (GRB) for further consideration. Requests for a Second-Level Appeal must be made within60 business daysof the receipt of the First-Level Appeal determination letter. The request for appeal and any additional information must be submitted toOxfor Grievance Review Board, P.O. Box 29134, Hot Springs, AR 71903. If these rights are available to you, you or your Designee will need to include all information we previously requested (if not already submitted), and any additional facts or information that you believe to be relevant to the issue. The appeal will be resolved not later than30 daysfrom the GRB’s receipt of your request for a Second-Level Appeal. Employee Retirement Income Security Act (ERISA) Rights If we have not approved your claim after all reviews have been completed, group members may have the right to file a civil action under 502(a) of the Employee Retirement Income Security Act. New York State External Appeal Process A denial based upon clinical reasons subject to the Utilization Law of New York, such as (1) lack of medical necessity, (2) experimental/investigational, (3) clinical trial provision, (4) rare disease treatment, or (5) that the out-of-network health service is not materially different from the health services available in-network, may be eligible to be appealed through New York’s external appeal program. You will be notified of your eligibility to pursue an external appeal in the appeal determination notice. You may obtain additional information about the New York external appeals process by calling Customer Care at 1-800-444-6222. TTY/TDD and Language Assistance Notice If you have a hearing impairment and need help, please call our TTY/TDD line at 1-800-201-4875. Please call 1-800-303-6719 for assistance in Chinese, 1-888-201-4746 for assistance in Korean, or the telephone number on your health plan ID card for assistance in English and other languages. NY-14-166 BENJAMIN 000204 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 190 of 237 48 Monroe Turnpike Trumbull, CT 06611 R E M I T T A N C E A D V I C E OHPI NY INC Please see last page for Appeals Rights ATTENTION: THIS MAILING MAY CONTAIN DOCUMENTATION ON VARIOUS MATTERS HANLEY CENTER INC 7789 NW BEACON SQ BLVD BOCA RATON FL 33487 Vendor Name: HANLEY CENTER INC TIN: 592500657 Vendor ID #: P2500657-A883799 Check Number: 12188608 11-12-2014 Member Name: BENJAMIN, AMY Provider Name: CARON RENAISSANCE Member ID: 10953193*01 Provider ID: A883799 Patient Acct #: 14614 Claim #: 4304213629 Serv Date CPT Code Description QTY Billed Amt Max Amt Withhold Amt Deductible Amt Copay/Co-ins Amt Adj Code COB Amt Payment Amt 07-24-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 0.00 D2 0.00 07-25-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 0.00 D2 0.00 07-25-14 80050 GENERAL HEALTH PANEL 1 999.00 0.00 0.00 D2 0.00 07-25-14 80101 DRUG SCREEN, SINGLE 1 40.00 0.00 0.00 D2 0.00 07-25-14 80101 DRUG SCREEN, SINGLE 1 35.00 0.00 0.00 D2 0.00 07-25-14 80101 DRUG SCREEN, SINGLE 1 8.84 0.00 0.00 D2 0.00 07-26-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 0.00 D2 0.00 07-27-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 0.00 D2 0.00 07-28-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 0.00 D2 0.00 07-29-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 0.00 D2 0.00 TOTAL CLAIM: 4304213629 63732.76 0.00 0.00 0.00 0.00 0.00 0.00 HANLEY CENTER INC 7789 NW BEACON SQ BLVD BOCA RATON FL 33487 Why wait for this to arrive in the mail? Save time, money and paper with electronic payments and remittance advice. To sign up or learn more: • Go to OxfordHealth.com • Click on Providers or Facilities • Select Tools & Resources • Select Direct Deposit & Electronic EOBs 48 Monroe Turnpike, Trumbull, CT 06611 OHPI NY INC BENJAMIN 000205 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 191 of 237 R E M I T T A N C E A D V I C E Vendor Name: HANLEY CENTER INC TIN: 592500657 Vendor ID #: P2500657-A883799 Check Number: 12188608 11-12-2014 Member Name: BENJAMIN, AMY Provider Name: CARON RENAISSANCE Member ID: 10953193*01 Provider ID: A883799 Patient Acct #: 14614 Claim #: 4304213629 Serv Date CPT Code Description QTY Billed Amt Max Amt Withhold Amt Deductible Amt Copay/Co-ins Amt Adj Code COB Amt Payment Amt 07-30-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 0.00 D2 0.00 07-31-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 0.00 D2 0.00 08-01-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 0.00 D2 0.00 08-02-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 0.00 D2 0.00 08-03-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 0.00 D2 0.00 08-04-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 0.00 D2 0.00 08-05-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 0.00 D2 0.00 08-06-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 0.00 D2 0.00 08-07-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 0.00 D2 0.00 08-07-14 80101 DRUG SCREEN, SINGLE 1 40.00 0.00 0.00 D2 0.00 08-07-14 80101 DRUG SCREEN, SINGLE 1 35.00 0.00 0.00 D2 0.00 08-08-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 0.00 D2 0.00 08-09-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 0.00 D2 0.00 08-10-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 0.00 D2 0.00 08-11-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 0.00 D2 0.00 08-12-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 0.00 D2 0.00 08-17-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 0.00 D2 0.00 08-17-14 80101 DRUG SCREEN, SINGLE 1 40.00 0.00 0.00 D2 0.00 08-17-14 80101 DRUG SCREEN, SINGLE 1 35.00 0.00 0.00 D2 0.00 08-18-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 0.00 D2 0.00 08-19-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 0.00 D2 0.00 08-20-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 0.00 D2 0.00 08-21-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 0.00 D2 0.00 08-22-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 0.00 D2 0.00 08-23-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 0.00 D2 0.00 08-24-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 0.00 D2 0.00 TOTAL CLAIM: 4304213629 63732.76 0.00 0.00 0.00 0.00 0.00 0.00 Member Name: BENJAMIN, AMY Provider Name: CARON RENAISSANCE Member ID: 10953193*01 Provider ID: A883799 Patient Acct #: 15243 Claim #: 4304213632 Serv Date CPT Code Description QTY Billed Amt Max Amt Withhold Amt Deductible Amt Copay/Co-ins Amt Adj Code COB Amt Payment Amt 08-26-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 0.00 D2 0.00 08-26-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 0.00 D2 0.00 08-27-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 0.00 D2 0.00 08-28-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 0.00 D2 0.00 09-03-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 0.00 D2 0.00 09-03-14 80101 DRUG SCREEN, SINGLE 1 150.00 0.00 0.00 D2 0.00 09-04-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 0.00 D2 0.00 09-05-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 0.00 D2 0.00 09-06-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 0.00 D2 0.00 09-07-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 0.00 D2 0.00 09-08-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 0.00 D2 0.00 09-09-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 0.00 D2 0.00 09-10-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 0.00 D2 0.00 09-11-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 0.00 D2 0.00 09-12-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 0.00 D2 0.00 09-13-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 0.00 D2 0.00 09-14-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 0.00 D2 0.00 09-15-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 0.00 D2 0.00 09-16-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 0.00 D2 0.00 09-16-14 80101 DRUG SCREEN, SINGLE 1 150.00 0.00 0.00 D2 0.00 09-17-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 0.00 D2 0.00 09-18-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 0.00 D2 0.00 09-21-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.00 0.00 0.00 D2 0.00 09-21-14 80101 DRUG SCREEN, SINGLE 1 150.00 0.00 0.00 D2 0.00 TOTAL CLAIM: 4304213632 47324.80 0.00 0.00 0.00 0.00 0.00 0.00 BENJAMIN 000206 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 192 of 237 Great News! Oxford has introduced new auto attendant options on its customer services lines and new dedicated provider support teams to meet your unique needs. Watch for future service enhancements. R E M I T T A N C E A D V I C E Billed Amt Max Amt Withhold Amt Deductible Amt Copay/Co-ins Amt COB Amt Payment Amt Claim Payment Summary 111057.56 0.00 0.00 0.00 0.00 0.00 0.00 Check Summary Total Paid . . . . . . . . 0.00 Check Date. . . . . . . . November 12, 2014 Paid To . . . . . . . . . . . HANLEY CENTER INC Check Number. . . . . 12188608 Adjustment Code Descriptions D2 These services were formally denied because they were not authorized in advance Why wait for this to arrive in the mail? Save time, money and paper with electronic payments and remittance advice. To sign up or learn more: • Go to OxfordHealth.com • Click on Providers or Facilities • Select Tools & Resources • Select Direct Deposit & Electronic EOBs Are you getting all that you can out of oxfordhealth.com? Oxford® is dedicated to helping your practice run smoother. Our website is easy to use and available for you to interact with us at your convenience. Let us give you the VIP tour. Log on as a Provider or Facility on oxfordhealth.com.Go to Tools & Resources > Manage Your Practice > Administrative Ease and register for a webcast training session today. BENJAMIN 000207 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 193 of 237 R E M I T T A N C E A D V I C E OXFORD’S MISSION At Oxford, we recognize the importance of the provider-patient relationship, and know that good care starts with you. We want to complement the care you provide to help asthma patients breathe a little easier help new mothers deliver healthy, full-term babies…help your patients with heart disease and diabetes adopt healthy lifestyles -- to help your patients live longer, healthier and happier lives. OXFORD KEEPS IT SIMPLE At Oxford, we know that being a successful health plan depends on the “simple things”: network, brand, service, product diversity and most importantly, customer satisfaction. We also know that one of the most important questions a Member will ask is “Is my doctor in your plan?” Thanks to you, we’re able to offer our Members access to a network of over 50,000 physicians* and 200 of the area’s finest hospitals. Our commitment to the simple things has allowed us to offer quality healthcare coverage for over a decade. We look forward to your continued participation with Oxford. *The number of physicians available to Members varies by geography and product type. BENJAMIN 000208 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 194 of 237 ADJ CODE Adjustment code. The code we assign to describe how we processed this claim line. Generally, the adjustment code shows a correction, adjustment or denial. BILLED AMT Billed amount. The amount billed by you. CLAIM # Claim Number. The number we assign to your claim. The first four digits of a claim number reflect the date the claim was received. (Example: Claim Number 8049234568 - The first digit (8) indicates the year 2008 and the following three digits (049) indicate the day of the year in Julian date format. In this example, the claim was received on the 49th day of the year, or February 18, 2008.) COB AMT Coordination of Benefits. The amount covered by the member’s other health plan when that health plan is “primary.” CO-INS AMT Coinsurance amount. The portion of the maximum amount the member must pay for covered benefits during the plan year. Coinsurance (when part a member’s plan) typically does not apply until after the member meets the deductible. COPAY AMT Copayment amount. The amount the member is required to pay directly to you for in-network covered benefits at the time of the service. Copayments generally apply when receiving services from participating providers. CPT CODE A five-digit alpha numeric identifier used to define the medical service, supply or drug billed. Unless otherwise noted, the code is assigned by you. DATE RECEIVED The date we received the claim. DEDUCTIBLE AMT Deductible amount. The amount the member must pay for covered benefits during the plan year before we begin making payments for covered benefits. In most instances, the deductible amount must be met before coinsurance applies. DESCRIPTION A brief explanation of a code used to describe the medical service, supply or medication billed. DIAGNOSIS CODE A three- to five-digit code used to explain the medical diagnosis code billed. Unless otherwise noted, the code is assigned by you. DIAGNOSIS DESCRIPTION A brief explanation of a code used to describe the medical diagnosis. MAX AMT Maximum amount. The most that is available to pay for covered benefits under a member’s health benefits plan. For a participating provider, it is an agreed upon amount. If the member’s plan has out-of-network benefits, it is the lower of the billed amount, the amount available for payment using the plan’s out-of-network reimbursement rates and rules, or the amount you have agreed to accept as payment. DEFINITION OF TERMS BE ON THE LOOKOUT FOR FRAUD Fraud can affect members, providers and health plans alike through increased insurance premiums and health care costs. Those who file a claim with intent to defraud, or helps commit fraud against an insurer, is guilty of a crime. Fraud includes intentional misrepresentation of any of the following: • Charges for a service, procedure or supplies • Type of service, procedure or supplies provided • Dates of services or treatments • Medical record of services or treatments provided • Condition treated or diagnosis made • Identity of the provider or member Please contact us at 800-666-1353 if you suspect or are aware of any fraudulent activities. Thank you for doing your part to stop abuse in the health care system. BENJAMIN 000209 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 195 of 237 PATIENT ACCT # Patient account number. Refers to your account number or invoice number for the patient or claim. PAYMENT AMT Payment amount. The amount reimbursed under the member’s health benefits plan. QTY Quantity. Refers to the number of times a particular service was performed. SERV DATE Service date. The date you performed the service(s). VENDOR NAME/ID# Refers to the recipient of payment. This may be you, the individual provider, or the collective provider of services with which you are affiliated (e.g., medical group). WITHHOLD AMT Withhold amount. Refers to a contracted percentage of the fee that is not payable at this time. DEFINITION OF TERMS BENJAMIN 000210 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 196 of 237 Attention Non-contracted Medicare Providers Appeals Process for Non-contracted Medicare Providers Pursuant to federal regulations governing the Medicare Advantage program, non-contracted providers may request reconsideration (appeal) of a Medicare Advantage plan payment denial determination. To appeal a claim denial, submit a written request within 60 calendar days of the remittance notification date and include at a minimum: • A statement indicating factual or legal basis for appeal • A signed Waiver of Liability form (you may obtain a copy on www.uhconline.com) • A copy of the original claim • A copy of the remittance notice showing the claim denial • Any additional information, clinical records or documentation Mail the appeal request to UnitedHealthcare Appeals & Grievances Po Box 6106 Cypress, CA 90630 MS CA 124-0157 Payment Dispute Process for Non-contracted Medicare Providers Pursuant to federal regulations governing the Medicare Advantage program, non-contracted providers may file a payment dispute for a Medicare Advantage plan payment determination. A payment dispute may be filed when the provider disagrees with the amount paid, including issues related to bundling of services. To dispute a claim denial, submit a written request within 120 calendar days of the remittance notification date and include at a minimum: • A statement indicating factual or legal basis for the dispute • A copy of the original claim • A copy of the remittance notice showing the claim payment • Any additional information, clinical records or documentation to support the dispute Mail the payment dispute to Oxford, A UnitedHealthcare Company Attn: Provider Appeals Department PO Box 29136 Hot Springs, AR 71903 For additional information on the Non-contracted Appeal and Dispute processes including a form that may be used to facilitate your request for appeal or dispute, please go to www.uhconline.com. BE ON THE LOOKOUT FOR FRAUD Fraud can affect members, providers and health plans alike through increased insurance premiums and health care costs. Those who file a claim with intent to defraud, or helps commit fraud against an insurer, is guilty of a crime. Fraud includes intentional misrepresentation of any of the following: • Charges for a service, procedure or supplies • Type of service, procedure or supplies provided • Dates of services or treatments • Medical record of services or treatments provided • Condition treated or diagnosis made • Identity of the provider or member Please contact us at 800-666-1353 if you suspect or are aware of any fraudulent activities. Thank you for doing your part to stop abuse in the health care system. R E M I T T A N C E A D V I C E BENJAMIN 000211 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 197 of 237 RIGHTS OF REVIEW AND APPEAL If this claim has or is currently in the process of being appealed, please disregard the Appeals process described below. If you would like further clarification of this Remittance Advice (RA) or are not fully satisfied with the resolution of your claim, you may contact Provider Services at l-800-666-1353 and a Service Associate will investigate and attempt to resolve your concerns at the time of the call. Participating providers may also submit aClaim(s) Review Request Form.to Oxford, A UnitedHealthcare Company, Correspondence Department, P.O. Box 29135, Hot Springs, AR 71903.This form is available on Oxford’s website atwww.oxfordhealth.comLog in as a provider or facility, click on theTools & Resourcestab and then on Forms. If you remain dissatisfied, you may appeal the determination using the procedure listed below. APPEALS FROM PARTICIPATING PROVIDERS CONTRACTED WITH OXFORD You may appeal an adverse claim determination by following the appeal procedures specified in the Provider Reference Manual (PRM). and any subsequent updates. Please be advised that, with the exception of services rendered to New Jersey (NJ) commercial line of business Members after July 11, 2006, which has a different process (described below and in the PRM), you have180 days (6 months)from the date of this determination to send your written request for appeal toOxford, A UnitedHealthcare Company, Attention: Provider Appeals Department, P. O Box 29136, Hot Springs, AR 71903. To be processed, the appeal request must be submitted on theClaim(s) Review Request Form.The form must be completed in its entirety, including the reason(s) you believe the claim should not have been denied, the claim number(s) and any documentation you believe supports your position. Once the review is complete, you will receive Oxford’s written response. If you are not satisfied with Oxford’s decision, you may arbitrate the issue as set forth in your contract with Oxford. ALL PROVIDERS Retrospective Utilization Review Appeal Information for Services Provided to NY Commercial Members: Pursuant to Article 49 of New York Insurance Law, healthcare providers treating a Member in a New York Commercial line of business (LOB) may request a retrospective clinical review if: (1) the review of the procedure was requested only after the services were provided and (2) Oxford denied the service based upon medical necessity or the experimental/investigational exclusion if the Member has a life-threatening or disabling condition. If you have failed to seek a required precertification, a retrospective clinical review is not available. If a retrospective adverse determination is rendered in accordance with the above procedure, you may appeal as described below: Internal Appeal: You must appeal a retrospective adverse determination to Oxford’s Clinical Appeals Department within60 calendar daysof receipt of the retrospective adverse determination. To appeal, you must send an appeal letter, any information requested in the initial retrospective adverse determination and any additional information you would like to submit in support of the appeal to:Clinical Appeals Department, Oxford, A UnitedHealthcare Company, P.O. 29139, Hot Springs AR 71903(Fax 203-459-7351). The Clinical Appeals Department will acknowledge receipt of the appeal and request any information needed to conduct the review within15 business days. The appeal will be resolved within60 calendar daysof receipt of all necessary information. To review the policy used to determine coverage for a request for services, please submit a written request to:Policy Requests and Information, Oxford, A UnitedHealthcare Company, 48 Monroe Turnpike, Trumbull, CT 06611. External Appeal: In general, you may be eligible to file an application for external appeal of a retrospective adverse determination to an independent utilization review organization as provided by the New York Insurance Law, if the Clinical Appeals Department upholds, on medical necessity grounds or the experimental/investigational exclusion, all or part of such a retrospective adverse determination. Determinations based upon the experimental/investigational exclusion (including clinical trials) may be appealed through the external appeal process only if the Member’s condition meets the statutory definition of a “life threatening” or “disabling” condition. To determine eligibility for external review and file an external appeal, youmust file a written application with the New York State Department of Insurance (DOI) within45 daysof receipt of the denial from the Clinical Appeals Department. An application and instructions will be sent with the appeals determination. The DOI will assign the case to a state-licensed external appeal agent who has no affiliation with Oxford. The external appeal agent will issue a standard appeal decision within30 daysof receiving the application and an expedited external appeal decision within three days of receipt of the request. An external appeal agent’s medical necessity decision is binding on all parties, so long as the benefit is available under the Member’s plan. If you have a question concerning a particular member’s LOB, the information may be found on Oxford’s website atwww.oxfordhealth.com or by calling Provider Services at 1-800-666-1353. Claim Appeals for Services Provided to NJ Commercial Members: If you have a dispute relating to the payment of a claim for services that were rendered to a NJ commercial line of business Member on or after July 11, 2006, your dispute may be eligible for a two-step appeal process. Disputes involving medical necessity may not be appealed through this process and must follow the utilization management appeal process. The first step of the claim appeal process allows you to submit a claim appeal through Oxford’s internal appeal process and, if eligible, the second step allows your dispute to be referred to an independent arbitration entity selected by and contracted with the NJ Department of Banking and Insurance (DOBI). Internal Appeal: You must submit an internal appeal to Oxford’s Correspondence Department within90 calendar daysof receipt of an adverse claim determination.The appeal must be submitted on a form created by the DOBI, along with the information required to process your appeal (listed on form). The form is available on Oxford’s web site (www.oxfordhealth.com). The form and the information must be sent to:Oxford, A UnitedHealthcare Company, Attention: Provider Appeals Department, P.O. Box 29136, Hot Springs, AR 71903.The appeal will be resolved within 30 calendar days from the receipt of your appeal submission. If you have a question concerning a particular Member’s line of business, information may be found on Oxford’s web site atwww.oxfordhealth.comor by calling Provider Services at 1-800-666-1353. Arbitration: Disputes may be referred to arbitration when the internal appeal determination is in Oxford’s favor or when we have not made a timely determination on your appeal. To be eligible for the NJ arbitration process, the disputed claim amount must be at least $1,000. While you may aggregate your claims to reach this number, you must initiate the arbitration proceeding on a form created by DOBI on or before the90th calendar dayfollowing your receipt of the determination (or non-determination). The arbitration will be conducted according to the rules of the arbitration entity. Additional information will be provided if any part of the determination is not reversed on appeal. Information is also available on the DOBI web site atwww.state.nj.us/dobi. MS-07-215 BENJAMIN 000212 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 198 of 237 BENJAMIN 000213 20545035 0600 $2,232.14 iijfijif44 $1§,77§.00 l! (j ·[1{) 8sr:jamir:, Amy S Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 199 of 237 THIS IS NOT A BILL 48 Monroe Turnpike Trumbull, CT 06611 OHPI NY INC Please see last page for Appeals Rights E X P L A N A T I O N O F B E N E F I T S ATTENTION: THIS MAILING MAY CONTAIN DOCUMENTATION ON VARIOUS MATTERS Please note : Check(s) associated with your claim(s) will be sent to the subscriber of your family, unless payment is made to the provider. BENJAMIN, AMY 11 COVLEE DRIVE WESTPORT CT 06880 Subscriber Name: BENJAMIN, AMY Subscriber ID #: 10953193*01-10953193*01 11-14-2014 Member Name: BENJAMIN, AMY Provider Name: CARON RENAISSANCE Member ID: 10953193*01 Provider ID: A883799 Patient Acct #: 15469 Claim #: 4304211933 Date of Service CPT Code Description QTY Billed Amt Max Amt Deductible Amt Copay Amt % Co-Ins Amt Adj Code COB Amt Payment Amt 09-22-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 D2 0.00 09-23-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 D2 0.00 09-28-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 D2 0.00 09-29-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 D2 0.00 09-29-14 80101 DRUG SCREEN, SINGLE 1 150.00 0.00 D2 0.00 09-30-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 D2 0.00 REMINDER - Effective January 1, 2007, Quest Diagnostics is no longer a participating laboratory with Oxford Health Plans. To locate a participating laboratory or for more information log in to www.oxfordhealth.com or call 1-800-666-1353. BENJAMIN, AMY 11 COVLEE DRIVE WESTPORT CT 06880 48 Monroe Turnpike, Trumbull, CT 06611 OHPI NY INC BENJAMIN 000214 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 200 of 237 E X P L A N A T I O N O F B E N E F I T S Subscriber Name: BENJAMIN, AMY Subscriber ID #: 10953193*01-10953193*01 11-14-2014 Member Name: BENJAMIN, AMY Provider Name: CARON RENAISSANCE Member ID: 10953193*01 Provider ID: A883799 Patient Acct #: 15469 Claim #: 4304211933 Date of Service CPT Code Description QTY Billed Amt Max Amt Deductible Amt Copay Amt % Co-Ins Amt Adj Code COB Amt Payment Amt 10-01-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 D2 0.00 10-02-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.16 0.00 D2 0.00 TOTAL CLAIM: 4304211933 15775.00 0.00 0.00 0.00 0.00 0.00 0.00 Diagnostic Code: 300.00 Diagnostic Desc: ANXIETY STATE, UNSPECIFIED Billed Amt Max Amt Deductible Amt Copay Amt Co-ins Amt COB Amt Payment Amt Claim Payment Summary 15775.00 0.00 0.00 0.00 0.00 0.00 0.00 Check Summary Total Paid . . . . 0.00 Paid To . . . . . . . . . HANLEY CENTER INC Check Date. . . . November 14, 2014 Check Number. . . 12201527 Adjustment Code Descriptions D2 This claim was denied because these services were not authorized in advance. Please refer to your Certificate of Coverage for more information. To expedite the review of your correspondence, please include the following information at the top of your introductory letterbefore mailing: 1. Your Oxford Member ID # 2. Includeall relevantClaim #’s you are writing to us about 3. TheDate(s) of Serviceassociated with each claim 4. Please indicate thepurpose of your correspondence 5. If applicable, please include any other related documentation BENJAMIN 000215 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 201 of 237 % Percent. The portion of the Maximum Amount you are responsible to pay. Please see the coinsurance amount description for additional information. ADJ CODE Adjustment code. The code we assign to describe how we processed this claim line. Generally, the adjustment code shows a correction, adjustment or denial. ANNUAL LIMIT The amount your plan requires you to pay for deductible and out of-pocket maximums during the plan year. BILLED AMT Billed amount. The amount billed by the provider. CLAIM # Claim Number. The number we assign to your claim. The first four digits of a claim number reflect the date the caim was received. (Example: Claim Number 8049234568 - The first digit (8) indicates the year 2008 and the following three digits (049) indicate the day of the year in Julian date format. In this example, the claim was received on the 49th day of the year, or February 18, 2008.) COB AMT Coordination of Benefits. The amount covered by your other health plan when that health plan is your "primary" plan. CPT CODE A five-digit alpha numeric identifier used to define the medical service, supply or drug billed. Unless otherwise noted, the code is assigned by your health care provider. CO-INS AMT Coinsurance amount. The portion of the maximum amount you must pay for covered benefits during the plan year. Please see your Summary of Benefits for the coinsurance amount. Coinsurance (when part of your plan) typically does not apply until after you meet the deductible. COPAY AMT Copayment amount. The amount you are required to pay directly to a Provider for in-network covered benefits at the time of the service. Copayments generally apply when receiving services from participating providers. Please see your Summary of Benefits for the applicable copayment amount. DATE OF SERVICE The date the physician or facility performed the service(s). DEDUCTIBLE AMT Deductible amount. The amount you must pay for covered benefits during the plan year before we begin making payments for covered benefits. Please see your Summary of Benefits for the applicable deductible amount. In most instances, the deductible amount must be met before coinsurance applies. DESCRIPTION A brief explanation of a code used to describe the medical service, supply or medication billed. DIAGNOSIS CODE A three- to five-digit code used to explain the medical diagnosis code billed. Unless otherwise noted, the code is assigned by your health care provider. DIAGNOSIS DESCRIPTION A brief explanation of a code used to describe the medical diagnosis. DEFINITION OF TERMS BE ON THE LOOKOUT FOR FRAUD Fraud hurts everyone through increased insurance premiums and health care costs. Please compare your medical bills to your Explanation of Benefits (EOB) to verify that all services were actually provided. Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation. Please call member services at the phone number on the back of your health plan ID card if you suspect any fraudulent activities. Examples of fraud includethe intentional misrepresentationof any of the following: • The charges for the service, procedure and/or supplies provided. • The type of services, procedures and/or supplies provided. • The dates of services and/or treatments. • The condition treated or the diagnosis made. • The identity of the provider or member. BENJAMIN 000216 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 202 of 237 IN-NETWORK Services provided by a participating health care provider with a referral (if required) or by a non-participating (out-of-network) provider through an approved in-network exception request. MAX AMT Maximum amount. The most that is available to pay for covered benefits under your plan. For a participating provider, it is an agreed upon amount. If your plan has out-of-network benefits, it is the lower of the billed amount, the amount available for payment using the plan’s out-of-network reimbursement rates and rules, or the amount the provider has agreed to accept as payment. Please see your health benefits plan, including your Summary of Benefits for more information. OUT-OF-POCKET MAXIMUM The most you have to pay in deductibles and coinsurance for covered health services during the plan year. Depending on your plan design, the out-of-pocket maximum may also include copayment amounts. Items not covered by your health benefits plan, such as excluded services and penalty amounts, do not count toward the out-of-pocket maximum. For out-of network services, amounts above the out-of-network reimbursement (shown in the maximum amount column) are your responsibility and do not count toward your out-of-pocket maximum. Please see your health benefit plan, including your Summary of Benefits, for details about your plan coverage. OUT-OF-NETWORK Services provided by either a non-participating health care provider or a health care provider who participates in our network when a required referral has not been obtained. PATIENT ACCT # Patient account number. The provider’s account number or invoice number for you or your claim. PATIENT RESP Patient responsibility. The amount you are responsible to pay. This includes items not covered by your health benefits plan, such as excluded services, penalty amounts, deductibles, coinsurance, copayments and for out-of-network services, amounts above the maximum amount. (The patient responsibility shown on this EOB does not take into account any amounts paid at the time of service.) PAYMENT AMT Payment amount. The amount reimbursed under your health benefits plan. QTY Quantity. Refers to the number of times a particular service was performed. REMAINING BALANCE The portion of the annual limit remaining for the current plan year. DEFINITION OF TERMS BENJAMIN 000217 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 203 of 237 BE ON THE LOOKOUT FOR FRAUD Fraud hurts everyone through increased insurance premiums and health care costs. Please compare your medical bills to your Explanation of Benefits (EOB) to verify that all services were actually provided. Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation. Please call member services at the phone number on the back of your health plan ID card if you suspect any fraudulent activities. Examples of fraud includethe intentional misrepresentationof any of the following: • The charges for the service, procedure and/or supplies provided. • The type of services, procedures and/or supplies provided. • The dates of services and/or treatments. • The condition treated or the diagnosis made. • The identity of the provider or member. E X P L A N A T I O N O F B E N E F I T S Availability of Consumer Assistance/Ombudsman Services In addition to the Explanation of Member Appeal Rights attached, there may be other resources available to help you understand the appeals process. For questions about your rights, this notice, or for assistance, you can contact the Employee Benefits Security Administration at 1-866-444-EBSA (3272)or www.askebsa.dol.gov. Additionally, a consumer assistance program may be able to assist you at: Connecticut Office of the Healthcare Advocate P.O. Box 1543 Hartford, CT 06144 Toll-free telephone: 1-866-466-4446 Web site: www.ct.gov/oha E-mail: healthcare.advocate@ct.gov BENJAMIN 000218 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 204 of 237 RIGHTS OF REVIEW AND APPEAL If this claim has or is currently in the process of being appealed, please disregard the Member Appeal Information provided below and follow the instructions that were previously mailed to you. If you would like further clarification or have any questions regarding this Explanation of Benefits (EOB), or if you are not fully satisfied with the resolution of your claim, you may contact Customer Care by calling 1-800-444-6222, or by writing toOxford Correspondence Department, LLC, P.O. Box 29135, Hot Springs, AR 71903. A service associate will investigate and attempt to resolve your concerns at the time of the call. If you remain dissatisfied, you may appeal the determination by following the Appeal Procedures outlined below. If we have requested additional information to process your claim, this information must be submitted toOxford Correspondence Department - Resubmissions, P.O. Box 29133, Hot Springs, AR 71903. The requested information must be submitted within 45 days of the date of your receipt of this notice. Upon receipt of the information, we will elect to take the one-time, 15-day extension that is permitted under the Employment Retirement Income Security Act (ERISA) and will provide you with a written response not later than 15 days from receipt of the information. Failure to submit this information within 45 days will result in an automatic denial of this claim due to lack of information. No further notice will be provided to you. In the event that you fail to follow these procedures in the time frame specified but wish to submit relevant information outside the time frame and/or request an appeal, please follow the appeal procedures outlined below. Failure to comply with appeal process requirements as communicated by Oxford may lead to forfeiture of a consumer’s right to challenge a denial or rejection, even when a request for clarification has been made. Note: A claim is any request by a covered member for certification of a benefit, or payment for a service, as required under the terms of the member’s health plan. A claim is denied when it does not meet the criteria established by your plan. If your claim has been denied in whole or in part and you would like a copy of the criteria used, you must send a written request toOxf rd Disclosure Requests, P.O. Box 29133, Hot Springs, AR 71903. The criteria will be provided to you free of charge. Member Appeal Information You may designate a person (“Designee”) to act on your behalf to appeal this decision. To do so, you must provide us with the designation, in writing, at the time of the appeal. The designation must be signed by you, or by your guardian if you are a minor. First-Level Internal Appeal You or your Designee must submit a request for appeal within180 daysof receipt of this EOB. Unless otherwise specified in the denial description, the appeal must be submitted in writing toOxford Correspondence Department, P.O. Box 29134, Hot Springs, AR 71903,or by calling Customer Care at 1-800-444-6222 and requesting an appeal. The request must include the reason(s) you believe that the claim should not have been denied, your name and member ID number, a copy of this form (or the claim number on this form), and any documentation/ information you would like to submit in support of the appeal. We will provide you with a written response not later than30 daysfrom the Correspondence Department’s (or other department indicated in this correspondence) receipt of your request for a First-Level Appeal. Second-Level Internal Appeal Second-Level appeal rights are available for members of group plans. Individual plans only have one level of internal appeal and if applicable, may be eligible to pursue an external appeal after completion of the First-Level Appeal (see below for more information). If Second-Level Appeal rights are available, you will receive additional information in the First-Level Appeal determination notice. Second-Level Appeal rights allow group members or their Designee to appeal to our Grievance Review Board (GRB) for further consideration. Requests for a Second-Level Appeal must be made within60 business daysof the receipt of the First-Level Appeal determination letter. The request for appeal and any additional information must be submitted toOxfor Grievance Review Board, P.O. Box 29134, Hot Springs, AR 71903. If these rights are available to you, you or your Designee will need to include all information we previously requested (if not already submitted), and any additional facts or information that you believe to be relevant to the issue. The appeal will be resolved not later than30 daysfrom the GRB’s receipt of your request for a Second-Level Appeal. Employee Retirement Income Security Act (ERISA) Rights If we have not approved your claim after all reviews have been completed, group members may have the right to file a civil action under 502(a) of the Employee Retirement Income Security Act. New York State External Appeal Process A denial based upon clinical reasons subject to the Utilization Law of New York, such as (1) lack of medical necessity, (2) experimental/investigational, (3) clinical trial provision, (4) rare disease treatment, or (5) that the out-of-network health service is not materially different from the health services available in-network, may be eligible to be appealed through New York’s external appeal program. You will be notified of your eligibility to pursue an external appeal in the appeal determination notice. You may obtain additional information about the New York external appeals process by calling Customer Care at 1-800-444-6222. TTY/TDD and Language Assistance Notice If you have a hearing impairment and need help, please call our TTY/TDD line at 1-800-201-4875. Please call 1-800-303-6719 for assistance in Chinese, 1-888-201-4746 for assistance in Korean, or the telephone number on your health plan ID card for assistance in English and other languages. NY-14-166 BENJAMIN 000219 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 205 of 237 48 Monroe Turnpike Trumbull, CT 06611 R E M I T T A N C E A D V I C E OHPI NY INC Please see last page for Appeals Rights ATTENTION: THIS MAILING MAY CONTAIN DOCUMENTATION ON VARIOUS MATTERS HANLEY CENTER INC 7789 NW BEACON SQ BLVD BOCA RATON FL 33487 Vendor Name: HANLEY CENTER INC TIN: 592500657 Vendor ID #: P2500657-A883799 Check Number: 12201527 11-14-2014 Member Name: BENJAMIN, AMY Provider Name: CARON RENAISSANCE Member ID: 10953193*01 Provider ID: A883799 Patient Acct #: 15469 Claim #: 4304211933 Serv Date CPT Code Description QTY Billed Amt Max Amt Withhold Amt Deductible Amt Copay/Co-ins Amt Adj Code COB Amt Payment Amt 09-22-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 0.00 D2 0.00 09-23-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 0.00 D2 0.00 09-28-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 0.00 D2 0.00 09-29-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 0.00 D2 0.00 09-29-14 80101 DRUG SCREEN, SINGLE 1 150.00 0.00 0.00 D2 0.00 09-30-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 0.00 D2 0.00 10-01-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.14 0.00 0.00 D2 0.00 10-02-14 PDHSP IN HOSP PSYCH-PARTIAL STAY 1 2232.16 0.00 0.00 D2 0.00 TOTAL CLAIM: 4304211933 15775.00 0.00 0.00 0.00 0.00 0.00 0.00 HANLEY CENTER INC 7789 NW BEACON SQ BLVD BOCA RATON FL 33487 Why wait for this to arrive in the mail? Save time, money and paper with electronic payments and remittance advice. To sign up or learn more: • Go to OxfordHealth.com • Click on Providers or Facilities • Select Tools & Resources • Select Direct Deposit & Electronic EOBs 48 Monroe Turnpike, Trumbull, CT 06611 OHPI NY INC BENJAMIN 000220 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 206 of 237 R E M I T T A N C E A D V I C E Billed Amt Max Amt Withhold Amt Deductible Amt Copay/Co-ins Amt COB Amt Payment Amt Claim Payment Summary 15775.00 0.00 0.00 0.00 0.00 0.00 0.00 Check Summary Total Paid . . . . . . . . 0.00 Check Date. . . . . . . . November 14, 2014 Paid To . . . . . . . . . . . HANLEY CENTER INC Check Number. . . . . 12201527 Adjustment Code Descriptions D2 These services were formally denied because they were not authorized in advance Why wait for this to arrive in the mail? Save time, money and paper with electronic payments and remittance advice. To sign up or learn more: • Go to OxfordHealth.com • Click on Providers or Facilities • Select Tools & Resources • Select Direct Deposit & Electronic EOBs Are you getting all that you can out of oxfordhealth.com? Oxford® is dedicated to helping your practice run smoother. Our website is easy to use and available for you to interact with us at your convenience. Let us give you the VIP tour. Log on as a Provider or Facility on oxfordhealth.com.Go to Tools & Resources > Manage Your Practice > Administrative Ease and register for a webcast training session today. OXFORD’S MISSION At Oxford, we recognize the importance of the provider-patient relationship, and know that good care starts with you. We want to complement the care you provide to help asthma patients breathe a little easier help new mothers deliver healthy, full-term babies…help your patients with heart disease and diabetes adopt healthy lifestyles -- to help your patients live longer, healthier and happier lives. BENJAMIN 000221 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 207 of 237 ADJ CODE Adjustment code. The code we assign to describe how we processed this claim line. Generally, the adjustment code shows a correction, adjustment or denial. BILLED AMT Billed amount. The amount billed by you. CLAIM # Claim Number. The number we assign to your claim. The first four digits of a claim number reflect the date the claim was received. (Example: Claim Number 8049234568 - The first digit (8) indicates the year 2008 and the following three digits (049) indicate the day of the year in Julian date format. In this example, the claim was received on the 49th day of the year, or February 18, 2008.) COB AMT Coordination of Benefits. The amount covered by the member’s other health plan when that health plan is “primary.” CO-INS AMT Coinsurance amount. The portion of the maximum amount the member must pay for covered benefits during the plan year. Coinsurance (when part a member’s plan) typically does not apply until after the member meets the deductible. COPAY AMT Copayment amount. The amount the member is required to pay directly to you for in-network covered benefits at the time of the service. Copayments generally apply when receiving services from participating providers. CPT CODE A five-digit alpha numeric identifier used to define the medical service, supply or drug billed. Unless otherwise noted, the code is assigned by you. DATE RECEIVED The date we received the claim. DEDUCTIBLE AMT Deductible amount. The amount the member must pay for covered benefits during the plan year before we begin making payments for covered benefits. In most instances, the deductible amount must be met before coinsurance applies. DESCRIPTION A brief explanation of a code used to describe the medical service, supply or medication billed. DIAGNOSIS CODE A three- to five-digit code used to explain the medical diagnosis code billed. Unless otherwise noted, the code is assigned by you. DIAGNOSIS DESCRIPTION A brief explanation of a code used to describe the medical diagnosis. MAX AMT Maximum amount. The most that is available to pay for covered benefits under a member’s health benefits plan. For a participating provider, it is an agreed upon amount. If the member’s plan has out-of-network benefits, it is the lower of the billed amount, the amount available for payment using the plan’s out-of-network reimbursement rates and rules, or the amount you have agreed to accept as payment. DEFINITION OF TERMS BE ON THE LOOKOUT FOR FRAUD Fraud can affect members, providers and health plans alike through increased insurance premiums and health care costs. Those who file a claim with intent to defraud, or helps commit fraud against an insurer, is guilty of a crime. Fraud includes intentional misrepresentation of any of the following: • Charges for a service, procedure or supplies • Type of service, procedure or supplies provided • Dates of services or treatments • Medical record of services or treatments provided • Condition treated or diagnosis made • Identity of the provider or member Please contact us at 800-666-1353 if you suspect or are aware of any fraudulent activities. Thank you for doing your part to stop abuse in the health care system. BENJAMIN 000222 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 208 of 237 PATIENT ACCT # Patient account number. Refers to your account number or invoice number for the patient or claim. PAYMENT AMT Payment amount. The amount reimbursed under the member’s health benefits plan. QTY Quantity. Refers to the number of times a particular service was performed. SERV DATE Service date. The date you performed the service(s). VENDOR NAME/ID# Refers to the recipient of payment. This may be you, the individual provider, or the collective provider of services with which you are affiliated (e.g., medical group). WITHHOLD AMT Withhold amount. Refers to a contracted percentage of the fee that is not payable at this time. DEFINITION OF TERMS BENJAMIN 000223 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 209 of 237 Attention Non-contracted Medicare Providers Appeals Process for Non-contracted Medicare Providers Pursuant to federal regulations governing the Medicare Advantage program, non-contracted providers may request reconsideration (appeal) of a Medicare Advantage plan payment denial determination. To appeal a claim denial, submit a written request within 60 calendar days of the remittance notification date and include at a minimum: • A statement indicating factual or legal basis for appeal • A signed Waiver of Liability form (you may obtain a copy on www.uhconline.com) • A copy of the original claim • A copy of the remittance notice showing the claim denial • Any additional information, clinical records or documentation Mail the appeal request to UnitedHealthcare Appeals & Grievances Po Box 6106 Cypress, CA 90630 MS CA 124-0157 Payment Dispute Process for Non-contracted Medicare Providers Pursuant to federal regulations governing the Medicare Advantage program, non-contracted providers may file a payment dispute for a Medicare Advantage plan payment determination. A payment dispute may be filed when the provider disagrees with the amount paid, including issues related to bundling of services. To dispute a claim denial, submit a written request within 120 calendar days of the remittance notification date and include at a minimum: • A statement indicating factual or legal basis for the dispute • A copy of the original claim • A copy of the remittance notice showing the claim payment • Any additional information, clinical records or documentation to support the dispute Mail the payment dispute to Oxford, A UnitedHealthcare Company Attn: Provider Appeals Department PO Box 29136 Hot Springs, AR 71903 For additional information on the Non-contracted Appeal and Dispute processes including a form that may be used to facilitate your request for appeal or dispute, please go to www.uhconline.com. BE ON THE LOOKOUT FOR FRAUD Fraud can affect members, providers and health plans alike through increased insurance premiums and health care costs. Those who file a claim with intent to defraud, or helps commit fraud against an insurer, is guilty of a crime. Fraud includes intentional misrepresentation of any of the following: • Charges for a service, procedure or supplies • Type of service, procedure or supplies provided • Dates of services or treatments • Medical record of services or treatments provided • Condition treated or diagnosis made • Identity of the provider or member Please contact us at 800-666-1353 if you suspect or are aware of any fraudulent activities. Thank you for doing your part to stop abuse in the health care system. R E M I T T A N C E A D V I C E BENJAMIN 000224 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 210 of 237 RIGHTS OF REVIEW AND APPEAL If this claim has or is currently in the process of being appealed, please disregard the Appeals process described below. If you would like further clarification of this Remittance Advice (RA) or are not fully satisfied with the resolution of your claim, you may contact Provider Services at l-800-666-1353 and a Service Associate will investigate and attempt to resolve your concerns at the time of the call. Participating providers may also submit aClaim(s) Review Request Form.to Oxford, A UnitedHealthcare Company, Correspondence Department, P.O. Box 29135, Hot Springs, AR 71903.This form is available on Oxford’s website atwww.oxfordhealth.comLog in as a provider or facility, click on theTools & Resourcestab and then on Forms. If you remain dissatisfied, you may appeal the determination using the procedure listed below. APPEALS FROM PARTICIPATING PROVIDERS CONTRACTED WITH OXFORD You may appeal an adverse claim determination by following the appeal procedures specified in the Provider Reference Manual (PRM). and any subsequent updates. Please be advised that, with the exception of services rendered to New Jersey (NJ) commercial line of business Members after July 11, 2006, which has a different process (described below and in the PRM), you have180 days (6 months)from the date of this determination to send your written request for appeal toOxford, A UnitedHealthcare Company, Attention: Provider Appeals Department, P. O Box 29136, Hot Springs, AR 71903. To be processed, the appeal request must be submitted on theClaim(s) Review Request Form.The form must be completed in its entirety, including the reason(s) you believe the claim should not have been denied, the claim number(s) and any documentation you believe supports your position. Once the review is complete, you will receive Oxford’s written response. If you are not satisfied with Oxford’s decision, you may arbitrate the issue as set forth in your contract with Oxford. ALL PROVIDERS Retrospective Utilization Review Appeal Information for Services Provided to NY Commercial Members: Pursuant to Article 49 of New York Insurance Law, healthcare providers treating a Member in a New York Commercial line of business (LOB) may request a retrospective clinical review if: (1) the review of the procedure was requested only after the services were provided and (2) Oxford denied the service based upon medical necessity or the experimental/investigational exclusion if the Member has a life-threatening or disabling condition. If you have failed to seek a required precertification, a retrospective clinical review is not available. If a retrospective adverse determination is rendered in accordance with the above procedure, you may appeal as described below: Internal Appeal: You must appeal a retrospective adverse determination to Oxford’s Clinical Appeals Department within60 calendar daysof receipt of the retrospective adverse determination. To appeal, you must send an appeal letter, any information requested in the initial retrospective adverse determination and any additional information you would like to submit in support of the appeal to:Clinical Appeals Department, Oxford, A UnitedHealthcare Company, P.O. 29139, Hot Springs AR 71903(Fax 203-459-7351). The Clinical Appeals Department will acknowledge receipt of the appeal and request any information needed to conduct the review within15 business days. The appeal will be resolved within60 calendar daysof receipt of all necessary information. To review the policy used to determine coverage for a request for services, please submit a written request to:Policy Requests and Information, Oxford, A UnitedHealthcare Company, 48 Monroe Turnpike, Trumbull, CT 06611. External Appeal: In general, you may be eligible to file an application for external appeal of a retrospective adverse determination to an independent utilization review organization as provided by the New York Insurance Law, if the Clinical Appeals Department upholds, on medical necessity grounds or the experimental/investigational exclusion, all or part of such a retrospective adverse determination. Determinations based upon the experimental/investigational exclusion (including clinical trials) may be appealed through the external appeal process only if the Member’s condition meets the statutory definition of a “life threatening” or “disabling” condition. To determine eligibility for external review and file an external appeal, youmust file a written application with the New York State Department of Insurance (DOI) within45 daysof receipt of the denial from the Clinical Appeals Department. An application and instructions will be sent with the appeals determination. The DOI will assign the case to a state-licensed external appeal agent who has no affiliation with Oxford. The external appeal agent will issue a standard appeal decision within30 daysof receiving the application and an expedited external appeal decision within three days of receipt of the request. An external appeal agent’s medical necessity decision is binding on all parties, so long as the benefit is available under the Member’s plan. If you have a question concerning a particular member’s LOB, the information may be found on Oxford’s website atwww.oxfordhealth.com or by calling Provider Services at 1-800-666-1353. Claim Appeals for Services Provided to NJ Commercial Members: If you have a dispute relating to the payment of a claim for services that were rendered to a NJ commercial line of business Member on or after July 11, 2006, your dispute may be eligible for a two-step appeal process. Disputes involving medical necessity may not be appealed through this process and must follow the utilization management appeal process. The first step of the claim appeal process allows you to submit a claim appeal through Oxford’s internal appeal process and, if eligible, the second step allows your dispute to be referred to an independent arbitration entity selected by and contracted with the NJ Department of Banking and Insurance (DOBI). Internal Appeal: You must submit an internal appeal to Oxford’s Correspondence Department within90 calendar daysof receipt of an adverse claim determination.The appeal must be submitted on a form created by the DOBI, along with the information required to process your appeal (listed on form). The form is available on Oxford’s web site (www.oxfordhealth.com). The form and the information must be sent to:Oxford, A UnitedHealthcare Company, Attention: Provider Appeals Department, P.O. Box 29136, Hot Springs, AR 71903.The appeal will be resolved within 30 calendar days from the receipt of your appeal submission. If you have a question concerning a particular Member’s line of business, information may be found on Oxford’s web site atwww.oxfordhealth.comor by calling Provider Services at 1-800-666-1353. Arbitration: Disputes may be referred to arbitration when the internal appeal determination is in Oxford’s favor or when we have not made a timely determination on your appeal. To be eligible for the NJ arbitration process, the disputed claim amount must be at least $1,000. While you may aggregate your claims to reach this number, you must initiate the arbitration proceeding on a form created by DOBI on or before the90th calendar dayfollowing your receipt of the determination (or non-determination). The arbitration will be conducted according to the rules of the arbitration entity. Additional information will be provided if any part of the determination is not reversed on appeal. Information is also available on the DOBI web site atwww.state.nj.us/dobi. MS-07-215 BENJAMIN 000225 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 211 of 237 BENJAMIN 000226 - . - ;;_;j ·~; - --- - .~~~;~~r~. ~[i~§i~; Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 212 of 237 BENJAMIN 000227 ; -~ . I ,. .. - ·- - ~ ~ - - ~~ '=" ='?-;::: = - ~~ ·-==~-- • :---, o::o -- ~ --- ::-: = :- : . .. ~ ~ :-::-=-~;=~ .. . . - - - ~~ ...... .§!: """"-"'""---- ----, Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 213 of 237 BENJAMIN 000228 20150128 0600 11 Covlee Drive \Ves~port~ CT 06880 Centrai Escaiat1on Urnt PO Box 29134 Hot Spnngs~ ~A .. R 7 i 903 RE: iv1ember HJ #: 1 09531930! 4304211933 Date ufServH:es 09-22-14 th;u D9-23-14 and 09-28-14 thr-u 10-02-14 Dear ~A .. ppeals Kevle\-v Hoard~ authunzect 1n advance. ask1ng detmied quest~nns because I needed th~s treatrnent. treatment and tv enable the most opt1mum chance of succ~:;s fbr Sarai1's recovery ;,.vhen she returned home. with the compiete understanding that I was covered fron1 rny Hlsurancc. i have a!ready contacted Caron Renaissance ;_..__, send 3 .._,:.; rnv rnedicai records ft:r rny Hl panent Kegards Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 214 of 237 BENJAMIN 000229 -_.- L Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 215 of 237 BENJAMIN 000230 .... ... --·-. 7i903 P.O. Box 29134 Hot Springs, ~=~ 71903 corilplrum: or ou'ler 1tem wf-..ich nee:is to be n~n.di~d by ancther ill"~~- If your request doe.s not qualify a..~ an appeal; griev&"'1-c··:- or COJ.Hpiaint. we wHi for..vard the 1ssue to another unit for rev1e;,..v Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 216 of 237 BENJAMIN 000231 --- __ ,_,,_, ··'·:.-:: Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 217 of 237 BENJAMIN 000232 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 218 of 237 P.O. Box 29134, Hot Springs, AR 71903 February 24, 2015 AMY BENJAMIN 11 COVLEE DRIVE WESTPORT CT 06880 TRANSACTION#: Z0290747004 INSURER: OXFORD HEALTH INSURANCE, INC. SUBSCRIBER: AMY BENJAMIN ID #: 1095319301 PATIENT: AMY BENJAMIN PLAN: TECHSTYLE CONTRACT FABRICS PLAN #: TC23015 PROVIDER NAME: CARON RENAISSANCE SERVICE DATE(S): JULY 24, 2014 - OCTOBER 2, 2014 CLAIM AMOUNT: $126,832.57 DETERMINATION: UPHELD - FINAL ADVERSE DETERMINATION Dear Amy Benjamin: We reviewed the request received January 28, 2015, to review our previous decision regarding the service(s) that you received. We understand the appeal to state that these services should be covered because you were informed by a UnitedHealthcare (UHC) representative that they were covered services. We carefully reviewed the documentation submitted, our payment policies and the limitations, exclusions and other terms of your Benefit Plan, including any applicable Riders, Amendments, and Notices. Based on our review, according to your Benefit Plan, under Section XIV - Freedom PPO Schedule of Benefits, subsection Mental Health & Substance Use Disorder Services (Non-Participating), this request for payment was processed correctly: Outpatient Mental Health Care (Including Partial Hospitalization Intensive Outpatient Program Services): Pre-authorization Required Because the claim(s) for this service(s) was processed according to the above plan provision(s), our original determination remains unchanged, and the determination is upheld. Our administrative Oxford BENJAMIN 000236 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 219 of 237 decision does not reflect any view about the appropriateness of this service(s). Only you and your physician can make decisions about your care. A review of our records indicates that this claim was processed correctly. Your health benefits plan requires that you obtain pre-certification in advance for certain procedures. This service was not pre- certified. Additional Rights You have the right to receive, upon request and free of charge, reasonable access to and copies of all documents, records, and other information relevant to your appeal, as well as copies of any internal rule, guideline or protocol that we relied on to make this payment decision. You also have the right to receive, upon request and free of charge, an explanation of the scientific or clinical judgment that we may have relied upon in making this benefit decision as well as the diagnosis or treatment codes, and their corresponding meanings. To request copies, submit a written request, separate from an appeal request, to: Oxford Health Insurance, Inc. Appeal Document Request P.O. Box 29133 Hot Springs, AR 71903 We will fulfill your request within thirty (30) calendar days of receipt. Please understand that your request for information will not change the time you have to file any subsequent appeals. You may ask for verbal translation of this letter into a non-English language. For language translation, call the phone number on the back of your health plan ID card, or send your request to: UnitedHealthcare Central Escalation Unit ATTN: Language Translation 4316 Rice Lake Road Duluth, MN 55811 You may have the right to file a civil action under Section 502(a) of ERISA (Employment Retirement Income Security Act of 1974). Please remember that, before receiving services, our customers are responsible for verifying that the physician or other health care provider participates in our network. Your Benefit Plan, including any applicable Riders, Amendments, and Notices, explains this and other customer responsibilities. Typically, you will have lower out-of-pocket expenses by visiting physicians and other health care providers who participate in the Oxford Health Insurance, Inc. network. For a list of Oxford Health Insurance, Inc. network physicians and providers in your area, please visit our web site at www.myuhc.com or call Customer Care at the telephone number listed on the back of your ID card. If you are not satisfied with this decision, you or your authorized representative may request a second level review. To request a review, within 60 business days of receiving this letter, please call us at the telephone number listed on the back of your ID card, or write to: Oxford Health Insurance, Inc. Appeals Request Department P.O. Box 29139 Hot Springs, AR 71903 BENJAMIN 000237 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 220 of 237 Please include the following in your request for a second level review: (1) A specific request for a second level review (2) The name, address, and patient ID number of the person enrolled in the health plan (3) The name and address of any authorized representative with whom you are consulting (4) Information regarding the service(s) for which you are requesting additional payment (5) Any new, relevant information that was not already provided with your initial appeal If you are not satisfied with this decision, you or your authorized representative may contact the Department of Financial Services to request its review of this decision: Department of Financial Services Consumer Assistance Services One Commerce Plaza Albany, NY 12257 Phone: 1-800 342-3736 Availability of Consumer Assistance/Ombudsman Services In addition, there may be other resources available to help you understand the appeals process. For questions about your rights, this notice, or for assistance, you can contact the Employee Benefits Security Administration at 1-866-444-EBSA (3272). Additionally, a consumer assistance program may be able to assist you at: Office of the Healthcare Advocate P.O. Box 1543 Hartford, CT 06144 Telephone: 866-466-4446 Fax (860) 331-2499 Website: http://www.ct.gov/oha/site/default.asp Email : healthcare.advocate@ct.gov Your satisfaction is important to us. As part of our continuing efforts to increase Member satisfaction, it is our goal to thoroughly review your appeal and provide you with a prompt response. If you have questions, please call Customer Service at the number on your Oxford Health Insurance, Inc. Member ID card. As an added service to you, you may review claims, check referrals, change your primary care physician (PCP), and obtain other helpful Member information through our web site, www.oxfordhealth.com. If you have a suggestion about how we can improve your satisfaction with Oxford, please contact Customer Service at the number on your Oxford Health Insurance, Inc. Member ID card. For a hearing impaired interpreter, you may contact Oxford's TTY/TDD line at 1-800-201-4875. Please call 1-800-303-6719 for assistance in Chinese, 1-888-201-4746 for assistance in Korean, 1- 800-449-4390 para ayuda en Español, or the number on your Member ID card for assistance in other languages. BENJAMIN 000238 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 221 of 237 Sincerely, Rizwan K. Resolving Analyst BENJAMIN 000239 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 222 of 237 BENJAMIN 000256 -· - :.-~. j;0 5 l -! -,.; l '· _j__j 5,) - : __ . ·._.: ~ _J S~ c'7-;t ~ C- -.i \ ""':. ~ '- .. - 5 ~ :.......,;: """' ·_·: ,__;: :..:.:: - - .. ... - . -- - Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 223 of 237 BENJAMIN 000257 . ·-·--·-·- -.. ·····-·. ·- .... ···- .... ~ - ----·-··-· - .... ·····--· .... ·-· . -- . . . '""'""'" ,-·-"''""''·"' '""'""'''""' -··-········ .. ·-· . . - . .. . ... ~ -""'-~.:..~-=-----'~.:. :-:-. -=--...:-'--" ·-·: ------··-- -----·. - - ~ ~:O::==:~::::O::::-::~o::~-,::~:::: '' ,-;-, -, : ·.: -,::. .. -:: ·--- --..-.. -- ~~ ~ ~- - .... ~ ~ ~ -- • ------·· • • ""-""o:"" ---- : ~,,..,_. - ·-···- . --·. .,_ ~...., .-.. -.. ... . ... ~ ~ - .. "'"'" ::-.·-:--- . -- - ~ ~ -. ··----··· --~~~.:..'--'---~,_,-~---· -- ·- ---·· .... :-_: ____ o_ __ , ___ _ Claim amount:. 5126,832.57 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 224 of 237 BENJAMIN 000258 ----,_._.,.' ~--"~ ~ --' ~---' '---~~ c: '"'.--o· .. - - -- ---~ ~-- ·---"'-~'-'~'--':: ~ "-='--'~'--'-"-'--'-' . -.~:---.-"-'~-"----.-~-co---- .. .:.,~,_ :.·..::.:-,_ ::...:.'--'~'' '-"~'- -='-~~,_-....::::.~~'- ·--~ ~'-'~'-=-~=--0 -"'-·-:...::.·-·== ·---=- ===~ =--=--=-=--"'-'"-""- - --- --------- --" , .. ,,-_::.:=-. --- -·-··· ::i::~:::::~:.,::::··- '': __ --· :€~ ::~~:;.:.,:~~;_-_ -· ..... :. -=-~=-.:..:..=~~-=-:..:·-·-=-~ ·--~ '-'~'--"'- -------- - .. • .:-=--=-~'-'--"-'-~~- - .------ ____ j ----" ::.· : ;::. -' "-~ ·- ... =--=-== ~---=:::.::..·.:.. "::.:.::..,____·::._::::._::. Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 225 of 237 BENJAMIN 000259 D 0 s~ .. 291.}1. HOt' Spr~ngs. AR 71903 i i CQ\/LEE DRiVE: iNSURER: SUHSCRiBER.: ID #: PATIENT: PL.-\1 .... !: ·-, ! .,;~ .. -, :-, ..:, -: Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 226 of 237 BENJAMIN 000260 ... . . . . ,._:co:: '-''" :: : : :, ::-. . ... ---,._,, ,_,._._, ____ -·::- :-::- __ --- ==~, .. . .. ,,_., : . .. =~--= : =~-"' ::· ••• "::-~ "''-" - ....... -----:::·· . ,_,., ... :;,'· -- ---- - :_;..:;;: ....... ... ------ ·.:: .,_,:;:·.: .. .. :::· ::· . .-: '-'" pnJY!d.,::-:-. \rhu paniL·i;xu•.: ;;1 tiK' ·· ,,.,,, :.k.!! '' ;;:·-· ··.-:;,_._ ''""'· ,,_,:_;; .. - . ----- -----······ ,_,,,,__,._, ."O:c:: ''--' ...... : '""· ::: ..... ,,_,._,, - . :·.: =~_.,,. '""" ... - ....... .. . .... ----- ... . .• ,_,.;-,_, ;-(:f ~; ;_;~::_ :_:; n~_;t''-'••rk ph;;=-"ici::n:-,. ::nd f)rt:\·;;_h;rs !;~- y\·H.li' :;n;~;_ picasc vi:-:1! our -..;,:;;b site m \\'\',:;,=;_m,vuhc.corn or c;d~ c ...... t,,,.,_, C'an.:- '" .':-. : --,i::=n;..·· iiUf ;],._:r ,,-.;~·,l :•ll th;.: b_,,_-~,_ '',,:ur !!) ,._n\~ t !·.1· l. • ! : 1 ;·, - ;_' ;\.ppc~;i~;- i-zcqn;;:->t• DL"panmcm P_()_ Bu.\. 2{j i .-:t_J Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 227 of 237 BENJAMIN 000261 20150422 0600 Your ~.,,: i ... f.;.T:· •:; :-. :: llF'-'' :.:ni ;_ ........ \~~ p;tn i ·,f our c~ •rli in u i ng ;,::\Tuns io l ncr;,;u;;;; !vL:mbcr s~ii!S i a.;t:un. it , ... , n;r ~o::: u.; !hf;f;,)Uf!il:,. t\:vi::v·,· your appeal· :_uu_i p:-n•:~dt: y:Ht \\'ith <.i prompt n:~pon;-;c if ynu ha'"'.: qu:.:::.\i(;lb. ~-,i=.;~~=--~:: ,_-~i\! Cu-.;H·m•:l S.;:\ ,__. ~•! iht: n: .. n~-H ... .- u;i your O:·Joru r-;;;ai:i; ln:-.tH~UH .. :c. !w . ..:. f'-.,·i;;rnhcr fi J • ..-~in:i A~. ;m ::u\;',__·u'• "t:n ic'-· r,_, .,,-.u.. \-,_Hi ma'-· r•_''-·;,_'H' ,_·,':;,=:r:.-:..: c/;;__·;,_-~; rt:L·i'(:tf:-.. .. t.'iUul~~ your rrunar} .;:;;,.: pi:):-,;;,_u;; {!--"Li .. ;~ ,;,;id on:.,,in•oihcr hclp!::_:i fviL::nlht:F 5nk;nnauon U1roug11 our >v;,_:i_: sit;;, '.."-'\\''-'-' •"i'q,_;rc:hGH~no[:mn·. ii" yo;; h:n-T ;_; :..;uE~C:~i!nn othout hov.: w;,_: ::;:;;; i:r:pn-;\-'t: your ;;ausf::J.Cuon wH]i Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 228 of 237 BENJAMIN 000262 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 229 of 237 BENJAMIN 000263 ,-, 'c ,.-.., _J ~ ~~~0::::; .4'- -· ... ·- - ~ .-. -- . Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 230 of 237 BENJAMIN 000264 GHiNY SG GNET RDR 20i4 - - Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 231 of 237 BENJAMIN 000265 - ~. to..,~;ards Your Deductibie. Arnount ih!s means that the totai of Our coverage and any anHJunts You less than the Non-Partidpating. Provider's actual charge. GHiNY SG ONET RDR 20i4 - - ~ - Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 232 of 237 BENJAMIN 000266 ----- -· - .... -· o-~~\:s~~:c:::~ ~ :.. . ' -~ -, :-, ·' .-, :0 --, _._- --~ '~--= -:: -~ ~ -~ --~,~~~-~ ... ' ~ ....., ~ -~ ,_ .. _. ,_ ~ ---_,.:...._· ;_;:-...:--:--:'-:- ____ _ ----- -----'--- ..... ~~::...: '-'- ·-·c.: .:.... ' -~ ·: ~ ·o .- ·o -~ -:: .- ' ·' -' ---::...: ·...:---:: .:..... ~ ...:- ·.: ...:-..:.... ··- ... ""'--'''---~ -.. -. ·' .-, ' ~ ,-, -, -, --· -- - ::.::~ : '-' : -: . ·-· . . . . . - ·-·-- --- - ··--- ... --·-=--- ---"--~-= £-.:.e:=-'==--=-=-· - -- .. - - - - ------ - -_: :::;~~~ =~ ~-: .. ::==~ _,,,_·;___::·..:::::::=: ~~::-o~:..::o.'""~""" ~-'=~'=~~ :::"j.· ~~::o-~:""."'.0::: :.-o :~:::: :.::: ,-,o:; :..--::--::~;;:: R~:;:: ::-.-. .-: .. :.: ......... ··- ·--···-·- ---- -·--·---···- ······- :::::-:::-..: ::=::::::::--::-= treatment. Pi ease advise 1fyou need: additlonai Information to review and approve these cianns for pay;::ent. Regards, -·( Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 233 of 237 BENJAMIN 000267 205 50422 0600 : .... -:::· ~~· 8 a:_=. . ! i'i' (j / ~ < ;1}· ;:: 1 ;:: _] ;:: 1 ;:: 1 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 234 of 237 P.O. Box 29134, Hot Springs, AR 71903 May 21, 2015 AMY BENJAMIN 11 COVLEE DRIVE WESTPORT CT 06880 TRANSACTION#: Z1180837002 INSURER: OXFORD HEALTH INSURANCE, INC. SUBSCRIBER: AMY BENJAMIN ID #: 1095319301 PATIENT: AMY BENJAMIN PLAN: TECHSTYLE CONTRACT FABRICS PLAN #: TC23015 PROVIDER NAME: CARON RENAISSANCE SERVICE DATE(S): JULY 24, 2014 - OCTOBER 2, 2014 CLAIM AMOUNT: $126,832.57 Dear Amy Benjamin: We reviewed the request received April 22, 2015, to review our previous decision regarding the service(s) that you received. We understand the appeal to state you are requesting coverage for the denied unauthorized services based on the additional information submitted. We carefully reviewed the documentation submitted, our payment policies and the limitations, exclusions and other terms of your Benefit Plan, including any applicable Riders, Amendments, and Notices. Based on our review, according to your Benefit Plan, under the section Freedom PPO Schedule of Benefits, subsection Mental Health & Substance Use Disorder Services, this request for payment was processed correctly. Non-Participating Outpatient Mental Health Care 30% Coinsurance after Deductible (Including Partial $30 Copayment Preauthorization Required Hospitalization Intensive Outpatient Program Services) Oxford BENJAMIN 000271 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 235 of 237 Because the claim(s) for this service(s) was processed according to the above plan provision(s), our original determination remains unchanged, and the determination is upheld. Our administrative decision does not reflect any view about the appropriateness of this service(s). Only you and your physician can make decisions about your care. A review of our records indicates that this claim was processed correctly. Your health benefits plan requires that you obtain pre-certification in advance for certain procedures. This service was not pre- certified. Please understand that this is your final level of internal appeal with us. Additional Rights You have the right to receive, upon request and free of charge, reasonable access to and copies of all documents, records, and other information relevant to your appeal, as well as copies of any internal rule, guideline or protocol that we relied on to make this payment decision. You also have the right to receive, upon request and free of charge, an explanation of the scientific or clinical judgment that we may have relied upon in making this benefit decision as well as the diagnosis or treatment codes, and their corresponding meanings. To request copies, submit a written request, separate from an appeal request, to: Oxford Health Insurance, Inc. Appeal Document Request P.O. Box 29133 Hot Springs, AR 71903 We will fulfill your request within thirty (30) calendar days of receipt. Please understand that your request for information will not change the time you have to file any subsequent appeals. You may ask for verbal translation of this letter into a non-English language. For language translation, call the phone number on the back of your health plan ID card, or send your request to: UnitedHealthcare Central Escalation Unit ATTN: Language Translation 4316 Rice Lake Road Duluth, MN 55811 You may have the right to file a civil action under Section 502(a) of ERISA (Employment Retirement Income Security Act of 1974). Please remember that, before receiving services, our customers are responsible for verifying that the physician or other health care provider participates in our network. Your Benefit Plan, including any applicable Riders, Amendments, and Notices, explains this and other customer responsibilities. Typically, you will have lower out-of-pocket expenses by visiting physicians and other health care providers who participate in the Oxford Health Insurance, Inc. network. For a list of Oxford Health Insurance, Inc. network physicians and providers in your area, please visit our web site at www.myuhc.com or call Customer Care at the telephone number listed on the back of your ID card. If you are not satisfied with this decision, you or your authorized representative may contact the Department of Financial Services to request its review of this decision: BENJAMIN 000272 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 236 of 237 Department of Financial Services Consumer Assistance Services One Commerce Plaza Albany, NY 12257 Phone: 1-800-342-3736 Availability of Consumer Assistance/Ombudsman Services In addition, there may be other resources available to help you understand the appeals process. For questions about your rights, this notice, or for assistance, you can contact the Employee Benefits Security Administration at 1-866-444-EBSA (3272). Additionally, a consumer assistance program may be able to assist you at: Office of the Healthcare Advocate P.O. Box 1543 Hartford, CT 06144 Telephone: 1-866-466-4446 Website: http://www.ct.gov/oha Email: healthcare.advocate@ct.gov Your satisfaction is important to us. As part of our continuing efforts to increase Member satisfaction, it is our goal to thoroughly review your appeal and provide you with a prompt response. If you have questions, please call Customer Service at the number on your Oxford Health Insurance, Inc. Member ID card. As an added service to you, you may review claims, check referrals, change your primary care physician (PCP), and obtain other helpful Member information through our web site, www.oxfordhealth.com. If you have a suggestion about how we can improve your satisfaction with Oxford, please contact Customer Service at the number on your Oxford Health Insurance, Inc. Member ID card. TTY users can dial 711. Please call 1-800-303-6719 for assistance in Chinese, 1-888-201-4746 for assistance in Korean, 1-800-449-4390 para ayuda en Español, or the number on your Member ID card for assistance in other languages. Sincerely, Diane S. Sr. Resolving Analyst BENJAMIN 000273 Case 3:16-cv-00408-AWT Document 64-4 Filed 04/24/17 Page 237 of 237 1 UNITED STATES DISTRICT COURT DISTRICT OF CONNECTICUT AMY BENJAMIN, Plaintiff, vs. OXFORD HEALTH INSURANCE, INC., Defendant. ) ) ) ) ) ) ) ) ) ) ) ) ) ) CIVIL ACTION NO. 3:16cv-00408 (AWT) PLAINTIFF’S LOCAL RULE 56(a)1 STATEMENT OF MATERIAL FACTS Pursuant to Local Rule 56(a)1, plaintiff Amy Benjamin submits the following statement of material facts in support of her concurrently filed motion for summary judgment as to which she contends there is no genuine issue to be tried. A. Pertinent Policy Provisions 1. In 2014, Plaintiff Amy Benjamin was a participant in the Techstyle Contract Fabrics health plan (the “Plan”), a benefit plan governed by the Employee Retirement Income Security Act of 1974 (“ERISA”), 29 U.S.C. §§ 1001 et seq. BENJAMIN 236.1 1 Citations preceded by “BENJAMIN” refer to documents included in Oxford’s initial disclosures. True and correct copies of the relevant documents of those disclosures relied upon by Plaintiff in support of her motion for summary judgment are attached as Exhibit B to the concurrently Case 3:16-cv-00408-AWT Document 64-5 Filed 04/24/17 Page 1 of 7 2 2. The Plan was fully insured by Defendant Oxford Health Insurance, Inc. (“Oxford”) through a group insurance policy (the “Policy”) issued to Techstyle Contract Fabrics. BENJAMIN 1-139. 3. The Policy provides benefits for covered medical services and treatment incurred by its insureds. BENJAMIN 42-43. 4. Oxford administers all benefits and makes all claim determinations under the Policy. BENJAMIN 90. 5. Residential treatment for mental illnesses is a covered benefit under the Policy. BENJAMIN 27, 72-73. 6. The Policy provides that certain services require “preauthorization.” BENJAMIN 39. 7. Preauthorization is defined as “A decision by Us prior to Your receipt of a Covered Service, procedure, treatment plan, device, or Prescription Drug that the Covered Service, treatment plan, device or Prescription Drug is Medically Necessary.” BENJAMIN 39. 8. The preauthorization requirement applies to mental health services. BENJAMIN 27. 9. The Policy contains an Out-of-Network Benefits Rider which explains the details of obtaining preauthorization. BENJAMIN 123-27. 10. The Rider explains the consequences of not obtaining preauthorization for services that require it: filed Declaration of Peter S. Sessions. Plaintiff retains the citation method used by Oxford for ease of reference. Case 3:16-cv-00408-AWT Document 64-5 Filed 04/24/17 Page 2 of 7 3 If You fail to seek Our Preauthorization for benefits subject to this section, We will pay an amount $500 less than We would otherwise have paid for the care, or We will pay only 50% of the amount We would otherwise have paid for the care, whichever results in a greater benefit for You. BENJAMIN 124. B. Ms. Benjamin’s Treatment at Caron and Her Claim for Benefits 11. Ms. Benjamin was admitted to Caron Renaissance (“Caron”), a facility that treats behavioral and mental health disorders, on July 24, 2014. BENJAMIN 158. 12. Prior to her admission, Ms. Benjamin called Oxford in order to ascertain what type of coverage the Policy would provide for her treatment. BENJAMIN 141, 228. 13. Just after Ms. Benjamin’s admission, Caron called Oxford as well with similar questions. BENJAMIN 143. 14. Ms. Benjamin was ultimately discharged from Caron on October 2, 2014. BENJAMIN 220. 15. After her discharge, Ms. Benjamin submitted to Oxford a claim for benefits under the Policy for her treatment. BENJAMIN 158-225. 16. Oxford denied Ms. Benjamin’s claim on the ground that she had not received “preauthorization” for her treatment as required by the Policy. BENJAMIN 158-225. 17. On its Explanations of Benefits, Oxford stated that Ms. Benjamin’s claim was denied for the following reason: “These services were formally denied because they were not authorized in advance.” See, e.g., BENJAMIN 207, 215, 221. 18. On December 18, 2014, Ms. Benjamin submitted a written appeal of this decision. BENJAMIN 228. Case 3:16-cv-00408-AWT Document 64-5 Filed 04/24/17 Page 3 of 7 4 19. In her appeal, Ms. Benjamin informed Oxford that she had contacted it on July 11, 2014 and had been told that she was responsible for $500 and was covered for her stay at Caron. She also indicated that Caron had made a similar call on her behalf on July 29, 2014. Id. 20. On February 24, 2015, Oxford denied Ms. Benjamin’s appeal. BENJAMIN 236- 37. 21. In its February 24, 2015 letter, Oxford stated: Based on our review, according to your Benefit Plan, under Section XIV - Freedom PPO Schedule of Benefits, subsection Mental Health & Substance Use Disorder Services (Non- Participating), this request for payment was processed correctly: Outpatient Mental Health Care (Including Partial Hospitalization Intensive Outpatient Program Services): Pre-authorization Required Because the claim(s) for this service(s) was processed according to the above plan provision(s), our original determination remains unchanged, and the determination is upheld. BENJAMIN 236. 22. Oxford further stated in its February 24, 2015 letter that its decision “does not reflect any view about the appropriateness of this service(s).” BENJAMIN 236-37. 23. On April 17, 2015, Ms. Benjamin submitted a second-level appeal to Oxford. BENJAMIN 257-66. 24. In her April 17, 2015 letter, Ms. Benjamin quoted, and attached a copy of, the Policy provisions regarding preauthorization and the monetary penalty for failing to comply. BENJAMIN 257-58. 25. Ms. Benjamin further informed Oxford that under these provisions “lack of pre authorization is not grounds for denying payment of these claims.” BENJAMIN 258. Case 3:16-cv-00408-AWT Document 64-5 Filed 04/24/17 Page 4 of 7 5 26. On May 21, 2015, Oxford denied Ms. Benjamin’s second-level appeal. BENJAMIN 271-73. 27. In its May 21, 2015 letter Oxford contended that it had “carefully reviewed the documentation submitted, our payment policies and the limitations, exclusions and other terms of your Benefit Plan, including any applicable Riders, Amendments, and Notices.” BENJAMIN 271. 28. Oxford stated that it was upholding its prior decision, again on the ground that Ms. Benjamin had not complied with Policy provisions. BENJAMIN 271-72. 29. Again, Oxford stated that its “administrative decision does not reflect any view about the appropriateness of this service(s).” BENJAMIN 272. 30. Having exhausted her appeals with Oxford, Ms. Benjamin brought this action. DATED: April 24, 2017 FOR THE PLAINTIFF BY: /s/ Peter S. Sessions Peter S. Sessions, Esq. (admitted pro hac vice) Kantor & Kantor, LLP 19839 Nordhoff Street Northridge, CA 91324 Phone: (818) 886-2525 Fax: (818) 350-6272 e-mail: psessions@kantorlaw.net Ian O. Smith, Esq., ct24135 Local Counsel The Law Office of Ian O. Smith, LLC P.O. Box 33 Tolland, CT 06084 Case 3:16-cv-00408-AWT Document 64-5 Filed 04/24/17 Page 5 of 7 6 Phone: (860) 539-2156 Fax: (860) 896-9279 e-mail: iansmithlaw@outlook.com Case 3:16-cv-00408-AWT Document 64-5 Filed 04/24/17 Page 6 of 7 7 CERTIFICATION I, Peter S. Sessions, hereby certify and affirm that a true and correct copy of the above Plaintiff’s Local Rule 56(a)1 Statement of Material Facts in Support of Motion for Summary Judgment was served via ECF on the 24th day of April, 2017, upon the following: Michael H. Bernstein, Esq. Matthew P. Mazzola, Esq. SEDGWICK LLP 225 Liberty Street, 28th floor New York, New York 10281-1008 Attorneys for Defendant Dated: Northridge, California April 24, 2017 /s/ Peter S. Sessions Peter S. Sessions (Pro Hac Vice) Case 3:16-cv-00408-AWT Document 64-5 Filed 04/24/17 Page 7 of 7
