INCORRECTLY FILED CLAIMS (Applies to Pre-Service Claims only) If a Covered Person or Personal Representative attempts to, but does not properly, follow the Plan’s procedures for requesting prior authorization, the Plan will notify the person and explain the proper procedures within five calendar days following receipt of a Pre-Service Claim request. The notice will usually be oral, unless written notice is requested by the Covered Person or Personal Representative. HOW HEALTH BENEFITS ARE CALCULATED When UMR receives a claim for a service that has been provided to a Covered Person, it will determine if the service is a covered benefit under this group health Plan. If the service is not a covered benefit, the claim will be denied and the Covered Person will be responsible for paying the provider for these costs. If the service is a covered benefit, UMR will establish the allowable payment amount for that service, in accordance with the provisions of this SPD. Claims for covered benefits are paid according to the billed charges, a Negotiated Rate, or the Protection from Balance Billing allowed amount, or based on the Usual and Customary amounts, minus any Deductible, Plan Participation rate, Co-pay, or penalties that the Covered Person is responsible for paying. Refer to the Protection from Balance Billing section of this SPD for covered benefits that are payable in accordance with the Protection from Balance Billing allowed amount. Negotiated Rate: On occasion, UMR will negotiate a payment rate with a provider for a particular covered service, such as transplant services, Durable Medical Equipment, Extended Care Facility treatment, or other services. The Negotiated Rate is what the Plan will pay to the provider, minus any Co- pay, Deductible, Plan Participation rate, or penalties that the Covered Person is responsible for paying. If a network contract is in place, the network contract determines the Plan’s Negotiated Rate. Modifiers or Reducing Modifiers, if Medically Necessary. These terms apply to services and procedures performed on the same day and may be applied to surgical, radiological, and other diagnostic procedures. For a provider participating with a primary or secondary network, claims will be paid according to the network contract. For a provider who is not participating with a network, where no discount is applied, the industry guidelines are to allow the Usual and Customary fee allowance for the primary procedure and a percentage of the Usual and Customary fee allowance for all secondary procedures. These allowances are then processed according to Plan provisions. A global package includes the services that are a necessary part of the procedure. For individual services that are part of a global package, it is customary for the individual services not to be billed separately. A separate charge will not be allowed under the Plan. The specific reimbursement formula used will vary depending upon the Physician or facility providing the service(s) and the type of service(s) received. Reimbursement for covered services received from providers, including Physicians or health care facilities, who are not part of Your network are determined based on one of the following: • Fee(s) that are negotiated with the Physician or facility; or • The amount that is usually accepted by health care providers in the same geographical area (or th greater area, if necessary) for the same services, treatment, or materials based on the 85 percentile, or • Current publicly available data reflecting the costs for health care providers providing the same or similar services, treatment, or materials adjusted for geographical differences plus a margin factor. When covered health services are received from a non-network provider as a result of an Emergency or as arranged by Your plan administrator, eligible expenses are an amount negotiated by Your plan administrator or an amount permitted by law. Refer to the Protection from Balance Billing section of this SPD for more information. Please contact Your plan administrator if You are billed for amounts in excess of Your applicable Plan Participation, Co-payment or any Deductible. The Plan will not pay excessive charges or amounts You are not legally obligated to pay. -99- 7670-00-413597