iii Transplants .............................................................................................................................................64 Travel ......................................................................................................................................................64 Types of Care, Supportive Services, and Housing .................................................................................65 Vision and Hearing..................................................................................................................................65 All Other Exclusions................................................................................................................................66 Section 3: When Coverage Begins .........................................................68 How Do You Enroll?................................................................................................................................68 Cost of Coverage ....................................................................................................................................68 What If You Are Hospitalized When Your Coverage Begins?.................................................................68 What If You Are Eligible for Medicare? ...................................................................................................69 Who Is Eligible for Coverage?.................................................................................................................69 Eligible Person ........................................................................................................................................69 Dependent...............................................................................................................................................69 When Do You Enroll and When Does Coverage Begin?........................................................................70 Initial Enrollment Period ..........................................................................................................................70 Open Enrollment Period..........................................................................................................................70 New Eligible Persons ..............................................................................................................................70 Adding New Dependents ........................................................................................................................70 Special Enrollment Period.......................................................................................................................70 Section 4: When Coverage Ends ............................................................72 General Information about When Coverage Ends ..................................................................................72 What Events End Your Coverage? .........................................................................................................72 Fraud or Intentional Misrepresentation of a Material Fact.......................................................................73 Coverage for a Disabled Dependent Child..............................................................................................73 Continuation of Coverage .......................................................................................................................73 Uniformed Services Employment and Reemployment Rights Act ..........................................................74 Section 5: How to File a Claim ................................................................75 Claims Procedures..................................................................................................................................75 How Are Covered Health Care Services from Network Providers Paid?................................................75 How Are Covered Health Care Services from an Out-of-Network Provider Paid?..................................75 Required Information...............................................................................................................................75 Payment of Benefits................................................................................................................................76 Section 6: Questions, Complaints and Appeals....................................77 What if You Have a Question?................................................................................................................77 What if You Have a Complaint?..............................................................................................................77 How Do You Appeal a Claim Decision?..................................................................................................77 Post-service Claims ................................................................................................................................77 Pre-service Requests for Benefits...........................................................................................................77 How to Request an Appeal .....................................................................................................................77 Appeal Process.......................................................................................................................................78 Appeals Determinations..........................................................................................................................78 Pre-service Requests for Benefits and Post-service Claim Appeals.......................................................78 Urgent Appeals that Require Immediate Action......................................................................................79 External Review Program .......................................................................................................................79 Standard External Review.......................................................................................................................80 Expedited External Review .....................................................................................................................81 Urgent Care Request for Benefits*..........................................................................................................82 Type of Request for Benefits or Appeal ..................................................................................................82 Timing .....................................................................................................................................................82 Pre-Service Request for Benefits* ..........................................................................................................82 Type of Request for Benefits or Appeal ..................................................................................................82 Timing .....................................................................................................................................................82 Post-Service Claims................................................................................................................................83