iii Services Provided under another Plan....................................................................................................64 Transplants .............................................................................................................................................64 Travel ......................................................................................................................................................64 Types of Care, Supportive Services, and Housing .................................................................................65 Vision and Hearing..................................................................................................................................65 All Other Exclusions................................................................................................................................65 Section 3: When Coverage Begins .........................................................67 How Do You Enroll?................................................................................................................................67 Cost of Coverage ....................................................................................................................................67 What If You Are Hospitalized When Your Coverage Begins?.................................................................67 What If You Are Eligible for Medicare? ...................................................................................................68 Who Is Eligible for Coverage?.................................................................................................................68 Eligible Person ........................................................................................................................................68 Dependent...............................................................................................................................................68 When Do You Enroll and When Does Coverage Begin?........................................................................69 Initial Enrollment Period ..........................................................................................................................69 Open Enrollment Period..........................................................................................................................69 New Eligible Persons ..............................................................................................................................69 Adding New Dependents ........................................................................................................................69 Special Enrollment Period.......................................................................................................................69 Section 4: When Coverage Ends ............................................................71 General Information about When Coverage Ends ..................................................................................71 What Events End Your Coverage? .........................................................................................................71 Fraud or Intentional Misrepresentation of a Material Fact.......................................................................72 Coverage for a Disabled Dependent Child..............................................................................................72 Continuation of Coverage .......................................................................................................................72 Uniformed Services Employment and Reemployment Rights Act ..........................................................73 Section 5: How to File a Claim ................................................................74 Claims Procedures..................................................................................................................................74 How Are Covered Health Care Services from Network Providers Paid?................................................74 How Are Covered Health Care Services from an Out-of-Network Provider Paid?..................................74 Required Information...............................................................................................................................74 Payment of Benefits................................................................................................................................75 Section 6: Questions, Complaints and Appeals....................................76 What if You Have a Question?................................................................................................................76 What if You Have a Complaint?..............................................................................................................76 How Do You Appeal a Claim Decision?..................................................................................................76 Post-service Claims ................................................................................................................................76 Pre-service Requests for Benefits...........................................................................................................76 How to Request an Appeal .....................................................................................................................76 Appeal Process.......................................................................................................................................77 Appeals Determinations..........................................................................................................................77 Pre-service Requests for Benefits and Post-service Claim Appeals.......................................................77 Urgent Appeals that Require Immediate Action......................................................................................78 External Review Program .......................................................................................................................78 Standard External Review.......................................................................................................................79 Expedited External Review .....................................................................................................................80 Urgent Care Request for Benefits*..........................................................................................................81 Type of Request for Benefits or Appeal ..................................................................................................81 Timing .....................................................................................................................................................81 Pre-Service Request for Benefits* ..........................................................................................................81 Type of Request for Benefits or Appeal ..................................................................................................81 Timing .....................................................................................................................................................81