HomeMy WebLinkAbout96-02166
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STEFANON a GLACE
A1TORNRYS AT LAW
407 NO~nt PRONT STREET
POST OI'PlCE BOX 12027
HARRISBURG. PENNSYI.VANIA 17108.2027
ORJGINAL
-_.~,.,
....._--,-~............----.--........,. .
JAMES L. GEARY
Plaintiff
: IN THE COURT OF COMMON PLEAS
: CUMBERLAND COUNTY PENNSYLVANIA
I
v.
KEYSTONE HEALTH PLAN CENTRAL
INC. t/d/b/a KEYSTONE HEALTH
PLAN CENTRAT.,
NO. q" -..J./(.,-
CIVIL ACTION LAW
Defendant
: JURY TRIAL DEMANDED
PRAECIPE FOR ISSUANCE OF WRIT OF SUMMONS
TO THE PROTHONOTARY:
Issue a Writ of Summons against the Defendant Keystone Health
Plan Central, Inc. t/d/b/a Keystone Health Plan Central and deliver
that Writ to the Sheriff for service upon the Defendant at the
address set forth below:
KEYSTONE HEALTH PLAN CENTRAL, INC.
t/d/b/a KEYSTONE HEALTH PLAN CENTRAL
300 Corporate Center Drive
Suite 602, P.O. Box 898812
C..p Hill, PA 17089-8812
By
An hony
STEFANO
825497
407 No Streot
P.O. Box 12027
Harrisburg, PA, 17108-2027
(717) 232-0511
DATE:
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Commonwealth of Pennsylvania
County of Cumberland
JHml L. GPMY
w.
Court 01 Common Pleu
, 96-2166 Civil Term
No, n.__.._n__......___................ 19....
Civil Action - Law
In ._____.______________~____._~__~___________._
KEYS'<<R HEALTH PLAN COO'RAL
DC. t/d/b/a KEYS'roNE I/ElU1rn
PLAN cmrRAL
300 Corporate Center Drive
Suite 602. P.O.Box 898812
CaDp Hill, PA 17089-8812
To !<!l.xl!!9!!.E!_tl~!1.~!tu~~~!U~~~!f.l!!.ll'!.<:::J_.1OLd/b/a Keystone Health Plan Central
You are hereby notified thaI'
..__JiuDi8-~..Ge<u>y.--.._____.._._______._.._...__...._...__.___.___..___.._.._._...............
the Plain rill h.s commenced an action in _.___.<;:!.yH..'~g!LC2I:L.:-._~!!I_..___....... ..__............
against you which you are required to de/end or . delaull judgmenl may be entered aplnll you.
(SEAL)
r~wrence E. Welker
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JAMEEI L. GEARY
Plaintiff
I IN THB COURT OF COMMON PLEAS
I CUMBERLAND COUNTY PENNSYLVANIA
.
.
v.
Defendant
I
I NO. 96-2166
I
I CIVIL ACTION LAW
I JURY TRIAL DEMANDED
KEYSTONE HBALTH PLAN CENTRAL
INC. t/d/b/a KEYSTONE HEALTH
PLAN CENTRAL,
NOTICE
YOU BAVE BBlN SUBD IN COURT. If you wish to defend
against the claims set forth in the following pages, you must
take action within twenty (20) days after this Complaint is
served, by entering a written appearance personally or by
attorney and filing in writing with the Court your defenses or
objections to the claims set forth against you. You are warned
that if you fail to do so the case may proceed without you
and a judgment may be entered against you by t.he Court without
further notice for any money claimed in the Complaint or for any
other claim or relief requested by the Plaintiff. You may lose
money or property or other righte important to you.
YOU SHOULD TAXB THIS PAPER TO YOUR LANYBR AT ONCI. IF YOU
DO NOT BAVI A LAWYER OR CANNOT AFFORD ONII, 00 TO OR TILJ:PHONII
THI OFFICE SIT FORTH BBLOW TO rIND OUT HIlER!: YOU CAR GIT LJ:GAL
HILP.
Court Administrator
4th Floor
Cumberland County Courthollse
1 Courthouse Square
Carlisle, PA 17013
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into by and between Defendant and Plaintiffs' employer.
5. The terms and conditions of the aforesaid health insuranoe
plan are set forth in the Subscriber Agreement, a true copy of
which Agreement is attached hereto as Exhibit "A".
6. On April 8, 1993, Plaintiff was involved in a motor
vehicle collision in which he suffered personal injuries, and for
which injuries he received care and treatment during the ensuing
month~ and years.
7. At the time that the motor vehicle collision occurred,
Plaintiff was insured under a motor vehicle insurance policy issued
by Erie Insurance Group, which insurance policy proviried first
party benefits for medical expense up to a limit of $10,000.00.
8. During the course of Plaintiff's care and treatment,
Plaintiff received rehabilitation and physical therapy through a
company known as Occupational Rehab and Research Associates, Inc.,
located in Harrisburg, Dauphin County, Pennsylvania.
9. Erie Insurance Company paid for Plaintiff's rehabilitation
up through the end of April 1994, at which time the $10,000.00
limit of medical benefits under the motor vehicle insurance policy
was reached.
10. From May 2, 1994 through August 31, 1994, Plaintiff
continued to receive rehabilitation through Occupational Rehab and
Research Associates, Inc., whioh company billed Plaintiff for thome
services in the total amount of $4,836_00.
11. Occupational Rehab and Research Associates, Inc., as the
provider of services to Plaintiff, submitted its claim for payment
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to Defendant.
12. Defendant denied responsibility for the expenses incurred
by Plaintiff for treatment by Occupational Rehab and Research
Ilssociates, Inc., and Plaintiff received an Explanation of Benefits
from Defendant, reciting that denial. A copy of that docum~nt is
attached hereto as Exhibit "B".
13. Plaintiff requested a reconsideration of this denial, and
in relllponse to that reconsideration request received a letter dated
June 22, 1995 wherein Defendant stated that the reason for the
denial was that the services were not authorized by Plaintiff's
Primary Care Provider. A true copy of that letter is attached
hereto aa Exhibit "C",
14. At the time that the disputed services were provided to
Plaintiff, Plaintiff's Primary Care Provider was Vernne W. Greiner,
D.O. .
15, On July 11, 1995, Dr. Greiner addressed a letter to
Keystone Health Plan Central wherein he stated that the therapy
received by Mr. Geary was both appropriate and required, subsequent
to the surgical procedure which Mr. Geary had undergone. A true
copy of that letter is attached hereto as Exhibit "0".
16. Plaintiff, acting through counsel, submitted an initial
grievance letter dated July 21, 1995, incorporating Dr. Greiner's
letter dated July 11, 1995. A true copy of that initial grievance
letter is attached hereto as Exhibit "E".
17. By letter dated September 8, 1995, Defendant again denied
coverage for the disputed claims. A true copy of that letter is
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attached hereto as Exhibit "F".
COUNT I
Breach of Contract
18. The averments of the foregoing paragraphs 1 th1'ough 17 are
incorporated herein by reference.
19. Pursuant to the terms and conditions of the Subscriber
Agreement, all conditions precedent to Defendant's obligation to
pay for the medical expense.. incurred by Plaintiff have been
satisfied.
20. The care and treatment received by Plaintiff was
authorized by Plaintiff's Primary Care Physician as evidenced by
the letter of Dr. Greiner dated July 11, 1995.
21. Pursuant to the terms and conditions of the Subscriber
Agreement, Defendant is obligated to satisfy the claims of
Occupational Rehab and Research Associates, Inc. in the total
amount of $4,836.00.
22. Plaintiff has demanded payment of the claims and Defendant
has failed and refused to pay.
WHEREPORE, Plaintiff demands judgment against Defendant
Keystone Health Plan Central, Inc., t/d/b/a Keystone Health Plan
Central in the amount of $4,836.00 plus interest and cost of suit.
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COURT II
Bad raitb
23. The averments of the foregoing paragraphs 1 through 22 are
incorporated herein by reference.
24. Defendant's initial denial of benefits was based on the
theory that the services were not authorized by Plaintiff's Primary
Care Physician.
25. By letter dated July 11, 1995, Plaintiff's Primary Care
Physician notified Defendant that the services were, in fact,
authorized by him.
26. Despite receipt of that authorization both from the
Primary Care Physician and from counsel on behalf of Plaintiff,
Defendant persistad in its denial of the benefits sought by
Plaintiff.
27. Defendant has no reasonable grounds to deny the claim.
28. Plaint.iff has sought informal reconsideration and review
of the denial, and has provided full documentation to Defendant of
the reasons why Defendant's denial is unjustified.
29. Despite these informal efforts by Plaintiff, Defendant has
persisted in its denial, thereby requiring Plaintiff to file this
action in order to enforce Defendant's obligation to Plaintiff.
30. Defendant's conduct in continuing to deny the insurance
benefits to Plaintiff is wrongful, willful, and an exercise in bad
faith under the provisions of 42 PA C.S.A. S 8371.
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WBIRBFORl, Plaintiff demands judgment against Keystone Health
Plan Central, Inc., t/d/b/a Keystone Health Central for damages in
the amount of $4,836.00, plus interest, costs of suit, attorney's
fees, and punitive damages as authorized by statute.
B
Street
17108-2027
DATEr
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The undersigned hereby verifies that the facta averred in the
foregoing Complaint are true and correct to the best of hi.
knowledge, information and belief.
This Verification is made subject to the penalties of 18 Pa
C.S.A. S 4904 relating to unsworn falsification to authoritie..
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(/ JAMES L. GBARY C
'II
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Keystone
II Health Plant!>'
An~~p~~I~~~lc.nS8e of Inll Blue
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Subscriber
Agreement
IMPORTANT
Benefits described in this
agreement are covered only
when provided or authorized
by the primary care physician.
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Pennsylvania Blue Shield
IndeplIndel,ll.lcenSlle" of lh"
. . Blue CIOIlK iJJliJ Sluu Sl"llal(j As,c)clllllon
Ifl R~181I:lffl\!1 Mil".' ollhIJ 81tH! CIQS5 and Bhle Shield ASElOCllitlon,
;In Aa5uCloltlon nllrll/!:pt?r)tll'.";! Bluu CrO!i8 IUlll Blue Shlold PlAns
KC!1;!O '11j<l
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10, !NCOUNTER FORM meens the w""en report sUbm,hsd 10
~HP Centrel on e form proYlded by ~HP Centrll on which
811 CI3\t'ered Services pro\t'lded to Members by th. Primary
Cere PhysIcIan ere identified
11 !NROLLMENT FORM melns Ihe properly compleled,
written request for membership or enrollm.nt submitted on
I form proYlded by ~HP Cenlral, logelher wllh Iny
emendments or modifications thereof
12.EQUIVALENT PARTIAL SESSION VISIT . A YI'"
consisting of 8 period of 20-30 minutes devotea to Indl\t'ldual
or family medical psychotherapy for the treatment of
problems 'elated to lSubstance abuse, With continuing
medical diagno$tlc e\t'lIluatlon, and drug management when
Indicated, to Inr.lude IndiVidual psychoanalysts, inSight
oriented, bel,a\t'lor mOdifying or supportive Psychotherapy
Two Equl\t'Blent Partial Sessions equal one F-'uH Sesllon
VIOIt
13, EXPERIMENTAUINVESTIGATlVE - Thl use 01 any
treatment, procedure, faCility, equipment, drug, or drug
uSlgl doYlce or supply which KHP Cenlra', relYing on Ihe
advicl'J of the general medical community whIch Includes but
il not Umited to medical consultants, medics I Journals
and/or go\t'ernmental regulations does not accept as
standard medical treatment of the conditIon being treated, or
itny such Items requlrtng federal or oth.r governmental
agency appro\t'al which approval has not been granted at the
time the 5l!rylt:es were rlndered
14 FULL SESSION VISIT. A YI51t cons..llng of a period 01
45~50 mInutes devoted to indiVidual or famIly medical
psycholherlpy lor Ihe lrellmlnt 01 problem, related 10
substance abuse, wilh continuing medlcol dIagnostic
l\t'alu8tlon, and drug management when Indicated, to
Include Indl\t'ldual psychoanalysIs, InslQht oriented, beha\t'lor
modifying or supportIVe psychotherlpy
15 GROUP . Tha party enle"ng Into a conlrael wllh KHP
Central on behalf of the Members. including the employer or
representstl\t'e of and remitting agent 'or the Members who
collects and remits premIum peyments on behal' of the
Members
16 GROUP CONTRACT means an agreement between KHP
Central and ~ Group pursuent to whIch KHP Cantrsl
coverlJge under thiS or other applicable KHP Cenlral
SubSCriber Agreement 15 made available to persons eligible
to enroH In KHP Central's programs
17 GROUP OPEN ENROLLMENT PERIOD "'eans those
perIods or tIme established by the Group and KHP Central
from time to tlmo, but no less fre~uentJy than once In any 12
consecutive months, during which eltglbl& parsons who have
not pre\t'lously enroUed wllh KHP Central may do 50
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18 HOME HEALTH AGENCY Is In orglnlzlllon licensed by
Ihe Commonwealth of PennsylvanIa to render home h..lth
care Servlc.1 to Members
19 HOSPIC! CARE. Custodlll clre rendered to e lermlnally III
member WIth 8 life expectancy of SIX (6) months or Ie..
~O HOSPITAL . Iny Inslllullon duly IIclnsed, certlned and
operlled as e Hospllal In no ..ent ShIll the lerm Hospltel
ulclude a con\t'alescent faCility, nursIng home, or any
institution or plrt thereof which. is used as a convalescent.
rlClllty, rest IIClllty, nursing Ilc,lIty or Ilcll,ty for Ihe eged
21 HOSPITAL SERVICES (excepl es limited or e.cluded
herein) are those acute-clre Co\t'ered Servlc.. furnished by
I Hosplll' or Skilled Nurs,ng Faclllly which Ire eutho"zld
by I KHP Cenlrll Prlmery Clre Phys,clln end set forth In
ArtlC11 II, Ben ems
22 INFERTILITY . The diminished or Ibsent clpeclly to
produce offspring regardless of underlying CIUGe, Including
but net limIted to diminIShed or absent capacIty to concel\t'e
23 INPATIENT melns a Memblr who Is Idmlhed IS I bed
pollenl In I Hosplla', a Rehablllllllon Hospllal, I Skilled
Nursing Facility or 0 Substance Abuse Treatment FaCIlity
24 KEYSTONE HEALTH PLAN CENTRAL IKHP Cenlrellls I
health maintenance organization Which arranges (or the
provIsion at Co\t'ered Services to Members In a KHP Central
Service Ares
25 MEDICAID melns Hosp,lal or medical Insurance benems
provided by the UnIted States Go\t'ernment unc.:ler Titl. XIX
01 the SOCial Security Act 01 1985, a. amended
26 MEDICAL DIRECTOR meln. a physlc'"n designated by
KHP Central to monitor appropriate utilization and quality at
covered services rocelved by Members
27 MEDICALLY NECESSARY OR M!DICAL NECESSITY
means tho appropriate and necessary Covered S.rvlcea as
determined by the Primary Care Physictan and KHP Central
which are rendered by a Pro\t'lder to a Member for a
condition requiring, according to generally. accepted
prinCiples of good medical practice, the diagnOSIs or dIrect
care treatment of an Illness or Injury and which are not
prOVided only as a convenience
28 MEDICARE means HosPltcil or medical Insurance benefits
pro\t'lded by the IJnlted States Go\t'ornm.nt under TiUe XVIII
of the SOCial Security Act of 1965, as amended
1
29. MEMBER moana I,' IndlYldual who IS contrlctullly Inlltlld
to "CIIYO Cove"d SI",'clI .".ngld by KHP Clnlr.1 undor
Ihls Agr.lmlnt
30 OUT OF AREA SERVICES .r. tho.. COYI"d SI""CII
prOYldld oull'dl KHP Clnlr.l'. S'''''CI Aru COyorld
Servlces ar. limIted to Emergency Services and Covered
ServIces that 8re .rrBnged or lutho(lz.d by a I<HP Central
Primary Clr. PhYSician and/or the KHP Central MedIcal
Director
31 OUTPATIENT meln. a Momber who reCIIY.. Covered
Services or OUppJIe& while not an Inpot,ent
32, PARTIAL HOSPITALIZATION mo.n. the proYlslon of
medIcal, nursing. counseling or therapeutIC Covered
Services on lJ planned and regulqrly scheduled baSIS in a
faCility licensed I:IS 8 substance abuse treatment program by
the Department of Helllth, deSIgned for a patient or client
who would benefit from more IntenSive Covered ServIces
that afd ottered In Outpatient treatment but who does nof
require Inpatient care
33 PARTICIPATING PROVIDER me.ns a phy.,c,.n, .lIled
hellth prof..Slon.I, HOSPlt." Skilled NurSing FaCility,
Rehabllltetlon Hospital, Horn. Healtl' Agency, or Bny other
health care lnltltutlon or practitioner, hcenud by the
Commonwealth at Pennsylvsnlll, With which KHP Central
h81 arranged to prO\/lde CO\lered Services to Members
34 PRIMARY CARE PHYSICIAN me.ns a duly licensed doctor
at medlc;ne or osteopathy who hal a contract With KHP
C.ntral under thil Agreement to supeNlIsI, coordinate and
provide hllllSI and beslc care 117 members, Initiate their
re'erral for a spectallst care and mamtaln continuity at
pat/flnt care
35, REHABILITATION HOSPITAL 's a f.c,I,ly Provld.r which IS
engaged In prOViding rehabilitation Services on an InpatIent
basts
36 REIMSURSEMEIJT VALUE me.ns the .mounl ch.rged or
the amount KHP Central has e)(pended for a particular
h.alth UNlee In the geographical area In which It 15
performed
37 SERVICE AREA rrleans the geographical areas as
approved by the State wllhln which KHP Central imanges
for prOVISIon of Covered Services 10 Members
38 SKIL\.ED NURSING FACI\.ITV . An ,n",tutlon. ur a d'stlnct
part of an institution, faCIlity, rest raclllty, or faCility ror the
aged, which IS licensed as a S~llIed NurSing FaCility by Ihe
Commo~w8alth 0' Penn,ylvanla and approved by KHP
Central
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39 SUBSCRIBER mlln. I Member who.1 Imploymlnl or
othor stllu" exclpt for f.mlly dopln~.ncy, ,. th. b..l. 'or
IlIg,blllty 'or Inrollmlnlln KHP C.ntrll
40 SUBSCRIBER DATA CHANGE FORM mlln. I form upon
which the wrltt.n lut'million to KHP Centr,' of ching.. In
Subscriber dltl .".clIn~ Member eligibility II mlde. Thl.
'arm may bl obl.'ned from the employer or directly from
KHP Clntrll
41 SUBSTANCE ABUSE . The u.. of "'cohol or other
addlctlye drugs which produces . pl~ern of plthol09,cl' use
c8uslng Impairment In soclel or OCCup8ltQnll functionIng or
wh'ch produces phtllolog,c.1 d.pend.ncy IVldenced by
phy.lcaltoler.ncl or wlthdrlw.l. Drugs sh.1I bl dlfined .s
addlcllYe drugl end drugs of Ibuse listed IS schedule~
drugs in the P.nnsyly.nl. Conlroll.d Subsllnces, Drug,
DeVice and Cosmtittc Act
42 3UBSTANCE ABUSE TREATMENT FACILITY. A flclllty
PrOY,der which IS Iicen.ed by tho Dep.rlment of He.,th .nd
approved by thl Joint Commls.lon on thl Accredllltlon of
Hosplt.ls and by KHP Centrll or Its deslgnla which ..
prlm."ly eng.gld In proYld,ng Dltoxlficltlon Ind/or
rehabilitation treatment for alcoholism and/or drug abuse
ARTICLE II . BENEFITS
Subject to the lerms, conditions, de'inltions and exclusions
speCified In thiS Agreement and subject to the paymtnt by
Memb.r. of the .ppllclble Cop.yments, If Iny, Members shill
he entItled to recelv, the Covered Service. listed below
3a""c.1 Will be covered by KHP Centrl' only If Ihay Ire
Medically Necessary, and, except for emlilrgenCles, are proVided
or authortzed by the Members Primary Care Physician or KHP
Central
OUTPATIENT SERVICES
1. ALLERGY TESTING AND TREATMENT Allergy I.sts and
testing matertal$ and treatment, when authOrized by the
Prtmary Care Pnysrclan
2 AMBULANCE SERVICES M.d!cally Necessary ambullnce
services when ordered or authorized by the Primary Car.
PhYSICian and KHP Central In an Emergency, the Primary
Care PhYSICian's prtor authOrization is not required
3 ANESTHESIA Anesthesia Services when per'ormed In
connection With Covered Servlce!l which hIve been
authorized by the Primary Care PhYSICian and KHP Central
4 CHEMO-rHERAPY F.derllly approved chlmother.py
drugs, the administration of thellt drugs and all !IIsacI.ted
s
'.... ......... ..'.
I.boret_" 1.Ila/proc.dure. wh.n p,oYld.d or .ulhollZ.d by
Ih. P"mllY CII. PhYIICl.n 'nd KHP C.nlre'
5 DIACNOIlTIC, LABORATORY .nd X.RAY IlERVICES
M.dlcllIy N.c...lry x.rlY end labor'tory tilts, proceduros,
IINIC'I Ind mlt.rllll. Including dllgnoatlc x.rIYI,
f1uorolcopy, and ellctrocardlogreml when lulhorlzed or
p.,formed by the Primary Clre PhYllclln and/or aulhorlzed
by KHP C.nl,al
6 DIAL VSIS Medically Necesury dlillyal5 servlcea when
luthoflz.d by the Primary Car, PhYSICian and approved by
KHP C,ntr.1 and when provIded lit the Ho,pltal. a
'r..-,tandlng renel dialYSIS raclllty which he, been approved
by KHP Cenlral or. With KHP Cenlral'a approval, In the
hom., In the CilI' of ham. dlllysls. UltVIC.. Wilt mclude
equipment. trllnlng. Ind medical supplies The r1'clslon to
purchls. or rent nlSe.uary equipment for home dialYSIS Will
bt mlde by KHP Central When Ihe Member becomes
tliglble tor MedIcare coverage of dialySiS. coverage Will bit
trenstlfred to Medicare coverage
7, HEARING SCREENING HeannQ ",..n,ng 'or d,aQno.I'lc
purposes, when prOVided or authOrized by the Primary Care
Physlclsn (See ArtIcle III. E)Ccluslons )
8 HOME HEALTH CARE Ca'. proYlded by home h.a'th care
personnel In the Member's home I' located Within the
Service Are.. determined to b. MedlclUY Necenary, and
au~ho(lzed by the Primary Care Phy"clan and KHP Centrul
Such care II limIted to 100 "IS ItS per calendar year PTlvste
duty nursmg WIll only be covered If speCifically approved In
Idlllnce by the KHP C.ntral Mf'dlcal Director Horn~maker
servlc.a or other non~medlc81 servlcea are not covered
9 HOME VISITS PhYIlr.18n vllltS to Ihe Member', home. Ir
Within the Service Are., when performed or authoftZed by
the Primary Clrt PhYSICian Members may be reqUired to
p.y a Co payment 'or each home VISit Please refer to the
Schedule of Copayments
10. HOSPICE CARE HOlplce care :servlcel\ for a terminally III
Member With a IIf. expectancy of SIX (6) months or less
when authoflzed by the Pnmary Care PhYSICIan Subject to
. 81neflt MI)Clmum of $7.500
11 IMMUNIZATIONS Med'cally Neces..,y adu't
Immunizations and pedlatrlr, ImmunIzations as prOVided tor
below when prOVided ar authOrized by the Primary Care
PhYSICian (8)Ccept those required for fCJrltlgn travel)
Coverage Will be prOVided for those child Immunizations
Including Ihe Immunizing agents. which as determined by
the Department of Health. conform With standardS 0' the
(AdvISOry Committee an Immunization Practices at thQ
C.nter for Disuse Control) United States Department of
H.lllh and Humlln ServtCII Coverage for these child
6
..,
".'..... ..
ImmUniZation, Will not bl subject to Cup.y",.nl' or B.no'lt
MUlmums
12 INDIVIDUAL CASE MANAGEMENT KHP Centrel m.y
elect to arr8ng. for IIrvlCe'l under thiS Subscriber
Agreement through prof.lllon.1 or faCIlity prOViders
pursuant to an IndlVldu.llzed trellment plan Any ,uch
arrangements shall b. made 1011ly at KHP Cenlrll's
discretIon and only when Bnd for 10 long as It d.termlnes
that Ihe 8110rn8tlv, "rvlces are Medlc.lly Necllllry .nd
cost effective In no event shall KHP Central bl obllg.ted to
prOVide such alternative servlCII It a totel COlt great.r thin
for servlcefl to which the Member would Qtherwlll be
entitled under thiS SublCrlblllr Agreement KHP C.,1I(lI'1
electIon to prOVide servlcel In slJch a manner Ihlll not
obligate It to contlm.:e to prOVide the ume or IImlllr
,eNICIS 'or that or any other mlmber
IllNDIVIIlUAllZATION OF BENEFITS Under c.rta,,'
Clrcumstancel, KHP Central may be able to arrange
alternative serviCes for Members by provldmg seNICl1 net
speCifIed In thiS Agreement KHP Cenlral may prOVide luch
alternative 18rvlCII at Its sole dll5cretlon. and (Jnly when and
'or 10 long as It determine' that the alternatlv, SONIC" are
Medically NeclUaary and cost effecllve The provlllon of
Bltornatlve UNIC.I In a speCifiC Situation ShIll not obllgete
KHP Central 10 provuJe the same or similar lervlce. in
another slluatlo~. nor ShIll It be construed as a Wllver 0'
KHP Central's Tight to administer thiS SubSCriber AgrHment
10 accordance With Its express terms
14 'NFERTllITY In'.rt,llly coun.e'lng, IlIt,nQ and "",IC..,
IOcludlng artifICial Inummatlon. but .)(cludlng !lJ i1t!.2
fertilization, sUbJer.t to a cClpayment 0' 50% 0' the COlt 0'
treatmllnt, With a Benefit MaXimum of $2.500. inr.ludlng
InJectables related to ,"fertility services
15 INJECTIONS ,nJeclab'. medlcat,on. '0' Ihe treatm.nt 0' .n
Illness or Injury administered '" a phYSICIan's office as
deemed appropTlate by tho PTlmary Care PhYSICIan
16 MAMMOGRAMS One ba.ellne mammoQ,am al or aner 35
years of age, one mammogram in ear:h cslendar year at 40
years 0' age and older. and additional mammogrlphy
5ervlces as authoTlzed by the Primary Csre PhYSICIan
17 MENTAL HEALTH CARE Outpatlenl manta' ha.llh ce,e,
85 determined by the PTlmary Care PhYSICian and KHP
Centrol andlor Its deSignated agent to be nec.Slary and
appropriate for short rerm eVAluation and/or CriSIS
Intervention, for up to twenty (20) ViSItS per Member In .
calend;ar year Each OutpatIent mental health VISit Will b.
subject to a Copayment Please refer .0 the Schedule of
Copayments
18 NEWBORN CARE Ca,a 01 . newborn child 0' a memb.r 'or
a period 0' lhlrty.one 131) day. lOllow,nQ b,rth, I' medically
7
n.c....ry .nd .pproY.d by Ih. Prlm.ry Cor. Phy"cl.n
Such care ,hill Include roulln' nu,..ry ClfI, prematuflt)
uNle,.,' preventlv, health Clrt seNICes, 81 well U5
cov.,.g. tor InJurv or 11Ine.,. Including the neclnory cort:
end treltm.nt C)r medically diagnosed congenlhll delecb
end birth abnormalities ContinUing care II cover~d only If
I) the newborn II !1.!.Sltl2.!! tor enrollment. b) thl newborn ~
IllL2!lIl1 w,lhln Ihlrty-on. 1311 d.y. 01 birth, and CI
Ipproprllt. premium payments from th. date or birth or!?'
recllved
19 NURSE MIDWIVES m. eONIC.O 01 . nu,," mldw,'. .r.
covlred whln 8uthOrllld by the Primary Cafe PhYSIClsn ana
KHP C.nlral
20 08STETRICAL CARE Ob.lelrlc., c.re Inc,udlng p'.- and
pOlt-natal elrt, complications or pregnancy and childbirth
Member' may be required to PlY a Co payment Plesse
r.t., to the Schedule at Copaym.nts or copay rid.rs (See
Artlcl. III, Exclullon. )
21 OFFICE VISITS Offic. v,"I. p.rfo,m.d or .ul""rlzed by Ih.
Primary Care Physician Menlbers may be required 10 pay
I Coplyment for ,"ch office VISit PI.lse refer 10 the
Schedul. of Copayments or copay rider.
22 ORAL SURGERY L1mil.d or.' ourg'c.' procedur.. In .n
Outpallent setting when approved by a Primary Care
Physician and KHP tttntral end required In connection Wllh
tho lollowlng
A Bccidental injUry to the JBW or structure, contiguous to
Ih. J.w, inc,udlng .ccldent.lln)ury to Ih. t.oth, provid.d lnot
cllr, or tr.atment IS sought Within twenty-rour (24) hours 01
the eccld,,"t causing such InJIJry;
B the correction of a non.dentll phYSiological condition
which IS resulted In severe runctlonallmpBlrment, and
C, treatment for tumors Ind cysts requiring pathological
examination or the Jaws, cheeks, lips, tongue, roor and tloor
ollh. moulh (5.. Article III, Exclc"ono)
23. PREVENTIVE HEALTH SERVICES Preyenl,ve neallh
SlNICII, including periodiC health ISsessm.nt., well child
Clr., ilnd periodIc Papanicolaou (PAP) te,ts, according 10
sch.dul.. .pproyed by KHP C.nlr.', wh.n proYldod or I
authorized by the Primary Care PhYSICian or when r
.uthorlzed by KHP C.nlr.'
24 RADIATION THERAPY R.dl.llon Iher.py ..NIC.O, when
provided or authorized by the Primary Care PhYSICian and
KHP C.ntrol
25 REFERRALS R.lerrol. 10 P.rtlcIP.tIng ProYld." whe"
luthorlzed by the Primary Care PhYSICian Rtferrals to
non~p8rtlclp.tlng specialists and other duly licensed allied
8
health care perlonnel Will be :overed only when luthorlzed
by Ih. Prlm.ry C.re PhYllcl.n I1.!llI KHP Cenlrol Self
refer rails are excluded except In the CBSe or Emergencltl
26 SHORT-TERM REHABILITATION THERAPY SERVICES
Occupational, phyftlcal, respiratory and speech rehabilitation
therapy on an Outpattent basiS, when authOrized by the
Primary Core PhYSICian and KHP Centrll The..
rehabilitation theropv Servlcel\ Ire limited to treatment for
condlttons which. 10 the Judgment or the Primary Care
PhYSICian and KHP Central, Will result In slgnUlcant
Improvement Then theraplel5 are limited to eo days from
Initiation of treatment per condition, per lifellme Short term
rehabilitation therapy seNlcel mclude
A Occupational Thor.py wll.n proYid.d by . Ilc.n..d
prOVider actmg Within the scope of IlJCh hcenle,
B Physlo.' Ther.py \Yhen proY,ded by . IIc.n..d proYlder
acting wlthm th~ scope of such license,
C R..plratory Thor.py wh.n provld.d by . IIc.n..d
pro....lder acting Within the scope of such hcense,
o Speech Therapy wh.n proYlded by . ',c.n..d proY'd.r
acting Within the scope of such Ilcenll; (S.e Article III,
E)(cluslons, )
27 STERILIZATION - Oulp.llOnl y...ctoml.' .nd lub.1
ligations are covered If Medically Necllsery, 8S determined
by the Medical Director
28 SUBSTANCE ABUSE. O'.goo", .nd m.dical Ir..lm.nl
for the 8bu~~ of or addiction to alcohol or drugs when
determmed to be Medically Necessary and rererred by the
pmnary Car. Phy"cl.n .nd .pprov.d by KHP C.ntrel
and/or Its dlllgnated 8Qe"t, to Include
A Diagnostic ServiclI, Includtng psychiatric, psychological
and medical laboratory test,
B S.Nlce. proYlded by a olaff PhYllcl.n, P.ychologlol,
Registered or Licensed Practical Nur.., and/or Certified
AddictIons Counselor:
C R.habllltallon Iherapy .nd coun..ling,
o Family counseling Bnd Interventiol';
E Drugs, m.d,clne., .uppli.. .nd UII 01 .qu,pm.nl
pro....ld.d by a Substance Abuse Treatment FICillty
SeNlces for treatment of all forms of Substance Abuse Irt
limited 10 sixty (60) oulp.tl.nl Full S...,on VlOlt., Equly,'ent
PartIal Session Visits, or Partial Hospitalization Sessions
per y..r, with . IIlelim. limit 0' on..hundred .nd tw.nty
(120) Full 5",'on VII,I. E.ch EquIY.I.~1 P.rt,., S...'on
VISIt will count as one-hair VISit 8galnlt the annUli maximum
9
01 .lldy (60) Oulp.llOnl Full S...,on VII,I. In .ddlllon.
thirty (30) Oulp.ll.nl VIr,I. or P.rtlOl Ho.p,lallz.llon
S...lona per cII,nda, Y'" may b. l.cl'llnged on a
two-for.one bl.11 to IIcur. up to fltt..n (15) additional
non~hollplt.l, rtlld.ntlal subst.nce .bulI tr.atment day"
which ere In addition to the annuli and "'etlme mOXlmums
d..crlb.d In Art,cl. II, INPATIENT SERV,CES Qulp.t,enl
sub.t.nce abule treatment Vllltl may be subjlct to a
Cop.ym.nt Pi.... re'er 10 th. Sch.dul. 01 Copaym.nl.
(5.. Artlcl.llI, Exclullon,)
29. SURGERY Surgical "rYle.. required lor treatm.nl of
dl..... or Injury wh.n .ulhorlzed by Ih. Prlm.ry C.,e
Phy,'ci.n and KHP C.nlr.1 .nd p.rlorm.d by . KHP C.ntr.'
P.rtlclp.ling Provld.r .nd .1 . KHP Canlr.' part,clp.ling
I.clllly, Non.p.rtlclp.llng provld." or f.Cilll". m.y be
.pproved by th. M.dlc.' O".clor .nd/or KHP Cenlr., ,r th,
required .,rvlell ar. not 11/111.ble from participating
providers or fleWti...
30, VISION SCREENING VI.lon .c".nlng 'or dl.gno'I,e
purpo... wh.n proYidad by Ih. Prlm.ry C." Phy.,c,.n
(S.. Artlcl.llI, Exclu.,on.,)
INPATIENT SERVICES
ANESTHESIA An..th..,. "rYic.. only wh.n p.rlormed '"
connection with Cover.d S.rvice. which have been
aulhorlzed by th. PrimOlY C.re Phy,'cl.n .nd KHP Cenlr.'
2 CHEMOTHERAPY F.der.lly .pproved ch.mother.py
drug. .nd .11 ...ocl.led I.bor.lory I..I./procedu". when
proYld.d or .uthorized by tho prlm.ry C.r. PhySiCian end
KHP C.nlr.'.
3 DIAGNOSTIC, LABORATORY AND X.RAY SERVICES
Medlc.lly N.c....ry x-r.y .nd I.bor.tory 1..1., proc.dur..,
"rYlc.. .nd m.l.rl.,., Including dl.gno.t,c x-r.y..
nuoro.copy, .nd ,'.ctrocO/dlogram. wh.n .ulhorlz.d by Ihe
Primary Car. rhy,'cian ,nd KHP C.ntrol
4 DIAlYSIS M.dlc.lly n.c....ry dl.,y.l. IOrYica. and
.uppll.. wh." .uthorlzed by th. Prlm.ry C.ra PhYSlc,an
.nd .pproved by KHP C.nt", Whon Ih. M.mber b.comas
.lIglbl. for M.dlc.ro cover.g. of dl.'ysl., KHP C.ntra,
dlIIY'11 coverage will b. transterred to MedICI" cov~rage
~ DRUGS AND MEDICATIONS Drug., m.dlcal,on., and
inJ.ctions rec.iv.d end used IS In Inpatient In connectIon
wllh Covered S.lYIc.. which h.ve b..n .ulhorlzed by the
Prim.., C.ra Physicl.n.
6 HEARING SCREENING H..rlng Icra.nlng for dl.gnost,c
purpOl1I when provided or luthoriz.d by the Primary Care
Physlcl.n .nd KHP C.nlr.I, (S.. Artlcl. III, ExclUSion. )
10
7 HOSPITAL Unllm,t.d ,np.tlOnt d.y. In . Ho.pU.' 'or
Medically Nee....ry treatment when .uthorlzld by the
Primary Clre PhYllclan Dr KHP Centre I. 'lCC.pt II noted
herem for Inpatient mental healt" "NtCII Bnd ahort-term
rehablhtalive Service, (Sue Inpatlflnt Servlc.s, Artlclft 11(21)
IInd (24) 1 ElCC.pt 1M Emergencies, Hospital admissions
must be coordln.ted through the Member's Prrmary C.re
PhYlllclan When authOrized by the Primary Clre PhYSICian
end KHP Centrll, covered Hospital Services rnclud.
A Semi-private room and board (or prlvat. or specl.lty
accommodations when certified .5 Medically Necessary by
the attendmg phYltclan, the Pnmary Care PhYSICian and
Kf-'P Cenlral)
B General nursing care
C Pnvate duty nurf,lng care when MedlcllIy Necessary
and autnonzed by the Primary Care Physlclln and KHP
Cenlr.,
o Drug" medications, and bl~IQgicall.
E Me.'s (Includlrtg .p.cl.1 dlOt. wh." M.dlc.lly
N.c....ry)
F Use of the Qperatlng room and related faeillties,
G Use of IntenSive car. or cardiac units Bnd related
SeNlces
H Oxygen SeNI':lIs.
I Adm,n"tr.t,on of whol. b'ood .nd blood pl..m. 10
",clude tho processing and preparation
J M.dlc.lly N.c....ry .uppll.., .ppll.nc.. ."d
.qulpm.nl (5.. Art,cl.III, ExclUSion.)
.
8 IMMUNIZATIONS Medlc.lly N.c....ry .dull
Immunizations and pediatriC immunizations as pro....id.d for
below when prOVided or authOrized by the Primary Car.
PhysiCian (except those required for foreign travel)
Coverage will be provhJed for tnos8 child Immunlzltlons,
Including the ImmunIzing agunts. which, as determined by
the D.~.rtment of H..'th, conform wllh st.nd.rd. of the
(Advisory Committe. on ImmUnization Practices of the
C.nter for 0".... Conlrol) UrtIt.d Stal.. O.partm.nt 0'
Health and HumIn SeNic.s Coverage for these child
immunizations wlll not be subject to Co payments or Benefit
MaXimums
9 IMPLANTABLE DEVICES Surglc.lly Impl.nl.d pro.lh.tlc
devices wh.n determined to be Medrcally Necllllry by the
Prlm.ry C." Phy.lcl.n and KHP Canlr.' (5.. Artlcl. III,
ExclUSions. )
II
10 INDIVIDUAL CASE MANAGEMENT KHP e.nt,.1 m.y
Illct fa .rreng. tor ..NICtl under this Subscflber
Agreement through prof.Ulonel or facilIties providers
(pursuent to In Indlvldulllzed !r..tmen! plan) Any auch
Irrangem.nts shall be midi sollly at ~HP Central's
dllcretlon and only whln end tor 10 long I' It determmes
Ihlt thl allernltlve .lrvlcl. er. Medrc811y Necesssry and
COlt effectlv, In no event 'hili KHP Centrll be obligated to
provIde such IItern8tlvI '.""ICIS .t a total COl5t grelter than
for IINICI. to which the Member would othel'Vv'lse be
.nflUed under thll Subscriber Agreement KHP Central's
fl.ctlon to provide "Nitti In suen 8 manner shalt nol
obligate it to conttnue to provide the I8me or Similar
urvle" tor tha,' or any other member
11 INDIVIDUALIZATION OF BENEFITS Un~er certain
clrCUmstlnell, KHP Central mlY bll abt~ to erring. more
IfflctlVI medlcll care tor Members by providing ser\llces
not Ipeclned In this Agreement KHP Central may provide
such Ilt.rnat,.... servlcls at It I sole discretion, and only
wh.n Ind for so long I' it d.termlnes that the altern Clive
servlCIS ar. MedlclIlIy N.c....ry Bnd cost eff.ctl.... The
pro...illon of Itternltiv. S.rvlCes In II specific Situation shall
not obhglte KHP Clntrl' to pro"'lde the I8me or Slmltar
servlc.s In Inotl,., litulltion, nor shIll It be construed as a
Wllver of KHP Centre", right to Jdmlnlster thiS SubSCriber
Agreement In aecord.nc. With Its exprlll terms.
12 INPATIENT PHYSICIAN CARE G.n.rally .ccept.d and
Medlo.lly N.c....ry h..lth IO"':CO$ p.rfo,med, pre.crlbed
or IUPlrvislId by physicllnl within. hOlpltl1 for r'glstered
b.d pltl.ntl, Inctuding dlegnostlc end ther.p.utlc care
13. MENTAL HEALTH CARE Inp.lltnl m.nt.1 h..llh car.
s.rvlclS In e Pro'lIder f.cUlty whln authoriz.d by the
Pnmlry Cere PhYSICian and KHP Cenlral andlor Its
dtslgnlltd .g.nt, I,mlt.d to thirty (30) Inp.tltnt d.y. per
M.mb..ln. col.nd.. y... (5.. Art1CI.1I1, Exc,uSlon.)
14 NEWBORN CARE e..e of. newborn ohlld of. member for
. p.rlod of thirty-on. (31) d.y. 'ollowlng birth, 'f medlc.lly
n.c....ry Ind Ipproved by thll Primary Clre PhYSICian
Such clre ,hili Include routine nur..ry Clre, prematurity
"rvlc", prevenltv. h..lth clre ,.rvic.., IS Will 85
coverage for Injury or IIIn..s, IncludIng the nec.llary care
Ind tr.atment of medic Illy dl.gnotltd cO'1glMal defects
and birth abnormlhtle. Continuing car. II cov~red only It
.) the newborn I. l!llI!RlI for en,ollm.n!, b) tho nowborn !l
I.!l.C9llIll within th'rty-on. (31) d.y. 0' b,rth, and cl
Ipproprllt. pr.mlum paym.nts 'rom the date of birth Bre
"CIIVed
1 ~ NURSE MIDWIVES Th. .."'".. 0' a nurse midwife are
covered when authOrized by the Primary Care PhYSICIan and
KHP e.ntrel
12
...,.
16 OBSTETRICAL CARE Ob.tetrlco' cere 1"cludIMg prt- .nd
pOlt.natal C8rt, complications of pregn.ncy and childbIrth
(See Art,cle 1'1, Exc,'",on. I
17 ORAL SURGERY L'mlled or., .u'g,c.1 procedur.. wn.n
appro...ed by the Prlmery Car" Physlclln and KHP Central
and requited In connection With th. follOWing
A aCCidental Injury to the Jawor structures contiguous to
lhe J.w (exc,ud,ng I..thi.
e the correction Q' a non-dental phYSiological condition
which has resulted In a severe 'unctlon.llmps,rment, Ind
C treatment for tumors and cysts requiring pathologlcsl
examlnallon of the Jaws. Cheeks, I'ps. tongue, roof and noor
of the mouth
18 ORGAN TRANSPLANT Med,c.liy N.c....ry
transplantation SlNICII for member reclPI.nts wh.n not
deemed to b. Expertm.ntal/lnv.lllgatlonal end authorrzed
by the Prlm.ry e.rt PhYSlc,.n .nd KHP e.nlrel
Determination of medical neceulIy shill alia tak. Into
account the procedure's sUltabUlty for the pot.ntlll member
and availability of approprtlte 'acihtles for performing such
procedures KHP Central may arrange 'or c.rtlm trenlplent
procedures In accordanc. with UI' Indlvidul' Clse
Management prOVISIon of thiS Agreement SeNlces requltlld
by a Member relat.d to organ donation wh.n the Member
serves 8S the donor are not covered (5.. Article Ill,
Excluslona)
If not paid for by .ny oth.r .ourc., Ih. following ..",Ic.. of
donors donating orglns to Member reclpllntl Ire cov.red
A the removal ofthl org.n from the donor,
B donor pr.p.r.tory p.thologlc .ndlor m.dlc.1
examinations,
C donor post-surgIcal clre
19 RADIATION THERAPY Rodl.tlon th.repy ""'10" wh.n
prOVided or 8uthorlzed b1' the Primlry Care Phyt1clln Ind
KHP eenlrel.
.
20 REFERRALS R.f.".I. to p.rtlc,p.tlng .p.clolllt. wh.n
.uthoroztd by th. Prlmory C.re Phyllcl.n R.ferr.l. to
non,p.rt,c'p.tlng .pecl.II.t. ."d other duly IIc.n.td .lIItd
h..lth cert p.rsonn'l will b. COY.rod only wh.n .uthorlZtd
by tn. Prlm.ry Cere PhYSlclln .nd KHP C.ntrel
21 SHORT-TERM REHABILITATION THERAPY SERVICES
Occupellon." phYllc.l, rtsp".tory on~ Sp_h roh.blll!lllon
thtr.py on an Inp.tltnt bill', wh.n .uthor,ztd by the
Prlm.ry e.re Phy.lclln .n~ KHP C.ntr,'. T~...
rehlbllltatlon therlpy '.rvlell Ire limited to tre.tment tor
cond,tlcn. which, In Ih. judgm."t of the prlm.ry e.re
IJ
Phy,'cl.n .nd KHP C.ntr.I, will r..ult In IIgnll,c.nt
Improy.m.nt Thll. th.r.PI.' .re Ilmilod to 60 d.V' Irom
InltllUon of trlltment plr condition. per lifetime Short term
rthlblhtltlon therapy lervlC'1 Include
A OcCup.llon.1 Th.r.py whe" proYld.d by . licensed
provider .cllng within the Icope of such Ilclnsl,
B Phy.lc.1 Th.,.py wh.n proYld.d by . lic.n..d proYlder
.ctlng within the Icope of such Itcenu.
C R..plrolory Th.r.py when proYld.d by . "censed
provider Ictlng within the scope of such Ilc.nse,
o Spooch Th.ropy wh.n proYlded by . licensod proY'der
tcllng within the scope of such license (See Article III
Exclu.lon.)
22 SKillED NURSING FACiliTY SERVICES Sklllod NurSIng
F.cIIllV S.",'c.. up 10 160 d.y. per Y.lr wh.n .uthorlzed
by Ih. prlm.ry Cero Phy.,cl.n .nd KHP C.nlr.' Ch.rge.
which relDte to non-cuatodiel clr. Ind Covered SeNlel1
which Ire MedtcIlIy N.CI.llry end not I)(cluded elsewhere
In this Agr..mt"t (II' Artlcl. III, Exclusions) a,. CQvpred
CUlled", or domlcWlry Clr, In I Skill.d NurSIng Facility or
ellewher. II not covered Benetits are IImlt.d to semi-
prlvlt. Iccommodltlons or In IIUOWlnCe equI' to the
tlclllty'. mo.t frequ.nt ..llbll.h.d ch.rg. 'or seml,prly.,e
Iccommodeti"ns which mlY be applied to the cost of
prlvete iccommodltlons
23 STERiliZATION Inp.tl.nt y.secloml.S Ind lub.lllg.'lo",
.r. cover.d only If Medically NecesSlry, 81 determined by
the Medic,.1 Director, or If the procedure Is cOincident With
hOlpltllizltlon for another relSon (Ie, post-partum tubal
IIg.llon),
24 SUBSTANCE ABUSE Ol.gno.', .nd .hort-I.rm m.d,ca,
treltm.nt tor the Ibu.. of, or Iddlctlon to, .Icohol or drugs
includIng Detoxification, in In acute care Hospital or a
Sub,'.nc. Abu.. Tr..tm.nl Flclllty 'or lh. .bu.. 01 or
oddlctlon 10 .Icohol, whon d.torm",.d to b. M.d,cally
Nee....ry ond .".ng.d through .pproprlll. "t.,,"1 by the
Primary clre Physiclln, AI 8 .eparate benefit.
non~medlcel, rehabilitatIve servlclS for substlnce abuse will
b. covered In a Subslllnce Abu.. Treatment FICllity when
determln.d 10 c. Modlcllly N.c....ry .nd .".ng.d through
Ippropri.t. "",,"1 by tho Prlmory C.r. PhYSlcl.n
Inp.tl.nt e.n.m. ",clud.
A Oolo.llIc.t,on:
e \.odglng Ind Ol.'ory S.rvlce.,
C DiOgno.,lc S.""".. Includ,ng p.ychl.trlc, p.yoholog,cl/
.nd modlc.ll.bor.lory t..I.:
14
. . . . ~.' ~,",. ....' r
-'
o S.Nlc.. proY,d.d bV . .t.tI Phy.ic,.n, PsychologlSl,
R.glSter.d or l,,,nsed Prlctlc.' Nurse, .nd/or C.rt"lId
Addlcl,on. Couns.'or,
.
E Rehablhtltlon therapy and counseling,
F Family counseling and mterventlon,
G Drugs, mediCines, supplies and use of equipment
prOVided by the Substence Abuse Treatment Facility
For all forms 0' Substance Abu.e, the detoxification ben.flt
1$ limited to no more than &even (7) days per admiSSion and
four (4) admllllons per lifetime Similarly, the rehabilItative
Servlen benefit IS limited to thirty (30) d'lYs per yellr In a
Sub~tance Abuse Treatment FaCIlity, With a hfetlme limit of
nln.ty (90) d.y. (S.. Anlc,. 'I'. Exc,uSlona)
:25 SURGERY Surgical services re~ulred for treatment of
disease or injury when authortzed by the Primary Ctlre
PhVSlcl.n .nd KHP Cenlr., .nd p.rform.d by . KHP C.ntr.1
participating prOVIder and at 8 KHP Central participatIng
facility Non-participating pro"lders or facilitllS mey b.
.pproved by Ih. Medlc.1 Dlr.clor
26 VISION SCREENING VISion scre.nlng 'or dl.gno.tlc
purposes when prOVided or authOrized by the Primary Care
PhYSICian .nd KHP Cenlr., (Se. Article III, ExclUSIon.,)
EMERGENCY SERVICES
.
Within the :S.rvlc. Ar... Medl.::al care IS available through
KHP Central Primary Care Physlclsns 7 days a week. 24
hours a day Under almost all circumstances, the Member
must obtain treatment or authortzatlon for treatm.nt from
the Primary Care Physlclin or his designated covering
phYSiCIan
In the e".nt the member experlerces In Emergency
condition, the member should contact theIr Primary Care
Physiclsn If they cannot, the Member should seek medical
care from the most readily available sourc'
II 8 Member obtains cart In whyt th.y bell,,,. to b. an
Emergency Without obtslnina authOrization from the Prtmary
Care PhYSICian, the Member Will be requested to provide
information about the occurrence KHP Central will then
review the flcts of the sltultlon lInd the nllure of the
services provided Only if KHP Central determlntl the
UrvIC'S constitute 8n Emergency I' defined In thiS
Agreement Will charg.. Incurred b. co"."d Each
emergency room VISit shill be subject to . copeymln'
Pl.... r.'.r to Ih. Schedul. 01 Coplym.nt.
An Em.rg.ncy 10 .n .ccld.nl.1 Injury or Ih. .udd.n
on..1 01 . condlllon which po..o . .Ignlllconl Joop.rdy
10 Ih. M.mbo,'o h..lth, requlrlnglmmodl.l. modlc.1 or
,u'glc.1 c.r.. H..rt .IIICk., .Irok.., pol.onlng., lOll
of con.clou.n... or ".plretlon, and convul.tona .r.
.umpl.. 01 modlc.' .m.rgonel..,
I~
!
;i
i
~
f'
2 Oullld. Ih. SI",le. A.... Subj.elto Ihl Conllnulng C.,e
prOyl.,on. III 'orth bilow, thl ch.'g.. 'or Med,e.lly
N.CI..lry Covered SeNlc" whiCh .r. the relult or IIn
Emerg.ncy occurring outSIde the Service Area are covered
only It, In Ihe delermln.',on 0' KHP Cenlrll
(1) the Member could nol hlye antlclplt.d the need for
'uen .eNle.. prior tu l.ilMng th, Servlc, Area, and
(2) d".ylng c." unlll the Member could b. expecled to
r.turn to the clre of the Primary Caf. PhYllclan might
IIgnlficlnlly j.operdlz, the Memb.rs h..llh or life
3 Continuing elr.. Services of any PrOVider other tllan Ihf,J
Pnme'Y Caf. Physician Will be covered only until the
Member eln be traMf'fred, without medically harmful
consequences. to the care or the Member's Primary Care
Physlcl.n 0' . speclollsl deSlgn.ted by the Prlm.ry Car.
Physlci.n
ARTICLE III - EXCLUSIONS
Th. rollowing ar. excluded from coverage under thiS
Agreement
S.rvlce, or supplill which af.
(A) not provided by or .uthoriz.d by the Prlm.ry C.,.
PhysiCIan;
(6) not Medlc.lly N.c....ry, u d.termln.d by the Primary
C." Phy,'cl.n .nd/o' KHP Centr.l, 'or th. dl.gnoSls or
tr'ltment at illness, injury or restoration of phYSIological
functlc.ns
2 The cost of services or supplies Whlc.:h are payable under
Worker's Compensation or employer's liability lav..s or other
legislation of SimIlar purpose.
3 Care for military service conn~ct8d disabilities and
condItions for which the Member IS legally entitled to
..rvlces, IInd for which faCilities are r.aso"ably acceSSible
te the M.mb.r
4 Clr. for co"dltlons thlt fed.rll, stlte or local law reqUIres to
b.t".t.d ,n . pubhc t,cil"y
5 Th. COlt of servlc." covered under the Medicare Act when
MedlClre IS primary In such situ It Ions, KHP Central or Its
d'llgn.. Will file the Member's Medicare claims tor health
IIrvtC" Medica,. will pay KHP Central or Its deSignee
dlr.ctly Howev.r, If for any reason Medicare pays the
Member directly, KHP Central or Its deSignee will bill the
M.mber for the amount to which the Member 15 lIJntltled
16
,." .,- .".., ,-"
under M.dlcl" How.yer. thiS .xelullon .hlll not Ipply
when th. group IS obllgllld by I.w to oHlr th. Subs.llber .11
the benefIts of thus contract anr1 the SubSCriber so elects thIS
coversge 13S prtmary
6 The COlt of Hospital, rnedlcBI or other Covered SeNlc,s
resulting from Bccldlnt.1 bodily InJurl" arising out or a
motor vehICle aCCIdent, to the extent such ben.flts Ir.
payable under any medical expense paym.nt proviSIon (by
whatever terminology u!ild, Including such benefits
mandoted by law) or any automobile Insurance poliCY unless
otherwlls8 prohibited by applicable law
7 Dental cure, pertodontal care, Including but net limited to
treatment of tho teeth, e""rnctlon of teeth, treetment of
dental abscel5Ses or granuloma, tr.atment of glnglvll
tiSSUes (other thin for tumors), dental ,xamlnatlons, and
Bny other dentel product or servlc, unlell specifIcally
prOVided el~ewh.re In thiS Agreement Anesthesia and
facUlty charyes. related to ntIM-covered dental serv;ces shall
not be covered
B Any serviCes related to and rendered tn connection with I
non.covered service shill not be covered
9 Treatment or temporomandibular Jotnt syndrome (only
evaluation covered) If dental In nature or not Medically
Necenary as determined by the Primary Care Physician
.nd/or KHP Cenlr.l.
10 The cost of any l:.xperlmentalJlnvestlgatlve medlcll,
surgIcal, or other hes:th car. servIces, proc.1dures or
supplies, Including org.n transplant procedures deemed to
be ExperlmentelllnvestlgatlV. will not ba covered.
11 Routine physical examination and pr.paratlon of specialized
rllports solely ror Insurance, licenSIng, employm."t, or other
non-preventive purposes, such as pre-marital examinations,
phYSicals for collegllt, camp, sport or trsvel, which are not
Medlc.lly N.e....ry
,
l
12 Cosmellc surgery. defined IS any plastic surgery don.
prlt'narlly to Improve the appesrance of IIny portion of the
bOdy, and from which no Improvement In phYSiologic
functIon could be reasonably expected
13 All reh.billt.t,v. therapy exclpt .. due'ibld in this
P,g"emenl, Including but nolllmlt.d to pl.y Ind "c""tlon"l
ther.py
14 All routine viSIon and hearing .x.mlnltlons and I8Mc..
except i1B described In thIS Agr..ment
15 He.ring .,ds, .y.gl....., eonll:! I.n..., or the fitting
thereor
16 Acupuncture
11
17 R.d,.1 kor.totomy
'8 M.nt.1 h..lth/.ub.t.nce .buII ..rvlC., th.t .re not coyor.d
Includ. biofeedback, chronic cer" court ord.red care,
Including el" IS . ccmdltlon of plrol. Of prnbltlon.
.ducatlonBI testing. .vllu.tlon tettlng. hypnosll, Interpreter
..rvlell, methadon. mltnt.nance ment.1 retardation
"Nlctl, psychologlca' t.sttng and 8","I,on defiCit disorder
and oth.r '..'ninO dlsabllltle'
19 Immunllltlons required for foreign travel
20 CUltodll1 end domiCIliary care, resid.ntllil cere, protective
end supportive car. including educational seNICes, rest
curti, convaleae'nt care
21 Weight redUction programs, including 811 diagnostic testing
rel.t.~ to w.lght r.duct,on progr.m.
22, Perlonel or comfort items, Including but not limited to,
admilllon kltl, slippers, television, telephone, air
conditione's, humidlf".rs. barber or be.uty servleell. guest
service end simile' incidental services and supplies which
a.. not M.d,c.lly N.c....ry
23. Norm.1 d.llyori.. outSide th. S.rvic. Ar.. Within thirty (30)
d.y. of lh. IXp.ct.~ d.I,y.ry d.t.
24 Any procedure or treatment deSIgned to slter phYSIcal
ch.ractensttcs of the Member to those of the opposite sex.
and Iny other trutm.nt or studl" related to 58X
trlnaformationa.
25 Treltment of bunions (except cspsular or bone surgery), toe
nllll, (except surgery for ingrown naUs), cornEl, calluses,
f.U.n Irches, flat reet. woak teet. chronIC foot strain or
symptomatic complaints Clf the (.et, unlell, deemed
M.d,c.lly N.c....'lI by tho pnm.ry C.r. Physlc,.n and
KHP C.ntr.I,
28, Contraceptive devic.., Including their Insertion a"d
,mplant.tlon, and birth control pIli,
27, In Yltro t.rtili..t,on, .mbryo tran.pl.nt.
28, R.versal of VOluntary sterilization
2ij S.rvlclI or ,uppll.. for which th.r. is no l.g.1 obllg.tlon on
tho part of tho M.mb.r to p.y
30, Exc.pt II sp.clflc.lly proYld.d for In th,. A~r.sm.nt,
prosthetic dtvicII, horn. medical equipment. durable
m.d,c.' .qulpm.nt .nd .ppll.nc.., Including hu'th
.ervlCIS Issociated with such dtvlCII
31 Prescribed drugs 8nd medIcations, except those whIch are
.dmin,.tor.d to .n lnp.ti.nt or ... provld.d by . Sub,t.nc.
Abu.. Tr,.'m.nt F.clllty
18
..'....,.,...". .
32 Ambul.nc. ..rvIC.., un,... M.dlc.lly Noc....ry II
d.torm,n.d by th. Pnm.ry e.r. PhYSlclIn .nd KHP C.ntrll
33 Whol. blood, blood pl..m. or blood compon.nt.
34 Servlce~ reqUired by I Member re'ated to organ donation
where the M,mber IIrvea althe organ donor Expensll for
donors donatIng organs 10 MlImbers ar. covered only I'
deSCribed In thiS Agreement No payment Will bo mlde for
human organs WhIch are sold rather tl18n donated
35 Court ordered servtCta when not Medically Necessary. II
determined by the Primary Care PhYSICian and KHP Centr.1
36 Charges 'or completion of any Insurance form
37 Any Services. supplies or treatments not speci'lcally listed in
thiS Agreement. except those reql.llred I)y the Pennsylvanll
Department of Health as bllllC health services
38 Artifici.1 h..rt.
39, Surglcel oper8tlons or procedure, for correction of Obesity,
,nc,uding but not Ilm,t.d to g..trlc ".pllng or b.lloon
procedures
40, Inferttllty injectables or other suppllls and drugs prelcnbed
on an out-patient baSIS for or In connection wIth IIrtlficl.'
Insemination
41 Grov..1h hormone,. unless determined to b. Medlc'lIy
Necessary by KHP Central
42 S.rvic., for .I..p dl.ord... .nd .l..p thl/.py
43, Private duty nuraes, except IS specified tn thiS Agreement
44 Ch.rg.s tor f..'ur. to k..p . .ch.du,.d ,ppolntm.nt
45, Any se!"VIces related to InJUrlll Incurred whll. committing I
r.'ony
ARTICLE IV . GENERAL PROVISIONS
ELIGIB,UTY AND ENROLLMENT
A, The Sub.crlber, To b. .I'g'ble to b.. SUb,crlbl/, .n
,nd'Yldu.1 mU'1 re.ld. in . KHP C.ntr.' S.rvle. Ar.. .nd
(1) li.. m.mbl/ of .n .lIglbl. Group who I. .ntitled
to p.rt,c'p.t. In h,s Group'. h..lth b.n.nt. proprom,
,nc,udlng comph.n". with .ny prob.tlon.ry or w.,tlng
p.nod .,t.bll.h.d by tho Group, .nd/or
19
(2) be entltl.d to coverage under B trust sgre.ment or
.mployment contrsct. and/or
(3) hovlng boon 0 Sublcnbtr, loove . Group and
continue KHP Central coverage without Intenuptlon
B, Eligible Dependentl, To be ehg'ble to be onrolled .. .
M.mber, I D.p.ndent 0' . Subscriber mUlt meet .11
.lIglblllly requ,,"mentl ell.blllh.d by the Group, bo h.led
on 8n EnrollmenUChange Form completed by Ihe
Subscriber, and bit
(1) The Sublcrlber'. leg.1 .pouse, or
(2) an unmarried dependfilMt child (Including natural
child, legolly odoplOd child, or .tepch"d) or IIlher Ihe
Subscriber or the 5ublcrlb"r's spouse, who IS under Ihe
age or 19 years or age Additionally, a dependent child
shall Include I chIld for whom the Subscriber or
Subscriber's spouse Is a court-appointed guardIan, or
(3) an unmarried Dependenl child 19 yea" 0' age or
older, who, In the JudglTlent or KHP Central, IS Incapable
of selt81upport because of mental or phYSical handicap
(for which continuing justification IS reqUired) and whose
disability occurred prior to age 19, or
(4) on unm.rrled Dependent child, between 19 .nd 23
years at ag.. who rosldes II"! the Service Area and IS a
rull8time student enrolled in and attending an accredltel;1
educational institution.
KHP Central may require approI', llle proot ot a Dependent's
It.tUS before enrolling ..Id Dependent
C;, Newborn children, Newborn children or a Member are
covered under thll Agreement for the ',rst th'rty-one (31)
dOYI Immediotely following birth Coveroge .n.. lhlrty-one
(31) deys is contingent upon the newborn be,ng eligible for
enrollment Ind the Subscriber enrolling the newborn child
018 Depondont wllhin Ihe thirty-one (31) day perl on and
paying any applicable premium charges due.
D, Enrollment.
(1) Inltlll Enrollment. DUring Ihe '",l'a, Group
Enrcllment Period, each .I'glb'o omployee shall b.
entltlld to apply 'or coverog. for h,mself ann ellglb'e
Dependents whO must be listed on the
EnrollmenUChango Form prov'ded by KHP Central No
proof 0' ,nsurob,nty ,hall b. req,,,ed
(2) Newly Eligible Employ", Eoch new emp,oyee
0' tho Group entering employmont subsequent to lho
Group's initial EffectIve Oate at Covltrage shall be
permitted to appl! ror cov.rage ror hlmselt and eligible
Doplndonts wlth,n thirty-one (31) days of bacomm9
20
eligible. subject to the enrollfTlent regulations In ,ffect
With the'Group, Without proor at u1lur,blllty
(3) Newly Eligible Dopendentl, Any person
attaining eligibility to become 8 Dependent may be
enrolled by the Subscrloer t1y con'lpletlng and submIttIng
to KHP Central II Signed EnrollmenUChanglt Form Within
thirty-one (31) days of Ihe Dependent's atta"'" .I~
eligibilIty No proof or Inl5urablllty shall be reqUIred
(~) Group Open Enrollment. A Group Open
Enrollmo~t Period shall be hreld 8t leasl, annually at
which ftme eligible Subscribers andlol' eligible
Dependents may enroll as Members under Ihls
Agreement No proof or Insurablllt.y shalll'l. reqUIred
(5~ Llmitlltlon. Persons Initially or newly eligible for
enrollment who do not enroll wlthrn thlrty.one (31) days
of becommg ellRible, or already-elIgible Dependents who
do not onroll dUring a Group 'Jpen Enrollment Period
may only be enrolled dUring a subsequent Group Open
Enrollment Period Exceptions may be made only by
wmten con!\ent or the Group and KHP Centrel
E, Nollce 01 Ineligibility, It ,holl be the Subsc"bor'. or
Group's responSIbility to notify KHP Central 01 any changes
which Will affect the Sub,r.rlber's eligibility or that or
Dependents ror ServIces c:lr Benefits under this Agreement
Failure or the Subscriber or Group to notify KHP Central
WIthin thIrty (30) days ot any such changes shall render
SubSCriber Bnd Group liable tor any costs 0' Services or
Benefits prOVided by KHP Central after the Subscriber or a
Dependent became Ineligible to cOrltlnue coverage under
thiS Agreement
F, Rul.. 01 Eligibility, No person will be reru..d
enrollment or re~enrollment by KHP Central becauSl! at
health status. age /except as prOVided in ArtIcle IV, Section
18.). requirements tor health Services, or the eXistence, on
the Effective Date or Covarage under thiS Agreement. or a
pre-existIng phYSical or mental condition, Including
pregnancy In addition, no Member's coverage shraJl be
terminated by KHP Central due to health status or health
care needs
2 EFFECTIVE DATE OF COVERAGE
A, Subject to the paym.nt or applicable prom'um
payments by the Group for the IndiVidual, KHP Centrel',
receipt ot an EnrollmenUChange Form rrom or on behaU or
each prospective Member Bnd the provillons of thIS
Agreement (except as may be otherwise prOVided In the
Group Contract), coverage under this Agre.em.nt shall
hecome effective on the earliest or the followIng dates
(1) When a person mllkes written Il:lphcation tor
membership on or prior to the date he sati,fiea the
21
tllglblllty requlrementl of Article IV, Stctlon 1, cover.g.
'hili bl Ifflcllve .. of Ihe dill Ih. IlIg'b'hly
requlr.ments are 'atllfled
(2) When a person make, wnnen applicatIon lor
memberlhlp Inlr the date he IItllfl15 the eligIbility
requirements for Article IV. Section 1, cov.rag. Will be
.NlCtlv, 81 of the flrat dAY of the calendar month
follOWing the month In whIch the EnrollmenUChl)nge
Form II ~ecelved by KHP Central, except a5 olherwlae
provided by the Group Contract In addition, lIe!"/lcea
IIhlll be provided startln!) at birth for nlM'born children of
Members for thirty-one (31) day', and continue In effect
there.ner if tho l1trWborn II ellglblo and enroHild by the
Subl\cnber Within thllty-one (31) days of the newborn'l
birth
(3) Excopl "' olheM"o agreld 10 by Group and KHP
Centrer, when a person makll wrlnen application for
m.mborahlp dUring the Group Enrollment Penod,
coverage will be on the first dey of the calendar month
next follOWing the conclUSion of the Group Enrollment
Period
(4) Exclpl "' provided In Artlcll IV, Socl,on 7 hlrool.
this Agreem.nt continues In 'orc8 for the period of one
year from the Eff.ctlve Oal. of Coverage 81 shown on
the recordl of KHP Central find from year to year
thereafter unleu terminated as hereinafter specified,
provided that KHP Central may change the promlum
rat.s 8S heremafter provided. With the approval of the
Commonwealtt' of Pennlyl'/ant.
B, If, on the date on which coverage under thIS Agreement
becomes eNectlve, the Member IS an Inpatient In a Hospital.
benefits will be provided under thiS Agreement to the extent
that they are not provided under a prior group Insurance
Ig,""ment
3 MULTIPLE COVERAGE
A, Work.,,' Compln,.tlon, Tho Benffits under thiS
Agreement ror Members eligible ror Workers' Compensation
ar. not deSigned to duplicate any 8eneflt to which such
M.mberl are eligible under the Workerl' Compensallon
Law All sums payable pursulnt to Workelrs' Compensation
for Services prOVIded hereunder to Members ere payable to
and retamed by KHP Centr'l It IS understood that coverage
hereunder II not In lieu of, and shall not aNect, any
requirements ror coverage under Workers' Compensatlon
8, Medlclre, Exclpl "' othl1WI.1 provldld by Ippl'cabl.
fedlltr.llaw, the 8eneflts under thiS Agreement for Members
age 65 and order, or Membltl otherwlSl elIgible for
Mtdlc.r. payments, do net duplicate any Benefit to which
such Members are eligible under the MediC.'" Act. Including
P.rt B of luch Act. Where Medica" II the responSIble
22
I'" ..
plyor, III '~m' pIYlble pursulnt 10 Ihl MedIC"" progrlm
'or ServlC'1 provld.d hereunder to M.mbers I,. payabll 10
Ind rl'",nld by KHP Clnlrll
C, Mlmbe,,' Cooperltlon, Elch Mlmblr 'hili com pilI.
oM submit to KHP Cenlral such conslntl, "I'.UI,
a59lgnments and other docurnentl II m.y be reqUired by
KHP Central 1M order to obtlln or Inur. reimbursement
undtlr Medlcar, Dr Workers' Compen5l110n Any Member
who fBlll to 10 cooperate (IncludIng a Member who falls to
enroll under Part B Dr Ine MedlCI.,e prcgram where Medica"
III the responSible plyor) WIll b. responSible to KHP Central
ror thl! Relmburument Value of Servn:es subJf.lct to thll
Sletlon 3, and may be terrntnaled In accordsnce WIth Article
IV, Socllon 7, E
4 LlM,TATIONS
In the Bven that, due to circumstances not Within the control
of KHP Central, Inchldlng but not lImIted to a malar diluter,
epidemIC, the complete or partlal destruction of facllltle.,
flat, CIVil Insurrection, or Similar caules, the rendition of
Services prOVided under thiS Agreement II d.layed or
rendered Impractical, KHP Central ,hall make 8 good faith
effort to arrange for an alternative methud of prOViding
coverage In such event, KHP Centrel shall prOVided
Covered ServlclI covered under thiS Agreement Inlofar 85
practical. and according to ItS belt Judgment, but neither
KHP Central nor PrOViders shall Incur liability or obligation
for dolay, or failure to prOVIde or arrange for ServICes If such
failure or delay IS caused by such event(l) Except In
Emerger.cles, the Pflmary Cere t'hysiclan musl coordinate
and approve ServiCes to be coverod
5 RELAT,ONSHIP OF PAR1 05
KHP Cenlral Pflmary CarB PhYSICians maintaIn the
phYSICian-patient relationshIp With Members and are solely
ruponslble to Members fer aU medIcal Services The
relationship between KHP Central and KHP Central pnmary
Car. Physlclam., and between KHP Central and other
contracting Providers of health Services, IS an Independent
contract relationship KHP Cenlral Primary Care PhYSICians
are not agents 01' employees of KHP Central, nor 15 any
employee of KHP Central an employee or aQent of KHP
Central Ptlmsry Care PhYSICians KHP Central shall not be
liable for any cl81m Qr demand on account or damage'
arising out a', or In any manner connected With, any InJunls
suffered by the Member wh'le receiving care tram any KHP
Central Ptlmary Care PhysIClln or from any PrOVIder to
whlr.h tM Member has baen referred by the Ptlmary Care
PhYSICian or KHP Central
23
e PAYMENT OF BENEFITS
A. Id.nllne.llon C.rd. For pur po... of Identlficetlon end
specific cov8reg8 Information, B Member's Identification
cerd must be presented when 8 service is requested
B. Allport. .nd Record., The Member con.ent. to .nd
luthorlZ" .ny person or orglnlzatlon which proYldes
Covered Services to Member to furnIsh to KHP Centrel and
to other prOViders of Covflred Servlc.s, Information or
record I pertaining to the Member, Including but not limited
to records Bnd informetlon regarding the Member', phYSical
or mentel condition. history, or treatment Further, the
Member consents to and authorizes KHP Central to furnish
such Information or records concerning the Member to such
providers of Cov.red Services and to other IndIVIduals or
organizations for peer review or utthzatlon review purposes,
Ind 81 otherwllse required by law Finally, the Membar
agre.. that approy.1 by KHP Centr.1 ot p.yment. 'or .ny
Cov.red SeNices, facilities, or suppllel il contingent on
KHP Centrll', receipt of such information or records as It
mey request.
C, M.mber LI.blllly. Except when certein Cop.yment or
other IImltationl .re specified in this Agreement, th18
Member il not lieblB for any 1;harges for Covered Services
when Covered Service, have been authOrized by the
M.mba~. Primary C.re Phy.,ci.n or the KHP Centr.,
M.dical D"'Clor.
O. O.I.rmln.llon of Modle.1 Nec'lIlly, Tha SerVll:e"
f.clllll.. or .upplla. da.crlbed In Artlcla II 0' thl. Agreemenl
are covered only when they are Medically Necessary for the
ra.toration 0' the Melnbe~. he.lth, .. determined by the
Prim.ry Cara Phy.,cian or KHP Centr.l. Any Service.
requested by a Member which are not Medically Necessary
will not b. covered.
E. AIIlgnm.nl, Any rlghl. 0' . Member 10 recelye
Covered Services or payments under this Agreement are
personal to the Member and may not be assignod to any
person, Proylder or ent,ty, wilhout written conaent 0' KHP
C.nlr.'
F, Coordln.llon of Ben.flla Wllh Olher H..llh Cor.
PI.n.. II th. Member I. .1.0 enlltl.d to receive Benefit,
under any other Group health care plln for ..rvices covered
by thiS Agreement or under any governmental program for
which any parlodlc premium payment I. m.de by or for the
M.mber, payment. m.y be coordin.ted b.twaan KHP
C.ntral and tha other health c.re pl.n In.iI c...., KHP
Centrel will p.y benefit. fir.t .nd determine lI.bllity I.'er II
It I. datermined th.t KHP Centtll I. th. ..cond.ry p,.n,
KHP Central h.. the rlghl to recover the .xpen.. alre.dy
paid In exca.. of it. ".bllity a. th. ..condary plan The
Member wHI be reqUIred to furnish information Bnd to take
such other action as IS nec.ssary to assure the rights of
24
KHP Centre I In datermlnlng whathar KHP Centlll or
.nother Group health plan h.. primary Ii.b'lity, the 'allOWing
will .pply
(1) It the other plan does not Include a coordination of
benefits or non~dupltcatlon prOVISion, thlt plln will be the
primary plan
(2) It the other plan does Inclllde iJ coordination of
benefits or non-duplication prOVISion
(a) The plan covering the patltnt other than 85 a
Dependent Will belhe prlm.ry p,.n
(b) Where both pl.n. Coyar Ihe p.'lOnt .. .
Dependent child. the plan covering the patl,nt as B
Dependent child of a parent whose date or bIrth,
excluding the year 0' birth, occurs earlier In iii
cBlend8r year, shall be tile primary plan, If both
parents have the same blrthdflY, the pial' which
covered the parent longer Will be the primary plln. If
the other plan does not include this provIsion. the
p~ovlslonl of that plan will determine the order of
benefits
(c) If the p.rent. .re .ep.r.ted or dlyorced. the
follow,ng will .pply
(i) The plan which cover! the Member as a
Dependent of the p.rent with cu.'ody w,lI be the
prlm.ry pl.n The .,epp.ren, w,lI h.ye .econd.ry
responSIbility and the parent Without custOdy will
have tinal responsibility
(II) Whare lhera i. . court decrae which
e.t.bll.h.. fin.nc,a' re.pon.,bllily for th. he.lth
c.re .xp.n... of the D.pendent ohlld, the plan
which covers the child as 8 Dependent of the
parent with such financIal responslbUft'y will be
the prlm.ry pl.n,
(Iii) The Benem. of e pl.n coyerlng tha p.tlant
as a laid~otf or retired employee or IS the
Depend.nt of . '.Id-ort or retired employ.e .h.1I
be determined aft:.r the Benefits of any other plan
covering such person as an employee Ihlll be
determined aft.r the Senefits of any other plln
covering such perlon as an eITlploy.. or
D.pend.nt of .uch person If th. other plan do..
not have the rule regarding lald~otf or retired
.mploy.... and If, a. . re.ult, th. pl.n. do not
.grfll on the order 0' b.nem., the rulo will b.
ignored
(iY) Whera tha determinatiOn cannot b. m.d. In
.ccordanca with th. proc.dlng p.ragroph.. tho
plan which h.. covered th. pelient for th. long.r
period ot 11m. will beth. primary pl.n,
25
(Y) Servlc.. proYlded undor .ny goy.rnm.nlal
program tor whleh any pe"odlc premium
peyment 15 mad. by or lor lhe SubsCriber 'hall
alway. b. the primary ptan, e)Ccept where
prohlblt.d by lew
(3) Service. under thiS Agreement for thl!t treatment of
Ir.jury 6Irlllng out or the matntt"e"ce or use or II motor
vehicle shall be covered only to the extent that 5uch
ean.flts are In IXCes, of. and not In duplication of
Servlc.s p.ld or payaole
(I)under 8 plln or poltey 01 motor vehH;le Insurance,
provldfld that non-duplication IS contained herein IS
not prohlblled by 'ew or
(b)lhrough Ihe C.lulrophlc Los. Trusl Fund, or
(c) through a pro~r.m or oth.r err.ngemenl 01 quall,..d
or certified self-Insuranc.
KHP Centrel may release to or obtain from any person
or organizltion any informetlon about coverage,
')(13'"1" and Benefits which may be neeenary 10
coordinate Senefits. For the purpose of coordination of
8lnetltl, If the Member reCllVIS IIrvIC.S, faCilities or
suppll.. .Ylllablll und.r IhlS Agrl.meot but not proYlded
by nor lulhorlzld by Ih. Membl~s Prlmlry Care
Phys,clen, paymenl w,lI not b. mlde by KHP Central
Thle proYlsion do.. not Ipply 10. In IndlYldual he.llh
car. plan issued to or in the name ot the M.mber; group
or group-type hospllll Indemnity benems of $100 per
day or less; cr school Iccident-type coverage,
0, Sub,,,,,ellon.
(1) If Iny Coy.r.d Service Is provided to the Membor
under this Agr..ment, KHP Centr.' sh.,1 be subrogaled
and succeed to the Member's rights or recovery wllh
resp.ct to the Covered Servlc., or supplies Involved
Iglll1lSt B responslbl. third party and/or Insurance
complny,
(2) Subrogetlon me.ns thlt If Ihl Subscrlb.r or lhe
Subscrib.~s Deplnd.nt(s) is injured beclu.. of the
nlgllgenc. or wrong doing of aoolher plrry, KHP Centr.,
hi' the right to Silk recovery ot the R.rmbur:1ement
Vllu. or rellted Covered Services prOVided The
M.mb.r Is expected to cooperate With KHP Central and
t.ake any sction nec.ss3ry to protect Bnd to assure lhe
subroglllon rights 0' KHP Cenlrel
(3) This provision do.. not Ipply to In mdlYidua,
insurance policy covering a Member Th.re will be no
right of subrogltlon where prohibited by 'ew
26
". ".,,,.,
KHP Central may, Without con"nt of or notice to any
person, release to or obtain from Bny Insurance complny or
other organization or person any Information, With respect to
any person, which KHP Cerltrsl deems to be necessary for
Ihe purPOIiI of determining lis liabIlity under thiS Agreement
Any person claiming Benefits under thl5 Agreement agrees
to furnish KHP Central such Informatton II may be
necessary to !mplement thll prOVISion KHP Central has the
right. at any time, to ,equlre such mformiltlon to be
furniShed 10 It wllhout cost or e>cpense III a conditIon
precedent to liability for any claim for Covered Services
under the terms IJf thlb' prOVISion
H. Wllver of Lllblllly, KHP Car,tra, shall not be habl. lor
InJunes ~esulttng form negllgenc., misfeasance,
nonfeasance or malpractice on the part 0' any PrOVider In
Ihe course of performing Cov~red Services for Members
I. Legal Action. No legal actIon may be commenced
against KHP Central with respftct to the Agreement until
ninety (90) days atter KHP Central hss rec.ived 8 properly
completed claim form or Encounter Form, nor may such
action be tsken at all later than two years efter the Covered
Servicea or supplies were performed or prOVided
J. Grlevanc. Procedur..
Informal R'.olutlon Procedure Members haVing
concerns, problems or complaints mvolvlng Benefits under
Ihls Agreement, the availability or dellv.ry of Covered
Servlc,s, Ihe Member's Primal)! Care PhYSICian or other
prOVIders; Ihe operation of KHP Central. or the terms of thiS
Agr~ement should contact KHP Central's Member Serv!c81
Department Staff members will work With the Member to
attempt to resolve concerns or disputes Informally In
communicating with the Member Services Dllpartme"t, the
MerT'!ber Should prOVIde pertinent Information regarding th,ir
concerns InqUIries may be directed to the Member
ServIces Department at the following address, or by callrng
lhe Department .t 1-800-622-2843
Member Services Department
Keyslone H.a'th Pl.n C.ntr.'
Post Office Box 898812
Camp HIli, P.nnsylyanll 17089-8812
If a Member II not satisfied With KHP C.ntral'!I response
concerning their complaint, the Member may file . formal
grievance There are mo steps in the Keystonl Health Plan
Central grievance process
Form.' Grievance Procedure The grllvlnce wlll flr.t b.
r"","wed and Inv..t'gal.d by the l!!lIlI!-.Qd~
~mmittu:, composed 0' two or more managem.nt staff.
The member Should forward pertinent written information
regBrdlng the grievance to the committee The commIttee
27
WIll p.ovlde . written deCISion wltl'lIn thirty (30) daya or Its
r,cllpt of a grievance The Inlhll Grl.vance Committee's
O"Clllon will bu binding, unle" It'le Member appeals tt'l,
decIsion
The appeal of the Inlllal Grl8\1snCe Commlttee'a deCISion
It'llll be to the Grievance Review BoarJJ The Guevance
Review Baird IS estllbllshed by Ihe Board of Dlrflctors Bnd
Includes It le..t one-third Subscribers to the HMO The
GrI.venc. RtvllW Board will hold an mformal he8r1ng In
which the Member (and any other Inlerested party) may
prl..nt, In person or In Writing, Ihelr pOSItions on the
disputed matt.r The Member hos the right. but 1\ not
reqUIred, to attend the hesrlng, Such a hearing WIll be held
It a time which IS mutually acceptable to the Member. Ihe
Board end any other persons In'v'olved KHP Central Wilt
prOVIde the Member wilh written Information on Ihe hearing
procedurea KHP Centn'l Will hold the hl8r1ng wllhln thirty
(30) doys ", receipt 0' the Member. reque.t At eny stage
or the grievance proces', the Member has the right to
requllt that KHP Central appoint a Itaff member who has
no direct Involvement to assIst the Member
Th. Grievance Review BaIrd Will Issue 8 fornlal 08CISlon
'v'llhln ten (10) days of the h.anng The Board's deCISion II
binding unl'" the Member apPells thu deCISion to the
Bureau of Health FinanCing and Program Development,
IOClted In the Pennsylvonlll Departm.nt fJ' Health, Room
1025 Heelth end Welfare BUlld,ng, Po.t Office Bo. 90,
Herri.burg, Pennsy,van,a 17108,0090,(717) 787-5193
Grievances usually deal with claim denials end the remedy
.ought " peyment 0' the c,,'m by KHP Centr.1 However,
In thosl CISII In which . Member believes Ihlt UrlOU,
mldlcll consequences Will arise from KHP Central's failure
to prOVide the requested ".alth Slf\lICeI, the mllmber may
request an excedlted review
To do ao. the Member should contact Ihe Member ServIces
Deportment, IdentifYing Ihe particular nlld tor In expedIted
review An expedited review may be conSidered
Urgent Review Case IS r,vlewed by the medical
dlrectQr and a deCISion IS rendered In writing to tn. Memblr
within fine.n (15) day.,
Emltrgency Review' C..e IS re\llewed by the medical
director and 8 decl!Slon IS rendered In writing 10 the Member
within two (2) working days, With ,nitl., notlf,cetlon by
telephone, when appropriate
If the medicet director', deCISIon IS adverse to t~e Member,
the M.n'lbtr may appeal the deCISion Immediately to the
Medlcll R,vlew Commlttl' by contacting the Member
Services dip art mint
Thl medical dlfector Will contact thl Medical Review
Commltt.. to present the Member'1 case This commltt.t,
2M
compo led 0' It least two phYSICians. Will 'IvUIW the call
and render un Immedl8hl deCISion The Member Will bt
mformed VIEl letter ond by telepho,e. when appropriate The
Member Will be Informed or the fight to appelll the deCISion
to the Pennsylvania Dlfpanmenl or "i.alth
7 SUBSCR'8ER AGREEMENT
A. Entire Contract. The enllr, contract betweon KHP
Cenlrol and the Member conslst$ or Ihe Group Contrlct, the
Enrollment Form, thIS Agreement, any amendments to It,
and the appropriate premium rate
B. Premium RI". The Group, or In the case of Indlvldull
or group converSion contracl$, the SubSCriber. sareeslo pay
KHP Contral In advllnce, on a monthlv basIS, unless
othef'INl5e agreed. the applicable premium rat, 81 filed with
Bnd approved by Ihe Commonwealth of Pennsylvania
C, Ch.ng.. of Premium R.t., KHP Centrel, .ub,ect to
the approval of the Comm~nwearth of Pennsylvanll, may
change the premium retes In th, event of luch change, the
Group shall be notified In advance of Ihe effectIve dll. of
change Any notice will be considered given when delivered
to the Group
0, Termln.llon of Group
(1) Subject to ennuo' renewe' by the Group end KHP
Central, this Agreement, IS amended from time to time,
Will remain In effect from year to year unless terminated
either by the Group or KHP Central
(2) The Group or KHP Central mey termlnete thl.
Agr.ement u~on thirty (30) d.ys wrihen notice 01
termInation given to the other plrty
(3) This Agreement .hell autom.tlcelly termln.te .,
KHP Central'. .ole di.cretlon " KHP C.ntrel doe. not
rece've the periodiC premium peyment w,th,n thirty (30)
dey. 'ollowing the due d.t.
(4) In lhe ..ent 01 termlnetion 0' the Group, eovereg.
'or Members 0' thet Group will end es 0' the lul d.y 01
the period for which the lesl premium peyment hll baan
recelvld
(5) Members 0' a discontinued Group m.y b.com.
converSion Members provldld the Group do.. not
participate In or secure co".rlgl under I he.lth benefit
plan made eV'llable by lome other orglnlzltlon and the
termination Is not done with th, antiCIpation of ..curing
health benefit coverage With another org.nlzltlon
E, T.rmln.tlon 01 Sub.erl..... .nd M.m...... In
uddltlon to terminating coverage under thIs Agreement for
the Group es e who,e, KHP Central mey termln.t. this
29
Agr..m.nt I' to .n IndIvidual Sublcrlb.r or Member 0&
'ollowI
(1) upon thirty (30) day' written nollee of termination
for cau" (Iueh I' fraudul.nt UII of 8n Identification
clrd) by KHP C.ntrll However. l<HP Central Will nol
termln.te thll Agreem.nt beclull of 8 Member'1
Medlcallv Nlelnlry ullllzatlon of Services covered
under thiS Agreement.
(2) If the Subactlblr In obtaIning coverage hereunder
.hall hrve 8cted fraudulently or n\lareprllented or tailed
to disclose a mat'rlBI fact In such case, KHP Central
mey, II Its option, terminate thll Agreemenl In
Iccorr1anCI with paragraph (1) above The Group or
SubSCriber will forfeit any charges paid to the extent of
the liability Incurred by KHP Centrll.
(3) 11 the Member IS unable to maintain a ISt1l5factory
physicien-patlent relationship (See Artlcl. IV, SectIon 7,
J),
(4) If the Group or SubSCriber fralls to cC'operate on
CClordlnatlon of benefits or subrogation ISSUes.
(5) for misuse of the Mamber identification card
F, Obllgatlona on T.rmlnatlon, In th. .v.nl 0'
termlnatron by the Group or by KHP Central
(1) KHP Central .hall not b. hOb,e for any """c..
Incurred by any Member In the name of KHP Central
beyond the petlod for which the premium rate snail halle
bOln paid, and KHP Cenlral .hall b. entitled to
Indemnification by eIther t". Group or the Subecrlber for
Bny e>cptnse paid by KHP Central under such
circumstances
(2) When thIS Agreement IS terminated. ,>ccept for
termln,tlCn by Incorrect !nformatlon or
mIsrepresentation, and. Member IS receiving Inpatient
Services bIlled by a Hospital on the date of termination,
benefils WIll continue to t)e prOVided only to the date of
dlScharg. or ft>cplflillon of eligible benefit days.
whlchev.r IS earher
O. R.ln.tatem..nt. Any IndllJ1dual Member whose
m.mbershlp shall have been termlnat.d may be reinstated
It the dIscretion of KHP Central, and upon paYl":1ent of any
retroactive premium payments and penalty due
H, Other Chang.. In St.tu.. Appllcet'on. tor change. "
conrract type or addItion, or deletions of eligible Dependents
shill b. filed on Subscriber Ofltl Change Forms supplied by
KHP C.ntral and shall become ,ff.ctlv, Ind a part of thiS
Agreement upon acceplenc. by KHP Centr.1
10
I, ~"on.ou. P.ym.nt., If KHP C.nlral Ihall pay 'or any
excluded ServlclI or luppllll through I"'dllettence or .rror.
the Group or Member Ihlll relmbufl. KHP Cenlrsl for such
payment.
J. COnver.lon.
( 1 ) The Sublcrlb.r who becom', Ineilglbl. for
cOllerage under tnll Agreement bftcause of termination
of emplo!'ment under hi' Group and who II not eligible
to become enrolled under any other group h.mlth benefit
p,an may apply w"hln thirty (30) day I an.r luch
terminatIon 0' omployment to continue coverage under
an Agreement 0' the type tor which he IS then elIgIble
F or Members currently enrolled under a family contract,
thiS conversion priVilege IS also available to the surviVIng
Dependents In the event of the Sllbscrlber's dealt" to a
spouse when divorced from the SubSCriber, and to a
child who centis to be an eligIble Dependent due to
attaining the maximum age of eligibility ThiS conversion
Dflvllegd 15 not available to Member~ who have bun
terminated for cause by KHP Central (See Article IV.
Section 7, E l. cr for Members who have 'ailed to apply
tor conver.ion Within tho lI"rty (30) day period The
terms of conversIon coverage may be dIfferent than the
terms herein
(2) It lhe Momber be com.. eilglble lor Medicar. Part
A or Part U, tho Member shall have tt.,e right at that time
to convert to such programs as may tnen be available 10
prOVide coverage In conjunctIon With governmental
programs
(3) It a Member enrolled ,n KHP Centra, through a
Group voluntarily elects to terminate hl~ coverage With
KHP Central while remaining eligIble ror Group
coverage, the Member shall not be eligIble for
conversIon to such non-Group programs as KHP Central
may have available
K, Continual Ion of CO'I.,.g., Federal law {"COBRA")
requires that under certain ctrcum~tanc8S the Group offer to
the SubSCriber andlor Dependents of tne Subscriber
("Qualified BenefICiaries") the option of conflnl.,lIng coverage
under the Group's contract With KHP Central when such
coverage would othel"NlS8 terminate The circumstances
under which thiS option IS 10 be e>ctended 10 the Qualified
Sene'lclsrles Include (.II termination of the SubSCriber's
employment. either voluntarily or 1n1J0luntarlly. (b) the death
of the SubSCriber. (cl divorce or legal separation or the
SUbGcrlber, (d) D.pendent children reaching otherwise
applicable age limits und.r thll Agreement, and (.)
SubSCriber becoming eligible 'Or M.d:elre benefits
SUCh QuallfleQ 8eneflclarl.' milY able In the S8me cover.g.
as the Subscnber IS entitled to, for 8 period of three Y.",I
follOWing the event In queltlon In the case of termination of
employment. tho applicable Pltlod is elght.en months Th.
11
, ,
00
Keystone
Health Plan"'
Central
",
, ~"
An IndltpeMenl LlceMee ollM Bill"
Cro!l!l aM BIlJ9 S/'llelfl .A!\!I0Clatlon
i
Keystone Health Plan Central, Inc.
P.O. Box 898812
Camp Hili, PA 17089-8812
17'17) 783-3894 or (800) 822-2843
Keyllone
IIIIIIh PIIn~'
Centrel
(~'~~~::X"IM)n
KOVllono H..llh Plln Control, Inc.
P,O, Bo.898812. elmp HIli, PA 17089.8612
r I
GEARy,JA~~~,L
15'18F HIGrl ?CL~TE OR
HARRISBUqG.?A 17025
DATE
CLAIM NUMBER
PATIENT NAME
PROV'DER NAME
PAID TO
CHECK NUMBER
If you hlvO quoaUona Iboul Ihla
hpllnlllon of Bonofila cIII
(7171 763.3894 If oul of tho
Hlrri;ourg' aroo. cIII HIOCHI22.2&43,
03/13/Q5
425dC'4.::1 7J'~
GiOARY,H'1i:5,L
OCCU~ATIO~A" ~~rlA8 & RESEA~CH
GEA"y,JA'-1,:~,I.
NO CHeCI<
L
.J
AGREEMENT NUMBER 1 S : .. ~ 14 6 9
GROUP NUMBER 1 3 I; 9 3 0
EXPLANATION OF BENEFITS
SERVICE OESCRln,ON AMOUNT BillED AMOUNT AllOWED LESS INELIGIBLE AMOUNT AMOUNT PAID __~N
CO'IS,
.
0: J;i:;4 PHYSICAL 'l~OICINE TR 2",,? .,:J 0.00 1').0,.J ,.).00 ....1...9
C'.;: ';=~394 ~HYS I CAL "'::JICI;~E TR -:07. ;J O.(lO :1. '~I,J 0.00 Wl"'9
03 ;: c::.: S,,4 PHYSICAL ,'l';JEI'~E TR 2C 7. ~,.J O.'1C '1.0.J ';.0'1 ....149
C,+ .)~~,., ,4 PHYSICA~ '1'01 C !.'~E TR "'1. ) 'J 0.00 '1.':I.J 0.00 '~149
0, ~ ~ ~ : 94 ~HYSICAL M,JICINE TR 2 v 7. I') ~ 0.00 'J.:1 .j (l.00 W149
Cc; ';',394 PHYS ICAl M'o:JTC INE TR 49.~J 0.01) O.JO '~.OO \0/149
C7 .iS2S94 ~HYSICAL ,'Ir.OTC I;~E TR 207.% O.CO ,~. 'J J '.).(lO \0/14':1
'J<3 J 'i';: . 94 ~HYSICAl /4" ')I: I NE TR 49.'J(l 0.00 ,J .1,j 0.00 \o/l49
... T J r .. - S .*. l.:.z.:.;J (l.OO O~:.:;. .J.(l0
K':ASON CO~.SI
~l49 SERVICE ~~s ~OT AUTHORIZED BY THE PRIMA~Y CARE PHYSICIAN.
You afe not responsible for any dltferflnce between me amount billed and' Ihe amount paid tor an'} eOI/ered Services. unless an amount is
speCllledlnltle "LESS INELIGIBLE AMOUN'T" ,::OhJmn Please reler to Ihe e.llplBnl1110n above tor any Ineligible amounls, If your claIm has been
denied In wh()lo Qr In pari, you have Ihe rlqht 10 rsqUF,lst 11 revIew To appeal l) claim IlIe a WAlnlN A'PIAL WITHIN 10 DAY' ..'T."
RlellVING THI. EXPLANATION 0' RINE"TS STATIMENT. Please refer 10 the "Grlevance Procedure" ,ection 0' your Member Agroemenr
for I1ddlllonRlmlormnllon rhf} Appoal f,hoIJld be !ent 10 Keystone Health Plnn Cenual, Inc:, Member Hervices Cept. 80.ll898812. Camp Hili. fiJA 1708l}..8812.
..,01>
";.',.,
KeyItone
II..... PIan,~/
Central
.""'~l,.~...oIlh.
l~ IIuI'CfY)II'Ind'" ShIIold "11OO1Inu.1
r
GEARy,JA~Af:S,L
:SOdF Hlr.rl pn:~TE OR
HARRISeUoG,PA 17025
..,
DATE
CLAIM NUMBER
PATIENT NAM~
PROVIDER NAME
PAlO TO
CHECK NUMBER
If VOU hlvl qUllllonl Ibout thl'
bpllnltlon 01 Blnlflt. 0111
(717) 7&3-3&84. II ;;;: of tho
o 3/1 3/9 5 Harrl'bur~ "", c'1I1-MO~22-21lo13.
425804620C"
GEARY,JAMES,L
OCCUPATIONAL REHAB & ReseARC~
GEARY, JAMES, L
NO CHECK
, K.Vllon. HIIUh Pl,n Conlrol, Inc.
PO. Bo. B98BI2, C.mp HIli. PA 17009-0012
L
.J
1~;:4614t'l
AGREEMENT NUMBER 1 36':' 3 0
GROUP NUMOER
eXPLANATION OF BENEFITS
F"""" ~ERVICE DAIf..L.. SERVICE DESCRIPTION ~UNT BI~ AMOUNT ALLOWEE.j LESS INElIfiIQLE!~ AMOUNT PAID [M[
c: ':;fl':'Q94 ~HYSICAL M~D!CINE TR 'tQ.00 0.00 O.C\.i \.i.OO W149
(12 ~-7,~9~ oHYSICAL ,~r OIL. IHE TR 1Q6.00 0.00 O.C'; 0.00 W149
03 :7:"09/. oHYSICAL Mf DIe I HE TI\ 196.00 0.00 o.co c.OO W149
04 ~7:'794 "HYSICAL ,~fOICINE TR 196.00 0.00 0.00 0.00 W149
05 ,: 7Z, 791.. rHYSICAL MfOlCINE TR 196.(:0 0.00 0.00 \.t.ce W149
o~ ~ ,'~':':? 94 ~HYSICAL MHll ,;! NE TI\ 1'16.00 0.00 C.':'C 0.00 .1149
07 V,!C 394 ~HYSICAL MEOlr.INE TR 196.0G 0.00 n.ow (,.00 W149
08 0d:OQ4 PHYSICAL MfOICINE TR 196.0C 0.00 O.OG (;.00 W149
09 ,':;Sj" 094 oHYSICAL MfOI( IHE TR 191>.1')0 C.OO o .Cu O.CO W149
... T 0 T t, ,- S ..* 16:7.00 0.00 C.Cu .,j.OO
REASON r.or " ~;
" 14" SE:RVICE WI. S rIOT AUTHORIZED F.Y THE PRIMARY CAf\E PHYS IC 1..'1.
You are ~L rElspcnslbla far Bny dllfert1nce belween the amount billed Bnd Ihe amollnl paid lor any COlJfH8d Services, unloss an amount I~
specified In the "lESS INELIGIBLE AMOUNT" column, Pleal\e nt'"r 10 the explllnnflon Above for any Inellglbltt amounts, II your clatm has been
denied In whole or In Pdrt, yOll have lhe right 10 l"equeIU 11 review To appeal 11 clAim tile fJ W'UTTIN AP'IAL WITHIN 10 DAYS AFTIR
"ICIIVING THIS IXPLANATION 0' IINI"TS STATIMINT. Ploltse reter to tl"le 'GrieVAnce PrQcedure" Secllon of your Member Agraement
'or .1ctdllicnal tn'ormallon The appeal sholJld be sent to: KeystoOft Hoalth Plan Cenrral, Int:. Member S"~IC8$ Oepl. Su,. 8988t2, Camp HIli. PA t7089~8812
KeyItoM
111.111 PIM<!IJ'
Cent...1
, Nt~ llClnMl otllW
~ IWCroIIMd"SIIlltIclANOC;1IDOn
Kly.,on. Hllllh PI.n elnlral, Inc,
P.o. Box 898812. e.mp Hili, PA 17089-8812
I I
GE4P,y,J4~E"l
1508F HIGH P~I~TE OR
HARRISBUQ~,~~ 17025
DAlE
CLAIM NUMBER
~AIIENr NAME
PROVIDER NAME
PAID 10
CHECK NUMBER
II you hovI qUllllon. Iboul thl.
hpllnllion ot Blnlllll cI11
(717) 783-3B94 If oul 01 Ihl
HI""bur~'orel, cllll~~22-2Ilo13,
03/13/95
43'J41380z.J'l
GEARY,JAMES,l
QCCUPATIJNA~ REHA6 & P,ESEA~C~
GE4P,Y ,JAME S, L
NO CHECK
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AGREEMENINUMBER U,46,469
GROUP NUMBER 1 36930
"".... SERV,CE OATE
SERVICE OESCRIPIION
EXPLANATION OF BENEFITS
AMOUNT BILLEO AMOUNT ALLOWED lESS INElIGiOlE AMOUNT
AMOUNT PAID
C'l :~H94 THERAPEUT I ': PROC EOUR 60."0 0.00 0.00
c.: : q 31 ';4 rH~P,APEUTI~ ~R':lC<:OUP, 9 'i.~:> O.CI) I).OJ
III T 0 T 4 l S III 15l?OO 0.00 ".0"
REASON COt);:! :
,,:..~ ~ERVICE ..~S :IIOT AUTHORIZED ~Y THE i'RIMARY CARE PHYSICIAIIl.
"
a.oo '11149
oJ.oo '11149
v.OC
You are not responsible for any difference between the amount bUled and the amount paId for any Covered 9.,vlclI, unl... In .mount II
speCified mIn. 'LESS INELIGIBLE AMOUNT" column Please refer to the explanation above for any Ineligible amount,. If your clllm hi' b..n
denied 10 whote t;lr In part. you h.:l\l8 !he rtght to requtJst a review To appeal a claIm file a W'UnIN "fIIIAL WITHIN 10 DAY' A'TI"
"ICIIVINO THIS IXPLANATION 0' BINI"" STATlMINT, Pl.... r.l.r 10 th. "Grl."nce Procedur." "Cllon 01 you, Mlmber Agrolmlnt
'or addUionalln'~rmal.tJn The appeal should be sent 10. Keystone Health Plan Central. Ine.. Member SeNte.. Olpt Box 898812. Camp Hill. PA 1101f01112.
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Keystone Health Plan, Central
An IndtplndenllJc....H of m, B1ut Croll and Blut ShI.'d AIIIOCllllQn
12080_898812
Camp HIli, PA 17089.8812
1717)183.3458 . Fu(717) 971H58915
June 22, 1995
James Geary
1508F High Point Drive
Harrisburg, PA 17025
Dear Ms, Geary:
Keystone Health Plan Central (KHPC) recently considered your request for
a review of KHPC's disallowance of services provided for yourself on April 26 to
August 31, 1994, by Occupational Rehab and Research,
When you enrolled in KHPC you agreed to use your Primary Care Provider
to provide or arrange for all of your health care needs, This applies to any
services arising from a motor vehicle accident, as well, even though another
insurance carrier may be primary. Since motor vehicle insurance usually has a
maximum payable amount, it is especially important to inform your Primary Care
Provider so tl1at he can authorize any services that are in excess of the other
insurance coverage,
Since the above mentioned services were neither provided nor authorized
by Susquehanna Internal Medicine Assoc., it has been decided that they are not
eligible for payment under Keystone Health Plan Central.
If you wish to pursue this matter further, you may submit a written appeal to
the Initial Grievance Committee within 30 days of the receipt of this letter.
If you have any questions regarding this procedure, you can contact our
Member Service Department at (717)763-3894 or 1-800-622-2843.
Sincerely,
JS/rf
I
i
J ce Shirey
Senior Member Service Representative
~
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.'t'IIII.yhlllliu IlIUl'Shll'ld
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8h,r! CI()!iS i.lnr1 81lm Shll~I(1 "~tir,cl,lllon
, Ht'ql',hJIl'll Mune,> <.tltlP. Hllll! CrL)'iS ;Jnll Shill Sh'lllfJ ASSOCIIllIOI1
.lr1 A'>'>')(I,II,,)I' d 1'\110pen(1IH11 BIL,jrl Cl<\'l~' anrj Bhle Shlelr1 Plan!!
FAMILy.PRACTICE ASSOCIATES
A Hell,hAnwrlC' Mtr1i(lIOffice
F. SAloMi F ABtR, M.D.
MlCf'Atl P. HOHNlI1, M.D.
M"",ON ), RUB'''S!tlN, M.D.
60'<'" L BURM~JM, M.D.
.
V'R'''' W, CRllN.R, O,Q.
IANl PURl!, P.A.-C.
CJ 2151 L1nglestown Road .Harrlsburg, PA 17110. (717) 652-5380 PHONE/17171 652-0812 FAX
CJ 5 Willow Mill Park Road .M~chanicJburg, PA 17055. (717) 691-0202 PHONE/(717) 691-0946 FAX
July 11, 1995
Keystone Health Plan Central
100 Senate Avenue
Camp Hill, PA 17011
Re: James L. Geary, Jr.
TO WHOM IT MAY CONCERN:
Jawes Geary had been under my care prior to May 1, 199~.
While under my care, James had been seen for injuries
resultant from an automobile accident in April, 1993. He
initially was cared for through the auto insurance, His
benefits apparently reached maximum while he was in a course
of physical therapy. He was undergoing physical therapy at the
order of Dr. Rex Herbert for rehabilitation following a Neer
acromioplasty of the left shoulder that was carried out on
April 8, 1994.
The reason for this letter is at the patient's request.
Obviously, therapy is appropriate following a procedure such
as he had undergone. Unfortunately, neither the consultant nor
the patient nor the physical therapy office realized at the
time that he had reached his maximal benefits under the auto
insurance. He did require therapy through the end of August,
1994, which I feel was appropriate, again given the procedure
that he had undergone. I am aware that K.H.P.C. has disallowed
coverage of the ser.vices from late April through August 31,
1994, for that rehabilitation. I am writing this letter to
request that you reconsider that rejection.
Thank you for your attention to this matter.
Very truly yours,
~{J&~ po
Vernne W. Greiner, D.O..
VWG/alp
cc: Anthony Stefanon & Glace
HealthAmerlcs"
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~erDton. aealth
Ju y 21, 1995
Paqe 2 of 2
Plan, Central
I look forward to your early
qrievance request.
ini tial
AS/djs
Bnclosures
pCI Jame. L. aeary, Jr.
I' '
.
,
...
Keystone Health Plan. Central
300 Corporote Center Drive
Suite 602
P,O, Box 898.3 12
Comp HIli. PA 17089.8812
(717)730-1719 . Fox (717)975-689~
IIobeIt S. Muac:alua. D.O.
ASSOCIATE MEDICAL DIRECTOR
September 8, 1995
Mr, James Geary
1508 F High Pointe Drive
Harrisburg, Penn3ylvania 17025
Dear Mr. Geary:
On September 6. 1995. the Inilial GrievWlce Committee of Keystone Health Plan Central.
consisting of Alison Mcllwee, R.N" Appeals Coordinator, Lisa Frey, MWlager, Sales and
Marketing De;lartment, Nancy Page. Manager of our Member Services Department, Brenda
Laudenslager, Provider Relations Representative, Rosemary Baer, R.N, Quality Management
Coordinator, and I met to discuss your grievancc as statcd in your letter, It is our understanding
that you are requesting payment of physical therapy services received at Occupational Rehab and
KeSeltrcil. mc., SIULUS pust motor vehicle accident on April 9, 1994.
In making its decision, the Initial Grievance Committee considered the following: we
reviewed letters from Anthony Stefanon. Esg.. dated May 26, 1995 and July 21, 1995, benefits
statement outlined by Keystone Health Plan Central, a letter from Vemne W. Greiner, 0.0"
dated July 11. 1995, medical record documentation from Occupational Rehab and Research
Associates, Inc" and documentation of recent telephone conversation placed by you to our
Member Services Department.
Based upon our review of the above intormation. it was the decision of the Initial
Grievance Committee to deny authorization for payment of physical therapy services at
Occupational Rehab and Research, (nc.. status post motor vehicle accident on April 9, 1994.
These services were obtained at an out-of-network facility. and they were no! coordinated nor
were they authorized by your primary care physician,
I have enclosed a copy of the cover of the Keystone lIealth Plan Central Subscriber
Agreement which clearly indicates that benefits are covered only when provided or authorized by
your primary care physician,
KHP Cent,III,''''' HMO ,MII,ted Wilt'!
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JAMES L. GEARY,
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
Plaintiff
v.
No. 96-2166
KEYSTONE HEALTH PLAN CENTRAL,
INC t/d/b/a KEYSTONE HEALTH
PLAN CENTRAL,
CIVIL ACTION - LAW
Defendant
JURY TRIAL DEMANDED
PRILIMINARY OBJECTIONS
Defendant, Keystone Health Plan central (KHPC), by its
undersigned attorneys, makes the following preliminary objections
to the complaint:
A. AORlaMlNT roa ALTERNATIVE DISPUTB RBSOLUTION
1. KHPC is a health maintenance organization ("HMO"),
certified to operate as such under the Pennsylvania Health
Maintenance Organization Act ("the HMO Act"), 40 P.S. 551551-
1567.
2. Plaintiff is a party to a contract issued by KHPC (the
"Subscriber Agreement"), pursuant to which KHPC is obligated to
provide to plaintiff certain health care services, as more
particularly set forth in the Subscriber Agreement.
3. The complaint alleges a dispute bet~ ,'en plaintiff and
KHPC relating to KHPC's obligation to pay for health care
services.
Committee's decision will be binding, unless the member appeals
the decision.
8. Since plaintiff was required by the Subscriber
Agreement to submit his complaint to the grievance process, but
failed to pursue that process to its conclusion, the complaint
should be dismissed.
B. DIMURRIR TO COUNT II or THI COMPLAINT
9. Count II of the complaint asserts a claim in bad faith,
allegedly arising under 42 Pa. C.S. 58371. That section of the
judicial code establishes a limited cause of action "in an action
arising under an insurance DOlicv, if the court finds that the
insurer has acted in bad faith toward the insured,..."
10. RHPC is not an insurer and the Subscriber Agreement is
not an insurance policy. Rather, KHPC is a specialized entity
organized under the HMO Act.
11. section 10 of the HMO Act, 40 P,S. 51560 provides:
"(8) except as otherwise provided in
this act, a health maintenance organization
operating under the provisions of this Act
shall not be subject to the laws of this
state now in force relating to insurance
corporations engaged in the business of
insurance nor to any law hereafter enacted
relating to the business of insurance unless
such law specifically and in exact terms
applies to such health maintenance
organization..."
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JAMES L. GEARY,
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY PENNSYLVANIA
Plaintiff
v.
KEYSTONE HEALTH PLAN CENTRAL
INC. t/d/b/a KEYSTONE HEALTH
PLAN CENTRAL,
NO. 96-2166
CIVIL ACTION LAW
JURY TRIAL DEMANDED
Defendant
PRAECIPB POR DISCO~INUANC.
TO THE PROTHONOTARY:
Mark the above captioned action DISCONTINUED.
By:
ANTHONY.
1.0. #254
407 Nor! Fro Street
P.O. Box 7
Harrisburg, PA 17108-2027
(717) 232-0511
DATE: -1. 2,1- ,..9
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