Blue Cross/Blue Shield
Indemnity Plan Member Handbook

Section III — Medical-Surgical Benefits

Basic Benefits For Your Medical-Surgical Care

When you are ill or injured, your coverage helps pay for covered services by a Professional Provider. These Professional Providers are:

• Certified Clinical Nurse Specialist
• Certified Community Health Nurse
• Certified Enterostomal Therapy Nurse
• Certified Psychiatric Mental Health Nurse
• Certified Registered Nurse Anesthetist
• Certified Registered Nurse Practitioner
• Excluded from eligibility are registered professional nurses employed by a health care facility or by an anesthesiology group.

Payment of Benefits

Usual, Customary and Reasonable (UCR) Method

The usual fee is that which an individual Professional Provider most frequently charges the majority of patients for the procedure performed. The customary fee is the fee determined by Blue Shield based on charges made by most Professional Providers of the same specialty in comparable geographic/economic areas for the procedure performed. The reasonable fee (which may differ from the usual or customary fee) is the fee determined by Pennsylvania Blue Shield by considering usual clinical circumstances; the degree of Professional involvement; or the actual cost of equipment and facilities involved in providing the service.

Payment for covered services performed by Pennsylvania Blue Shield Participating Professional Providers (those Professional Providers with whom Pennsylvania Blue Shield has a contract with respect to payment for services) will be made to the Professional Provider on the basis of 100% of the UCR allowance or the amount charged, whichever is less.

A Participating Professional Provider must accept Blue Shield’s allowance as payment in full for covered services. You are responsible for any deductibles and amounts exceeding the maximum (if applicable under your program) or any service not covered by Blue Shield.

Payment for covered services performed by Non-Participating Professional Providers will be made to you on the basis of 100% of the UCR allowance or the amount charged, whichever is less. Such payment will constitute full discharge of Blue Shield’s liability under the program. Non-Participating Professional Providers are not obligated to accept the UCR allowance as payment-in-full. You shall be responsible for payment of the remaining charges.

Service Benefits

If you had services performed by a Pennsylvania Blue Shield Participating Professional Provider and the Provider should bill you for other than the deductible, co-insurance, amounts exceeding the maximum or ineligible services, do the following:

Discuss the situation with the Provider.

If you do not come to a mutual satisfactory settlement of the disagreement, then:

1. Contact Pennsylvania Blue Shield at:

   Medical-Surgical: 1-800-345-3806

Blue Shield will review the situation to resolve the disagreement. The decision by Blue Shield shall be final.

How Benefits are Obtained

Participating Professional Provider

Present your Blue Shield identification card at the time services are provided by a Participating Professional Provider. The Professional Provider will in most cases submit a claim form directly to Blue Shield on your behalf. The payment will be sent to the Professional Provider and Blue Shield will notify you of the final disposition of the claim.

Non Participating Professional Provider

A Non-Participating Professional Provider in most cases will also submit a claim to Blue Shield on your behalf. If you would like to submit a claim yourself, you must do so within 1 year from the date of service. Request an itemized bill which shows:

1. patient’s name and address;
2. date of service;
3. type of service and diagnosis;
4. itemized charges;
5. Professional Provider’s complete name and address.

Then add the employee/subscriber’s name, group and agreement numbers (as shown on your identification card) and the patient’s birthdate. If you need assistance, either contact your nearest Blue Cross and Blue Shield office or call Pennsylvania Blue Shield. If you do not need assistance, please send your receipt to:

Medical-Surgical:	Pennsylvania Blue Shield P.O. Box 890062 Camp Hill, PA 17089-0062 Telephone #: 1-800-345-3806
Dental:	Pennsylvania Blue Shield P.O. Box 890400 Camp Hill, PA 17089-0400 Telephone #: 1-800-332-0366

When services are performed by non-participating Professional Providers, the payment is made directly to you.

Covered Services

You are entitled to payment for the following covered services provided that Blue Shield deems them medically necessary. This professional care can be performed anywhere unless otherwise stated.

Surgery

Surgery for the treatment of disease or injury. Separate payment will not be made for inpatient pre-operative care or any post-operative care normally provided by the surgeon as part of the surgical procedure.

If more than one surgical procedure is performed by the same Professional Provider during the same operative session, Blue Shield shall pay 100% of the UCR allowance for the highest paying procedure and no allowance for additional procedures except where Blue Shield deems that an additional allowance is warranted.

Oral Surgery

Oral Surgery for surgical removal of partial and full bony impactions.

Oral Surgical services not covered are described in the section "EXCLUSIONS".

Assistant Surgery

Services of an assistant surgeon who actively assists the operating surgeon when the condition of the patient or the type of surgery performed requires assistance. Surgical assistance is not covered when performed by a Professional Provider who himself performs and bills for another surgical procedure during the same operative session.

Maternity Services

Maternity services including pre-and post-natal care, performed by a Professional Provider for all females.

Routine Newborn Care

Professional visits to examine the newborn while the mother is an inpatient in a hospital or Birthing Center. Routine neonatal circumcision is covered.

Anesthesia

Administration of anesthesia in connection with covered services when rendered by or under the direct supervision of a Professional Provider other than the surgeon or assistant surgeon. Anesthesia services administered by a nurse anesthetist not employed by a Professional Provider will be paid at 50% of the UCR allowance.

Therapy Services

Radiation Therapy: The cost of the radioactive material is covered.

Chemotherapy: Including the cost of the drugs approved by the Food and Drug Administration (FDA) as antineoplastic agents.

Dialysis Treatment

Physical Therapy: To a participant who is an inpatient.

Diagnostic Services

Diagnostic services required to determine a definite condition or disease.

1. Diagnostic radiology, consisting of x-ray, ultrasound and nuclear medicine. One screening mammography per calendar year is covered for females 40 years of age and older. For females under 40 all physician recommended mammograms are covered. Benefits for mammography screening are payable only if performed by a mammography service provider who is properly certified by the Department of Health in accordance with the Mammography Quality Assurance Act of 1992.
2. Diagnostic medical, consisting of ECG, EEG and other diagnostic medical procedures approved by Blue Shield.
3. Diagnostic laboratory consisting of pathology tests performed, billed for, or ordered by a Professional Provider.
4. Allergy testing.
5. Benefits are provided for one (1) routine gynecological examination, including a pelvic examination and clinical breast examination and one (1) routine Papanicolaou smear per calendar year for all female Subscribers. Benefits are exempt from all deductibles and maximums.

Convulsive Therapy

Convulsive therapy including anesthesia for electroshock therapy.

Emergency Care

The initial treatment within 72 hours following an accidental injury or medical emergency.

Medical emergency is a sudden onset of a medical condition with acute symptoms of severity such that the absence of immediate medical attention could result in:

1. Permanently placing the patient’s health in jeopardy,
2. Causing other serious medical consequences,
3. Causing serious impairment to bodilyfunctions.
4. Causing serious and permanent dysfunction of any body part.

These benefits will not be provided if any other benefit of this program is payable. For example: If the accident services are classified as surgery (suturing, burn care, fracture care, etc.), payment will be made as a surgical benefit.

Transplant Services

Benefits are provided for eligible human organ transplant services, including the covered services for the removal of an organ from a donor when the donor is not a participant and not covered under another health care Plan.

Medical Care

Medical care by the Professional Provider in charge of the case to a participant who is an inpatient in a hospital or a skilled nursing facility for a condition not related to surgery, maternity services, radiation therapy or psychiatric care. These covered services are available for a total of 365 days for each period of hospitalization. At least 90 consecutive days must elapse between discharge from a subsequent admission to a hospital or a skilled nursing facility before inpatient stays will be considered a new period of hospitalization.

Psychiatric Care

Treatment of mental illness including visits for drug addiction or alcoholism rendered by the Professional Provider in charge of the case to a subscriber who is an inpatient in a hospital. Such care is available for 30 days in any period of 12 consecutive months. All psychiatric visits are applied toward the Benefit Period of 365 days available for inpatient medical care.

Skilled Nursing Care

Medical Care in a Skilled Nursing Facility. The participant shall be eligible if:

1. The subscriber’s illness or injury requires at least 3 days of hospitalization;
2. The participant’s condition requires skilled nursing care for continued treatment and;
3. The participant is admitted to the skilled nursing facility within 14 days following discharge from an accredited hospital.

These services in a skilled nursing facility are limited to two visits during the first week of confinement and one visit a week for each consecutive week of confinement thereafter. Each day of confinement in a skilled nursing facility counts as one-half day against the total 365 days available for inpatient medical services.

Concurrent Care

Inpatient medical care rendered by a Professional Provider who is not in charge of the case but whose particular skills are required for the treatment of complicated conditions. This does not include observation or reassurance of the patient, stand-by services, routine preoperative physical examinations or medical care routinely performed in the pre- or post-operative or pre- or post-natal periods.

Consultation

Inpatient consultations if the condition requires it and the Professional Provider in charge of the case requests the consultation. There is a limit of one consultation per consultant during any inpatient stay.

Second Surgical Opinion

Second opinion consultation to determine the medical necessity of an elective surgical procedure. Elective surgery is that surgery which is not of an emergency or life threatening nature.

Such services must be performed and billed for by a Professional Provider other than the consultant who provided the patient with the initial surgical consultation. One additional consultation, as a third opinion, is eligible in cases where the second opinion disagrees with the first recommendation. In such instances, you will be eligible for a maximum of two such out-of-hospital consultations involving the elective surgical procedure in question, but limited to one consultation per consultant.

Pediatric Immunizations

Benefits are provided for those pediatric immunizations, including the immunizing agents, which as determined by the Department of Health, conform with the standards of the Advisory Committee on Immunization Practices of the Center for Disease Control of the U.S. Department of Health and Human Services. Benefits are limited to dependent children and are exempt from deductibles or maximums.

Exclusions

Except as specifically provided in this booklet, you are not covered for the following:

• Services which are not prescribed by or performed by or billed by a Professional Provider.
• Services which are not medically necessary as determined by Blue Shield.
• Services, supplies or charges that are experimental or investigational in nature.
• Services performed in a facility by a Professional Provider who in any case is compensated by the facility for similar services performed for patients.
• Services performed by a Professional Provider enrolled in an education or training program when such services are related to the education or training program.
• Services which are paid, or payable, in whole or in part, by a Blue Cross Plan.
• Services which are incurred prior to your effective date or during an inpatient admission that commenced prior to your effective date.
• Services which are incurred after the date of termination of your coverage unless otherwise indicated.
• Services for any illness or bodily injury which occurs in the course of employment if benefits or compensation are available, in whole or in part, under the provisions of any legislation of any governmental unit. This exclusion applies whether or not you claim the benefits or compensation.
• Services for any illness or injury received from a dental or medical department maintained by or on behalf of an employer, a mutual benefit association, labor union, trust, or similar person or group.
• Services for any illness or injury suffered after your effective date as a result of an act of war.
• Service which you have no legal obligation to pay in the absence of this or similar coverage.
• Services provided by any governmental unit.
• Services which are provided by the Veteran’s Administration or by the Department of Defense for active military personnel for which you are eligible even if you have not taken the necessary action to obtain such benefits.
• Equipment costs related to services performed on high cost technological equipment as defined by Blue Shield, such as but not limited to Computed Tomography (CT) Scanners, Magnetic Resonance Imaging (MRI) and extracorporeal shock wave lithotriptors unless the acquisition of such equipment by a Professional Provider was approved through a Certificate of Need (CON) process and/or Blue Shield.
• Payment made under Medicare when Medicare is primary, or would have been made if you had enrolled for Medicare and claimed Medicare benefits. However, this exclusion shall not apply when the group is obligated by law to offer the subscriber all the benefits of this contract and the subscriber so elects this coverage as primary.
• Services directly related to the care, filling, removal or replacement of teeth, the treatment of injuries to or diseases of the teeth, gums or structures directly supporting or attached to the teeth. These include, but are not limited to, apicoectomy (surgical removal of the end of a root), root canal treatment, soft tissue impaction, alveolectomy and treatment of periodontal disease.
• Treatment of temporomandibular joint syndrome with intraoral devices, or any other method to alter vertical dimension.
• For the correction of myopia or hyperopia by means of corneal microsurgery, such as keratomileusis, keratophakia and radial keratotomy and all related services.
• Treatment of obesity, except for surgical treatment of morbid obesity when weight is at least twice the ideal weight specified for frame, age, height and sex.
• Treatment or services for injuries resulting from the maintenance or use of a motor vehicle if such treatment or service is paid or payable under a plan or policy of motor vehicle insurance, including a certified self-insurance Plan, or payable under the Catastrophic Loss Trust Fund established under the Pennsylvania Motor Vehicle Financial Responsibility Law.
• Personal hygiene and convenience items such as, but not limited to, air conditioners, humidifiers, or physical fitness equipment, whether or not recommended by a Professional Provider.
• Telephone consultations, charges for failure to keep a scheduled appointment, or charges for completion of a claim form.
• Custodial care, domiciliary care or rest cures.
• Palliative or cosmetic foot care including flat foot conditions, supportive devices for the foot, the treatment of subluxations of the foot, care of corns, bunions, (except by capsular or bone surgery), calluses, toenails (except surgery for ingrown nails), fallen arches, weak feet, chronic foot strain and symptomatic complaints of the feet.
• Routine or periodical physical examinations.
• Screening examinations.
• The detection and correction by manual or mechanical means of structural imbalance or subluxation for the purpose of removing nerve interference resulting from or related to distortion, misalignment, or subluxation of or in the vertebral column.
• Well-baby care and adult immunizations.
• For operations for cosmetic purposes except for those performed to correct a condition resulting from an accident which occurs while the participant is covered by Blue Shield. The participant must be enrolled without interruption from the date of the accident to the date of the operation in order to be eligible for cosmetic surgery.
• Hearing aids or examinations for the prescription of fitting of hearing aids.
• For treatment in connection with sexual dysfunction not related to organic disease, transsexual surgery, artificial insemination and for assisted fertilization techniques such as, but not limited to, In-Vitro Fertilization (IVF), Gamete Intra-Fallopian Transfer (GIFT), and Zygote Intra-Fallopian Transfer (ZIFT).
• Local infiltration anesthetic.
• Clinical pathology services for which a hospital or other facility bills for the technical component of the service and the Professional Provider bills for the professional component of the service.
• Charges for services which are submitted by a Certified Registered Nurse and another Professional Provider for the same services performed on the same date for the same patient.
• Routine neonatal circumcision.
• For elective abortions, except however, services rendered to treat illness or injury resulting from an elective abortion, services which are necessary to avert the death of the woman and services to terminate pregnancies caused by rape or incest will be covered.
• Any other medical or dental service or treatment except as provided in this booklet.

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