is board certified and qualified, by reason of his or her specialty, to give an opinion on the proposed Surgery; is not a business associate of the Covered Person's Practitioner; and does not perform the Surgery if it is needed. [ABC] gives second opinion forms to the Covered Person. The Practitioner he or she chooses fills them out, and then returns them to [ABC]. We cover charges for additional surgical opinions, including charges for related x-ray and tests. But what We pay is based on all the terms of this Policy, except, these charges are not subject to the Cash Deductible or Coinsurance. Pre-Hospital Review If the proposed Surgery is to be done on an Inpatient basis, the Required Pre-Hospital Review section must be complied with. See the Required Pre-Hospital Review section for details. Penalties for Non-Compliance As a penalty for non-compliance, We reduce what We pay for covered professional charges for Surgery by 50%] if: the Covered Person does not request a pre-surgical review; or [ABC] is not given at least 24 hours to review and evaluate the proposed Surgery; or [ABC] requires additional surgical opinions and the Covered Person does not get those opinions before the Surgery is done; [ABC] does not confirm the need for Surgery. Penalties cannot be used to meet this Policy's Maximum Out of Pocket, Cash Deductible or Coinsurance. ] [SPECIALTY CASE MANAGEMENT Important Notice: No Covered Person is required, in any way, to accept a Specialty Case Management Plan recommended by [DEF]. Definitions "Specialty Case Management" means those services and supplies which meet both of the following tests: They are determined, in advance, by Us to be Medically Necessary and Appropriate and cost effective in meeting the long term or intensive care needs of a Covered Person in connection with a Catastrophic Illness or Injury. While there are other covered services and supplies available under this Policy for the Covered Person’s condition, the services and supplies We offer to make available under the terms of this provision would not otherwise be payable under this Policy. Please note: We have sole Discretion to determine whether to consider Specialty Case Management for a Covered Person. "Catastrophic Illness or Injury" means one of the following: head injury requiring an Inpatient stay
is board certified and qualified, by reason of his or her specialty, to give an opinion on the proposed Surgery; is not a business associate of the Covered Person's Practitioner; and does not perform the Surgery if it is needed. [ABC] gives second opinion forms to the Covered Person. The Practitioner he or she chooses fills them out, and then returns them to [ABC]. We cover charges for additional surgical opinions, including charges for related x-ray and tests. But what We pay is based on all the terms of this Policy, except, these charges are not subject to the Cash Deductible or Coinsurance. Pre-Hospital Review If the proposed Surgery is to be done on an Inpatient basis, the Required Pre-Hospital Review section must be complied with. See the Required Pre-Hospital Review section for details. Penalties for Non-Compliance As a penalty for non-compliance, We reduce what We pay for covered professional charges for Surgery by 50%] if: the Covered Person does not request a pre-surgical review; or [ABC] is not given at least 24 hours to review and evaluate the proposed Surgery; or [ABC] requires additional surgical opinions and the Covered Person does not get those opinions before the Surgery is done; [ABC] does not confirm the need for Surgery. Penalties cannot be used to meet this Policy's Maximum Out of Pocket, Cash Deductible or Coinsurance. ] [SPECIALTY CASE MANAGEMENT Important Notice: No Covered Person is required, in any way, to accept a Specialty Case Management Plan recommended by [DEF]. Definitions "Specialty Case Management" means those services and supplies which meet both of the following tests: They are determined, in advance, by Us to be Medically Necessary and Appropriate and cost effective in meeting the long term or intensive care needs of a Covered Person in connection with a Catastrophic Illness or Injury. While there are other covered services and supplies available under this Policy for the Covered Person’s condition, the services and supplies We offer to make available under the terms of this provision would not otherwise be payable under this Policy. Please note: We have sole Discretion to determine whether to consider Specialty Case Management for a Covered Person. "Catastrophic Illness or Injury" means one of the following: head injury requiring an Inpatient stay
a50_Dadopt.docx