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«CICV Benefits Consortium Vision Plan 01/01/2010 Anthem Blue Cross and Blue Shield Blue View Basic Vision Care Member Certificate Your vision care ...»

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CICV Benefits Consortium

Vision Plan

01/01/2010

Anthem Blue Cross and Blue Shield

Blue View Basic Vision Care Member Certificate

Your vision care benefits are provided through a group insurance policy issued by Anthem Blue Cross

and Blue Shield to go along with the health benefits provided by your employer’s self-funded health

plan. This member booklet fully explains your vision care benefits and how you can maximize them.

Treat it as you treat the owner’s manual for your car - store it in a convenient place and refer to it whenever you have questions about your vision care coverage.

Important phone numbers Member Services 804-358-1551 in Richmond 800-451-1527 from outside Richmond Si necesita ayuda en español para entender este documento, puede solicitarla sin costo adicional, llamando al número de servicio al cliente.

(If you need Spanish-language assistance to understand this document, you may request it at no additional cost by calling the customer service number.)

Hours of Operation:

Monday-Friday 8:00 a.m. to 6:00 p.m. ET Saturday 9:00 a.m. to 1:00 p.m. ET

Visit us on-line at:

www.anthem.com Key words There are a few key words you will see repeated throughout this booklet. We’ve highlighted them here to make the booklet easier to understand. In addition, we have included a Definitions section on page 17 that lists the various words referenced. A defined word will be italicized each time it is used.

We, us, our, Anthem Anthem Blue Cross and Blue Shield.

Covered persons You and enrolled eligible dependents.

You The enrolled employee.

Your vision care plan Anthem vision care plan.

Copayment The fixed dollar amount you pay for some covered services.

Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans of Virginia, Inc.

V-INTRO (7/07) Coinsurance The percentage of the allowable charge you pay for some covered services.

Table of contents page How your vision care plan works.................................................. 1 Choose a vision care provider................................................... 1

–  –  –

Your vision care plan provides vision care services within a special network of vision care providers. You will receive benefits based on where you receive vision care services and the limits stated in the Summary of benefits (see page 2) and related exclusions. This section of your vision care booklet details how to access and make the most of your vision care benefits.

Carry your ID card Your Anthem Blue Cross and Blue Shield ID card identifies you as a member. When you show your ID card to your vision care providers, they will file your claims for you in most cases. Carrying your card at all times will ensure you always have this member information with you when you need it.

Choose a vision care provider To receive in-network benefits, you should receive care from a licensed optometrist, ophthalmologist, or optician that participates in the Blue View Vision Network. Refer to your participating provider listing to choose a vision care provider with a location that is convenient for you.

Many participating providers offer complete vision care services while others may offer only partial services such as dispensing eyeglasses or contact lenses. Follow the key in your provider listing to see which services each provider offers.

–  –  –

Out-of-network care Out-of-network care is vision care services received from a provider who does not participate in the Blue View Vision Network. Out-of-network care is covered at a lower level of benefits than in-network care. When you seek care from a licensed optometrist, ophthalmologist, or optician, you will receive a set dollar allowance for covered services as stated in the Summary of benefits (see page 2).

V-WORKS (7/06)

–  –  –

To help care for your eyes, your vision care plan includes benefits for one routine eye examination per covered person per calendar year.

In order to receive the highest level of benefits, you should seek care from a Blue View Vision participating provider.

Summary of benefits This chart describes your covered services and payment responsibility for care received in-network and out-of-network. For out-of-network care, you will be responsible for the difference between the allowance and the provider’s charge.

A list of services that are not covered begins on page 3.

–  –  –

V-EXCL (1/10) 4 - What is not covered

• for diseases contracted or injuries caused because of war, declared or undeclared, voluntary participation in civil disobedience, or other such activities.

–  –  –

We consider the charge to be incurred on the date a service is provided. This is important because you must be actively enrolled on the date the service is provided. Also, the dates of service will affect your payment allowances and other minimums described in the Summary of benefits and in this section.

–  –  –

If you go to a non-participating provider, we may choose to pay you. We will pay only after we have received an itemized bill and all the information we need to process the claim.





In the event that payment is made directly to you, you have the responsibility to apply this payment to the claim from the non-participating provider. In all cases, our payment relieves Anthem of any further liability for the service.

–  –  –

V-CLAIMS (7/06) 6 - Claims and payments Timely filing of claims Written notice of a claim is to be made within 20 days after the occurrence or commencement of any loss covered by the vision care plan. However, failure to give this notice shall not invalidate or reduce any claim if the notice is given as soon as reasonably possible. Claim forms will be furnished to you if needed within 15 days after this written notice.

Written proof of loss must be furnished within 90 days after the date of service. A proof of loss is not complete unless it is properly filed and contains all information that Anthem needs to process the claim. Failure to furnish the proof of loss within this time frame will not invalidate or reduce any claim if the proof of loss is given as soon as reasonably possible. However, no claim will be paid if we receive the proof of loss more than 15 months after the date of service, except in the absence of legal capacity of the covered person. All benefits payable for a claim will be payable within 60 days after receipt of the proof of loss.

When your claim is processed In processing your claim, your vision care plan may use protocols, guidelines or criteria to ensure that coverage determinations are consistently applied. Claims filed as outlined in the “When you must file a claim” paragraph of this section will be processed within 30 days of receipt of the claim. We may extend this period for another 15 days if we determine it to be necessary because of matters beyond our control. In the event that this extension is necessary, you will be notified prior to the expiration of the initial 30-day period.

Your vision care plan may deny a claim for benefits if information needed to fully consider the claim is not provided. The denial will describe the additional information needed to process the claim. The claim may be reopened by you or your provider furnishing the additional information. You or your provider must submit the additional information to us within either 15 months of the date of service or 45 days from the date you were notified that the information is needed, whichever is later. Once your claim has been processed by your vision care plan, you will receive written notification of the coverage decision. In the event of an adverse benefit determination, the written notification will include

the following:

• the specific reason(s) and the plan provision(s) on which the determination is based;

• a description of any additional material or information necessary to reopen the claim for consideration, along with an explanation of why the requested material or information is needed;

and

• a description of your vision care plan’s appeal procedures and applicable time limits.

–  –  –

Recovery of overpayment Anthem shall have the right to recover any overpayment of benefits from persons or organizations that

we have determined to have realized benefits from the overpayment:

• any person to, or for whom such payments were made;

• any insurance company;

• a facility or provider; or

• any other organization.

You will be required to cooperate with us to secure Anthem’s right to recover the excess payments made on your behalf, or on behalf of covered persons enrolled under your family coverage.

–  –  –

You are eligible for vision care coverage if you are a participant in your employer’s group health plan.

Your eligible dependents covered under the group health plan are also eligible for vision care coverage.

For more specific information on eligibility, please refer to your group health plan’s member booklet.

Ending coverage

When a covered person ceases to be eligible or the required premiums are not paid, the covered person’s coverage will end. Unless otherwise agreed to in writing by Anthem, the covered person’s coverage ends on the last day of the month for which payment is made. The covered person’s coverage ends on the last day of the month during which eligibility ceases.

V-ENR Important information about your vision care plan

–  –  –

You may examine, without charge, at your plan administrator’s office and at other specified locations, all plan documents. These include insurance contracts, copies of all documents filed by the plan with the Department of Labor (such as detailed annual reports), and plan descriptions.

You may obtain copies of all plan documents and other plan information by writing to your plan administrator. The administrator may make a reasonable charge for the copies.

–  –  –

Assistance If you have questions about your plan, contact your Plan Administrator. If you have questions about this statement about your rights under ERISA, contact the nearest Area Office of the Employee Benefits Security Administration, Department of Labor, listed in your telephone directory. You may also contact the Division of Technical Assistance and Inquires, Employee Benefits Security Administration, U.S.

Department of Labor, 200 Constitution Avenue, N.W., Washington, D.C. 20210.

Employer premiums Your employer is responsible for paying a monthly premium by the first day of the month for which coverage is purchased. We will allow employers a 31 day grace period to pay monthly premiums, except for the first month’s premium. During this grace period, coverage will continue unless we receive a written notice of termination from your employer. We will notify your employer at least 15 days prior to terminating the group policy for non-payment of a monthly premium. Anthem is not responsible for costs you incur during any period (other than the grace period discussed above) when your employer fails to pay full premiums.

Changes in the vision care plan We may amend this vision care plan by giving your employer at least 30 days written notice. Any amendment to the vision plan will change covered services to covered persons on the effective date of the change. Your employer and Anthem may mutually agree to amend or reduce benefits at any time.

Complaint and appeal process In order for your vision care plan to remain responsive to your needs, we’ve established both a complaint process and an appeal process. Should you have a problem or question about your vision care plan, a Member Services representative will assist you. Most problems and questions can be handled in this manner. You may also file a written complaint or appeal with us. Complaints typically involve issues such as dissatisfaction about your vision care plan’s services, quality of care, the choice of and accessibility to your vision care plan’s providers and network adequacy. Appeals typically involve a request to reverse a previous decision made by your vision care plan. Requests regarding claim errors, claim corrections, and claims denied for additional information may be reopened for consideration without having to invoke the appeal process.

Important information about your vision care plan - 11

Complaint Process

Upon receipt, your complaint will be reviewed and investigated. You will receive a response within 30 calendar days of your vision care plan’s receipt of your complaint. If we are unable to resolve your complaint in 30 calendar days, you will be notified on or before calendar day 30 that more time is required to resolve your complaint. We will then respond to you within an additional 30 calendar days.

Important: Written complaints or any questions concerning your vision care plan may be filed to the

following address:

Anthem Blue Cross and Blue Shield Attention: Member Services P.O. Box 27401 Richmond, VA 23279 Appeal Process Your vision care plan is committed to providing a full and fair process for resolving disputes and responding to requests to reconsider coverage decisions you find unacceptable. Types of appeals

include:

• internal appeals are requests to reconsider coverage decisions of pre-service or post-service claims.



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