Welfare Summary Plan Description

6.3 RESTRICTIONS AND LIMITATIONS OF THE UTILIZATION MANAGEMENT PROGRAMS

  • The fact that your Physician recommends surgery, hospitalization, or confinement in a specialized facility, or that your Physician or another provider proposes or provides other services/supplies doesn't necessarily mean that the recommended services/supplies will be determined Medically Necessary.
  • The Utilization Management Programs are not intended to diagnose or treat medical conditions, validate eligibility for coverage, or guarantee payment of Plan benefits. Certification of Medical Necessity does not necessarily mean that an individual is eligible for Plan benefits or that Plan benefits will be payable. For example, benefits would not be payable if your eligibility for coverage ended before the services were rendered, if the services were not covered by the Plan, or the maximum benefit had already been paid.
  • All treatment decisions rest with you and your Physician. You should follow whatever course of treatment you and your Physician believe to be the most appropriate. Benefits payable by the Plan may, however, be affected by the Utilization Management Programs.
  • The Plan and the Utilization Management Organization are not responsible for either the quality of health care services actually provided, or for the results if the Participant chooses not to receive health care services that the Utilization Management Organization determined to be not Medically Necessary.