Even if the payment of healthcare benefits to a Non- Participating Provider has been authorized by You, We may make payment of benefits to You. When benefits are paid to You, You or Your Dependents are responsible for reimbursing the a Non-Participating Provider . Initial Determination A claim for vision benefits will be reviewed upon receipt. We will notify You of Our decision to approve or deny the claim within 30 days from the date You submitted the claim, unless an extension is required due to matters beyond Our control. Any extension will not be more than 15 days. If We require an extension, You will be notified in writing before the end of the initial 30 day period. The notice of extension will explain the reasons for the extension and will state when a determination will be made. If an extension is required because We require additional information from You, the time from the date of Our notice requesting further information and the time We receive the necessary information does not count toward the time period We are allowed to notify You of the claim determination. You will have 45 days from the date You receive the request for additional information to provide the requested information. Claim Denial If Your claim is denied, in whole or in part, the notification of the claim decision will state the reason why Your claim was denied and reference the specific plan provisions upon which the denial is based. If the claim is denied because more information is needed from You, the claims decision will describe the additional information needed and why such information is needed. If We relied on an internal rule or other criterion when denying the claim, the claim decision will include the rule or other criteria or will indicate that such rule or criteria was relied upon and You may request a copy free of charge. To Whom Payable Vision benefit payments are assignable to the provider. When You assign benefit payments to a provider, You have assigned the entire amount of the payment due on that claim. If the provider is overpaid because of accepting a patient’s payment on the charge, it is the provider’s responsibility to reimburse the patient. Because of Our contracts with providers, all claims from contracted providers should be assigned. We may, at Our option, make payment to You for the cost of any Covered Vision Services from a Non-Participating Provider even if benefits have been assigned. When benefits are paid to You or Your Dependent(s), You or Your Dependent(s) are responsible for reimbursing the provider. If any person to whom benefits are payable is a minor or is not able to give a valid receipt for any payment due that person,
such payment will be made to that person’s legal guardian. If no request for payment has been made by that person’s legal guardian, We will make payment to the person or institution appearing to have assumed that person’s custody and support. In the event of the death of a Covered Person, We may receive notice that an executor of the estate has been established. The executor has the same rights as the Covered Person and benefit payments for unassigned claims should be made payable to the executor. Payment as described above will release Us from all liability to the extent of any payment made. Recovery of Overpayment When We have made an overpayment, We will have the right at any time to: recover that overpayment from the person to whom or on whose behalf it was made; or offset the amount of that overpayment from a future claim payment. In addition, Your acceptance of benefits under this Policy and/or assignment of benefits separately creates an equitable lien by agreement pursuant to which We may seek recovery of any overpayment. You agree that in seeking recovery of any overpayment as a contractual right or as an equitable lien by agreement, We may pursue the general assets of the person or entity to whom or on whose behalf the overpayment was made.
HCVIS-POB0
01-24
Termination of Insurance Termination of Your Insurance Your insurance will cease on the earliest date below: • the last day of the calendar month in which you cease to be in a Class of Eligible Employees or cease to qualify for the insurance. • the last day of the calendar month in which you have made any required contribution for the insurance. • the date the Policy is canceled or lapses due to a nonpayment of premium. • the last day of the calendar month in which Your Active Service ends, except as described below. • Your death. Any continuation of insurance must be based on a plan which precludes individual selection.
myCigna.com
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