2026 CODAC Benefit Summaries and Carrier Flyers

The specific reimbursement formula used will vary depending upon the Physician or facility providing the service(s) and the type of service(s) received.

When covered health services are received from a non-Network Provider as a result of an Emergency or as arranged by Your Claims Administrator, eligible expenses are amounts negotiated by Your Claims Administrator or amounts permitted by law. Refer to the Protection from Balance Billing section of this SPD for more information. Please contact the Patient Advocacy Center at pac@hstechnology.com or call their toll free number at (888) 837-2237 if You are billed for amounts in excess of Your applicable Plan Participation, Co-pays, or Deductibles. The Plan will not pay excessive charges or amounts You are not legally obligated to pay. See “Surgery and Assistant Surgeon Services” in the Covered Medical Benefits section for exceptions related to multiple procedures. A global package includes the services that are a necessary part of a procedure. For individual services that are part of a global package, it is customary for the individual services not to be billed separately. A separate charge will not be allowed under the Plan. If a claim is submitted by a Covered Person or a Provider on behalf of a Covered Person and the Plan does not completely cover the charges, the Covered Person will receive an Explanation of Benefits (EOB) form that will explain how much the Plan paid toward the claim, and how much of the claim is the Covered Person’s responsibility due to cost -sharing obligations, non-covered benefits, penalties, or other Plan provisions. Please check the information on each EOB form to make sure the services charged were actually received from the Provider and that the information appears to be correct. If You have any questions or concerns about the EOB form, call the Plan at the number listed on the EOB form or on the back of the group health identification card. The Provider will receive a similar form for each claim that is submitted. NOTIFICATION OF BENEFIT DETERMINATION • Pre-Service Claims: A decision will be made within 15 calendar days following receipt of a claim request, but the Plan may have an extra 15-day extension when necessary for reasons beyond the control of the Plan, if written notice is given to the Covered Person within the original 15-day period. • Post-Service Claims: Claims will be processed within 30 calendar days, but the Plan may have an additional 15-day extension when necessary for reasons beyond the control of the Plan, if written notice is provided to the Covered Person within the original 30-day period. • Concurrent Care Claims: If the Plan is reducing or terminating benefits before the end of the previously approved course of treatment, the Plan will notify the Covered Person prior to the treatment ending or being reduced. • Emergency and/or Urgent Care claims as defined by the Affordable Care Act: The Plan will notify a Covered Person or Provider of a benefit determination (whether adverse or not) with respect to a claim involving Emergency or Urgent Care as soon as possible, taking into account the Medical Necessity, but not later than 72 hours after the receipt of the claim by the Plan, and deference will be made to the treating Physician. TIMELINES FOR INITIAL BENEFIT DETERMINATION HealthSCOPE Benefits will process claims within the following timelines, although a Covered Person may voluntarily extend these timelines:

A claim is considered to be filed when the claim for benefits has been submitted to HealthSCOPE Benefits for formal consideration under the terms of this Plan.

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