Healthcare Health Plan Notice

HEALTHCARE HEALTH PLAN NOTICE

This Health Plan Notice explains coverage information, claims procedures, grievance and appeal rights, uses and disclosures of protected health information, and authorizations necessary for claims processing and benefits payment. Patient acknowledges receipt of this notice, agrees to the terms for claims and benefits administration, and provides consent where indicated below.

Patient Information

Insurance Information

Coverage Effective Date:   Plan Contact for Claims:

Medical History (for benefits coordination)

Notice of Coverage, Claims, and Appeals Procedures

Claims Submission and Adjudication: Claims must be submitted in accordance with plan procedures. The plan will acknowledge receipt of a complete claim and provide a timely determination. For any adverse benefit determination, you will receive a written notice describing the reason for denial, the relevant plan provisions relied upon, and instructions to request an internal appeal.

Internal Appeal Rights: You have the right to file an internal appeal within the timeframe specified in the denial notice. The plan will provide a written decision on appeal and the factual and legal basis for the determination. You may submit written materials and request copies of documents relevant to the claim.

External Review: If you remain dissatisfied after the internal appeal, you may be entitled to an external independent review. Instructions for initiating external review will be provided with the final internal appeal decision when applicable.

Urgent Care Claims: For urgent care or concurrent care decisions, expedited procedures apply and timelines will be communicated orally and followed by written confirmation.

Authorization, Assignment of Benefits, and Use/Disclosure of PHI

Authorization to Obtain and Disclose Protected Health Information: By signing below, I authorize my health care providers and facilities to disclose my protected health information (PHI) to the plan and its designees for purposes of enrollment, eligibility verification, claims processing, utilization review, quality assessment, and care coordination. This authorization includes medical records, billing records, and other information necessary to adjudicate claims.

Assignment of Benefits: I authorize payment of benefits directly to the rendering provider when applicable. I understand that the plan may offset payments or recover overpayments according to plan terms and recoveries may be sought from third parties when required by subrogation or coordination of benefits rules.

I consent to release PHI to the plan for the purposes described above.

I assign benefits to my health care provider when billing the plan on my behalf.

Revocation and Effect: I understand that I may revoke this authorization in writing at any time, except to the extent that action has already been taken in reliance upon it. The revocation will not affect disclosures made prior to receipt of the revocation.

HIPAA Privacy Acknowledgment

I acknowledge that I have been provided with, or offered, the plan's Notice of Privacy Practices describing how my protected health information may be used and disclosed and how I can obtain access to this information. I understand my rights under applicable privacy laws, including the right to request restrictions on uses and disclosures and the right to receive confidential communications.

Acknowledgment: I acknowledge receipt or offer of the Notice of Privacy Practices.

Grievance and Contact Information

If you have a question about benefits, coverage determination, or wish to file a grievance, contact the plan's customer service or grievance department as shown in your plan documentation. The plan will respond in accordance with applicable timelines and provide a description of further review rights, including external review where available.

Statements, Certifications, and Signature

By signing below, I certify that the information provided on this Health Plan Notice form is true and correct to the best of my knowledge. I authorize the release of information and assignment of benefits as indicated above for the purpose of obtaining payment or determining eligibility. I understand that making false statements or concealing material facts may subject me to plan remedies including denial of benefits or recovery of overpayments.

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