Important chapters to know in the Evidence of Coverage( EOC)
Important chapters to know in the Evidence of Coverage( EOC)
Chapter 3( III): Schedule of Benefits( SOB)
This chapter explains the types of services your plan covers, like doctor visits, hospital care and pharmacy benefits. Check your plan-specific Schedule of Benefits for the exact copays, deductibles, and coinsurance that apply to you.
Chapter 3( III): Balance Billing( Your Rights / Surprise Billing)
This section explains your protections from unexpected bills when you see out-of-network providers. It tells you when providers can or cannot bill you and how to avoid surprises.
Chapter 3( III): Emergency Services
Emergency care is for life-threatening or serious conditions. This chapter explains what counts as an emergency, how to notify the plan, and that emergency care is covered even without prior authorization.
Chapter 4( IV): Exclusions and Limitations
This chapter lists services that aren’ t covered or have limits. Reading this can help you avoid surprises with bills or denied services.
Chapter 4( IV): Urgent Care Services
Urgent care is for conditions that need quick attention but aren’ t life-threatening. This section explains the difference between urgent care and emergency care and notes that using the ER for non-emergencies may cost more.
Chapter 5( V): Utilization Management Program
This chapter explains when your care needs approval from the plan, including prior authorization and concurrent review. Knowing this helps prevent delays or denials for tests, procedures or treatments.
Chapter 8( VIII): Primary Care and Specialty Care Physicians
This section covers how to choose a Primary Care Provider( PCP), when you need referrals and the importance of staying in-network. It explains what to expect from both regular and specialist care.
Chapter 14( XIV): Member Claims and Appeal Procedures
Learn how to file claims, what to do if a claim is denied and how to use the appeals process. This is important if you ever disagree with a coverage decision.
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