|
Benefit |
Coverage* |
|
|
|
|
Hospital |
100% |
|
Inpatient |
100% |
|
Outpatient |
100% |
|
|
|
|
Emergency |
100% with a $35 co- |
|
|
|
|
Ambulance |
80% |
|
|
|
|
Pharmacy
Formulary |
100% for prescriptions with a $10 Generic co-payment $20 Brand co-payment $40 Non-formulary co-payment Maximum benefit per year is $2,500 |
|
|
|
|
Diabetic
Supplies & |
90% |
|
|
|
|
Home Health |
90% |
|
Medical Supplies
(used
in hospital or Physician’s office) |
100% |
|
Mental Health |
|
|
Inpatient |
100% with a $100 per day co-payment |
|
Outpatient |
100% with a $20 per visit co-payment |
|
|
|
|
Substance Abuse |
|
|
Inpatient |
100% with a $100 per day co-payment |
|
Outpatient |
100% with a $20 per visit co-payment |
|
|
|
|
Physical Therapy |
100% |
|
|
|
|
Physician visits |
100% with a $10 per office visit co-payment |
* All
benefits and stated coverage levels are exclusively for Medically Necessary
services authorized or provided by a
Table of Contents
|
Section
I |
Introduction |
4 |
|
|
|
|
|
Section
II |
Definitions |
4 |
|
|
|
|
|
Section
|
Eligibility
and Enrollment |
8 |
|
|
|
|
|
Sections
IV |
Premium
Payments |
10 |
|
|
|
|
|
Section
V |
Health
Benefits |
10 |
|
|
A. Physician-Patient
Relationships (Your Primary Care Physician) |
11 |
|
|
B. Emergency Care Benefits |
11 |
|
|
C. Covered Services |
12 |
|
|
D. Limitations & Exclusions |
15 |
|
|
E. Rates |
18 |
|
|
F. Important Dates |
19 |
|
|
G.
Excess Provision |
19 |
|
|
H. Third Party Liability |
19 |
|
|
|
|
|
Section
VI |
Informal
and Formal Grievance Procedures |
19 |
|
|
|
|
|
Section
|
How
to File a Claim |
21 |
Section I
Introduction
The
This Certificate of Coverage
constitutes the entire agreement between the Member and the Board of Trustees
of the
This document specifies the
benefits, which Members are entitled to receive as a Member of CampusCare in consideration of the
specified premiums paid by or on behalf of the Member.
Section II
Definitions
The
following definitions apply to all provisions of the Certificate of Coverage:
Academic Year
Shall mean the
period of time beginning at
CampusCare
Shall mean the
self-funded health benefits student program of the
Case Management
Is the process whereby a health care professional supervises the administration of medical and/or ancillary services to a patient.
Contract Year
Shall mean the same as Academic Year.
Co-payment
Shall mean the amount a Member must pay to a Provider in order to receive a specific service under this Certificate of Coverage.
Shall mean the rental or purchase as pre-approved and
at the discretion of CampusCare when
prescribed by a Health Center Physician and the CampusCare Medical
Director, obtained through a CampusCare
Provider and requested for therapeutic use.
Replacement equipment is not covered.
a. Durable Medical Equipment consists of, but is not restricted to, the following:
1. is primarily and customarily used to serve a medical purpose
2. can withstand repeated use
3. generally is not useful to a person in the absence of Injury or Sickness
4. hospital-type beds
5. traction equipment
6. wheelchairs
7. walkers
b. The following items are not considered Durable Medical Equipment:
1. exercise equipment
2. air conditioners
3. electric scooters
4. ramps or other environmental devices
5. dehumidifiers
6. whirlpool baths
7. other equipment that has both a non-therapeutic and therapeutic use
Discharge Planning
Shall mean planning by health care professionals as to how long a Member will be in the Hospital, what the expected outcome will be, whether there will be any special requirements on discharge and what medical services need to be facilitated in advance.
Domestic Partner
Domestic Partner |
Shall S
Shall mean an unrelated partner, same sex individual who reside in the same household and have a financial and emotional interdependence, consistent with that of a married couple for a period of not less than one year and continue to maintain such arrangement
To qualify, a completed
University of Illinois Affidavit of Domestic Partnership form, or its
equivalent from another governmental entity, must be submitted and approved by
the Gender and
If there is a change in status as
domestic partners, the student agrees to notify the Gender and
Enrollee
Shall mean the same as Member.
Enrollment Period
Shall mean
the first twenty eight (28) days of the Fall and Spring Term and the first
fifteen (15) of the summer term as established by
Formulary
Shall mean a listing of accepted outpatient drugs for various disease states as determined by the CampusCare Medical Director and the Pharmacy and Therapeutics Committee.
Group
Shall mean a Member and their eligible dependents enrolled in CampusCare.
Shall mean
approved or contracted
Home Health Care
Shall mean skilled nursing and/or therapeutic services, determined by a CampusCare Health Center physician to be medically appropriate, provided at a Member’s home by an RN or Home Health Aid from a state-licensed Home Health Agency which is eligible to participate under the Medicare program for the Aged and Disabled.
Hospital
Shall mean a duly licensed health care institution, engaged primarily in providing facilities for diagnosis, care and treatment of sick and injured persons under the care of a Physician and including the regular provision of bedside nursing by Registered Nurses. Institutions operated primarily for the purpose of custodial care shall not be included.
Inpatient
Shall mean a Member who is a registered bed patient and is treated as such in a Hospital.
Shall mean essential health care services, as determined by a
Medically Necessary
Medical Emergency
Shall mean a severe injury or medical condition that occurs unexpectedly and which, if not immediately treated, might cause serious complications, cause permanent damage, or death.
Member
Shall mean a
person meeting the Eligibility and Enrollment requirements of Section
Shall mean a Member who is provided services in a
medical clinic, Physician’s office or other health care facility where the
Member is not an inpatient.
Outpatient
Physician
Shall mean a person who is licensed to practice medicine in all of its branches in the state or county in which medical care is provided.
Premium
Shall mean the amount charged by CampusCare for benefits under this Certificate of Coverage.
Prosthetic Devices
Initial Prosthetic Devices are covered when medically
necessary and pre-approved by a
Replacement of an external
prosthetic appliance is not covered unless the replacement is necessary due to
growth or change in medical condition and pre-approved by a
Provider
Shall mean a Hospital, Physician, or other entity, which provides approved medical services to CampusCare Members.
RN
Shall mean Registered Nurse.
Referral Specialist
Shall mean a medical practitioner licensed to practice medicine in the state
where service is rendered and to
whom the patient was referred by a
Service Area
Shall mean the
geographic area within thirty (30) miles of the
Term
Shall mean the
academic session, semester, or summer session as defined by the
Shall mean the
Section
Eligibility and Enrollment
A.
Eligibility
The
The following requirements must be met in order to be eligible for enrollment in CampusCare:
- Student/Member
To be eligible to enroll
in CampusCare, an individual must be
a registered student of
A student is eligible to enroll in CampusCare as a subscriber for the summer Term if he or she was enrolled during the previous spring Term and pays the premium.
A student employed at
- Eligible Dependents
To be eligible to enroll in CampusCare as an eligible dependent, an individual must be either the Member’s:
- Spouse (marriage license must be provided), or
- Qualified Domestic Partner (Domestic Partner affidavit
must completed along with supporting documentation)
- Dependent, unmarried child under the age of
nineteen (19), including a natural or legally adopted child as well as a
child for whom the Subscriber or his/her spouse is the legal guardian.
(Birth certificate, adoption or legal guardianship papers must be
provided), or age twenty-three (23) if a full time dependent student at
an accredited institution of higher learning, who are not self-supporting
(Proof of current full time registration must be provided for each Term
of enrollment).
- Family Coverage means the
Student/Member and his/her family dependents are covered. Whenever “you” or “your” is used in this
Certificate of Coverage, it shall mean all eligible family Members covered
under CampusCare.
B. From Individual to Family Coverage/ Addition of
Family Dependents
You can change from individual to family coverage or cover additional dependents without evidence of insurability, by applying to CampusCare Administration and paying the required Premium for:
- Your new spouse and/or for any eligible
children of your new spouse within thirty-one (31) days of marriage;
- A child pending finalization of a legal adoption
or a newly adopted child within thirty-one (31) days of filing of the
legal documents or of the legal adoption;
- A newborn within thirty-one (31) days following
birth.
A newborn
is covered from the moment of birth only if you submit an application, provides
a copy of the birth certificate and pay the required premium to CampusCare Administration within
thirty-one (31) days following the date of birth.
CampusCare offers no
conversion plan when you become ineligible.
Conversion coverage is also not
available when the entire CampusCare
coverage has been terminated and there is a succeeding carrier.
C. Enrollment
If you are eligible and assessed the Premium as part of your tuition, and have not exempted from the program, you are covered under CampusCare for the applicable Term; therefore, no application is required. You may opt to insure eligible family dependents under the plan by submitting a completed CampusCare enrollment application and all required information and paying the additional Premium within the time designated herein. Request for addition of dependents will be accepted only if received by specified deadline dates and meet the requirements under Eligibility and Enrollment Section B.
Students who have exempted from
coverage and request reinstatement within the enrollment change periods will be
effective the first day of the term.
Students who request reinstatement after the enrollment change period will
become eligible for CampusCare benefits the date the request is received
in the CampusCare Administrative office.
No adjustment in the premium rate will be made.
If Hospitalized Before Effective Date
If you are hospitalized (“pre-enrollment hospitalization”) before the effective date of enrollment, you are not covered for that hospitalization by CampusCare. Discharge from the Hospital, which, as one of its purposes, is the obtaining of coverage for a subsequent hospitalization for the same or similar condition shall be disregarded and the subsequent hospitalization will be considered a continuation of the pre-enrollment hospitalization and therefore not covered by CampusCare.
Section IV
Premium Payment Provisions
You or anyone paying on your
behalf, including tuition payment through the
A. Changes in Premium Rates
The Premium rates will be effective
for a twelve (12) month period of time. They will then be subject to change on
a yearly basis on the Group’s anniversary date, which is the beginning of the
Fall Term. Notice to members of changes in Premium rates will be provided by
Section V
Health Benefits
Each Member of CampusCare is entitled to receive the following benefits, subject to the limitations and exclusions of coverage and benefits as described in the Benefit Summary, and subject to all terms, conditions, and definitions, as stated in this Certificate of Coverage.
Except in the event of a
Life-Threatening Medical Emergency, CampusCare
benefits are available only if they are provided, ordered or preauthorized by a
A. Physician-Patient Relationship
A.
TO RECEIVE
BENEFITS UNDER THIS CERTIFICATE OF COVERAGE
Confidentiality
Information from medical records and information received by CampusCare Health Center Physicians incident to the physician-patient relationship shall be kept confidential and in compliant with privacy rule outlined under Health Insurance Portability and Accountability Act (HIPAA). Information about Members’ care will not be disclosed without express written consent or, in the case of a minor, without the written consent of the minor’s parent or legal guardian, except as permitted or required by law.
B. Emergency Care
CampusCare will
be financially responsible for emergency health care services preauthorized
by a
1.
SEVERE OR
Life-Threatening
Medical Emergency as defined in this Certificate of Coverage, is a severe
injury or medical condition that occurs unexpectedly and which, if not
immediately treated, might cause serious complications, or cause permanent
damage or death. Heart attacks, cerebral vascular accidents (strokes),
poisonings, loss of consciousness, and convulsions are considered to be
examples of such Medical Emergencies.
In the
event of a life-threatening emergency go to the nearest emergency room for
treatment. The Member or someone on the
Member’s behalf is required to notify CampusCare
within forty-eight (48) hours of any services received. Such notification
does not guarantee that CampusCare will
be responsible for the incurred charges. The determination as to whether the
condition meets Emergency Care guidelines and therefore is payable under this
Certificate of Coverage will be made by the Medical Director or designee. After the emergency, all follow-up care
must be provided or preauthorized by a CampusCare
Health Center Physician.
2.
URGENT OR NON-
An urgent
problem requires immediate attention but is not life threatening. All care for an urgent problem or
non-life-threatening emergency must be provided or preauthorized by a
3. Emergency Ambulance
Services
Ground
ambulance service is provided when preauthorized by a
1. Physician
Services-Outpatient and Inpatient
All
services for the diagnosis and treatment of covered illness or covered
injuries, congenital defects, birth abnormalities and premature birth provided
or ordered by a CampusCare Health
Center Physician are covered, including all professional services, primary
care, consultation, referral, surgical procedures, anesthesia, and medical
supplies used in the hospital or physician’s office.
2.
Diagnostic and Therapeutic Services
Services
including laboratory, imaging, CT Scan, X-ray, pathology services, radiology
services and radiation therapy, electroencephalograms, electrocardiograms,
clinical lab treatments (chemotherapy) for covered illness, accidents,
congenital defects, birth abnormalities and premature birth are covered when
provided or ordered by a CampusCare
Health Center Physician or preauthorized referral provider.
3.
Preventive Health Services
Dependent Over Age 8
One annual
routine exam performed by a
Well Child
Care
Services for Well Child Care will be
provided for all eligible and covered dependents under age nine (9). This would include all required examination, vaccinations and
immunizations when performed by a CampusCare
Health Care Physician.
Cervical Cancer Screening Test
Cervical
Cancer Screening Test will be paid the same as any other sickness for an annual
cervical smear or pap smear test.
Colorectal Cancer Test
Colorectal
Cancer Test shall be provided on the same basis as any other Sickness when
ordered by a
Prostate Cancer Screening
Prostate
Cancer Screening shall be provided on the same basis as any other Sickness when
ordered by a
Mammography Benefits
Benefits
will be paid the same as any other sickness for screening by low-dose
mammography for the presence of occult breast cancer according to the following
guidelines:
a)
A baseline mammogram for women thirty-five (35) to
thirty-nine (39) years of age.
b)
A mammogram every one (1) to two (2) years, even if no
symptoms are present, for women forty (40) to forty-nine (49) years of age.
c)
An annual mammogram for women fifty (50) years of age
or older.
“ Low dose
mammography” means the x-ray examination of the breast using equipment
dedicated specifically for mammography, including the x-ray tube, filter,
compression device, screens, films, and cassettes, with an average radiation
exposure delivery of less than one rad per breast,
for two (2) views of an average size breast.
4.
Hospital
Services are provided for an unlimited number of days when hospitalization
occurs in a CampusCare approved
Hospital and is preauthorized by a CampusCare
Health Center Physician (see subsections
for provisions on Inpatient mental health care and Inpatient alcohol and drug
abuse). Hospital services include room and board, general nursing care and
Medically Necessary ancillary services, including Discharge Planning and Case
Management. Private duty nurses are covered when a
Members are
generally hospitalized in a semi-private (two-bed) accommodation. If it is Medically Necessary (as
preauthorized by the Health Center Physician) for you to occupy a private room
(one-bed), CampusCare will be
responsible for the cost. However, if a
Member decides to occupy a private room and it is not preauthorized as
Medically Necessary, the Member will be responsible for the difference in the
rate between the most common semi-private room rate and the private
accommodations.
All
Medically Necessary professional services provided or preauthorized by the
5.
Transfer from non-approved to approved Hospital
Immediate
transfer from a non-approved Hospital to a CampusCare
approved Hospital will be provided once a CampusCare Health Center
Physician or CampusCare Medical Director or designee has approved the
transfer. A Member’s refusal to transfer (for other than medical reasons) will
result in the loss of all benefits for any days at the non-approved Hospital.
6. Diabetic Treatment/Supplies
Insulin
Syringes, glucose monitors, lancets, needles and test strips up to one (1)
month supply per prescription when medically necessary and preauthorized by a
7.
Durable Medical Equipment
Covered
only when Medically Necessary and preauthorized by a
8. Asthma Treatment/Supplies
Peak Flow meters, and home
nebulizers, one (1) device per academic year when medically necessary and
preauthorized by a
9.
Home Health Care
When
Medically Necessary and preauthorized by a CampusCare Health Center
Physician, a Member will be provided with skilled nursing care and therapeutic
services at the Member’s home in place of inpatient hospitalization. Care must be given by a contracted CampusCare Home Health Agency. All Home Health Care must be ordered and
monitored under the direction of a
10.
Maternity Care
When Medically Necessary and preauthorized by a CampusCare Health Center Physician, all routine testing and screenings will be considered if all other policy provisions have been met.
11.
Maximum Lifetime Benefit
The Maximum Lifetime Benefit payable for all CampusCare benefit coverage afforded under this Certificate of Coverage is $500,000.
The
following services are not covered under this Certificate of Coverage:
1. Services Rendered by Non-CampusCare Physicians and/or
Non-approved Hospitals
Services or supplies provided by non-CampusCare Physician and/or in hospitals
other than CampusCare approved
hospitals except in a Life-Threatening Medical Emergency as defined herein or
authorized by the CampusCare Medical
Director or designee.
2. Member Responsibility
Services required because the Member did not comply
with a
3. Governmental Responsibility
Treatment in a Government hospital, such as the
Veterans Administration facility, unless there is a legal obligation for the
member to pay for such treatment.
4. Services Not Considered
Medically Necessary
Physical examinations for obtaining or continuing
employment, meeting educational requirements such as college entrance,
internships, residencies, etc., for governmental licensing, for securing
insurance coverage, or other services or supplies which are not, in the judgment
of the CampusCare Health Center
Physician, necessary for the medical treatment, maintenance or improvement of a
Member’s health or the most appropriate supply or level of service which can
safely be provided.
5. Cosmetic Procedures/Surgery
Plastic or cosmetic procedures or surgery with the
exception of restorative surgery to correct an Injury for which benefits are
otherwise payable under this policy when medically necessary and preauthorized-
by a CampusCare Health Center
Physician.
6. Acts of War, Armed Forces,
Riots and Felonies
Medical services needed as a result of injuries or
sickness caused by War or an Act of War, declared or undeclared, and/or Civil
Unrest, insurgency, or rebellion, or while in the service of the Armed Forces
of any country. Services needed as a result of participation in a riot or civil
disorder, commission of or attempt to commit a felony.
7. Corrective Appliance or
Devices
Special braces, splints, specialized equipment,
appliances, ambulatory apparatus or battery or atomically controlled implants,
Including, but not limited to eyeglasses, contact lenses, hearing aids,
orthotics boots and canes, except as specifically included under covered
services.
8. Custodial or Convalescent
Care
Custodial or convalescent care when the facilities
or services of an acute care Hospital are not Medically Necessary in the
judgment of the CampusCare Medical
Director.
9. General Dentistry
Dental treatment or services cause by accident or
illnesses.
10. Personal Comfort Items or
Services
Including, but not limited to, personal items,
telephones, slippers, personal hygiene items, robes, gowns, and televisions and
Federal, State or Local Government Tax.
11. Experimental/Investigational
Procedures
Any charges incurred for any procedure, including
organ tissue, or cell transplants, that are deemed to be experimental or
investigational in nature by any appropriate technological assessment body
established by any state or federal government and/or those not recognized by
the majority of the local medical community as appropriate and recommended
standard of care. In addition,
procedures, services or supplies related to sex transformation are not covered.
12. Outpatient Drugs
a) Including, but not limited
to non-FDA approved drugs, drugs prescribed for non-FDA approved indications, prescriptions and/or
treatments, and over-the-counter medications;
b) Therapeutic devices or
appliances, including hypodermic needles, syringes (except for diabetic
treatment), garments and other non-medical substances, regardless of intended
use;
c) Contraceptives, oral or
other, “whether prescription or non-prescription drugs” medication or devices,
regardless of intended use;
d) Biological sera, blood or
blood products administered on an outpatient basis;
e) Drugs labeled, “Caution –
limited by federal law to investigational use” or experimental drugs;
f)
Products used for approved or unapproved cosmetic indications;
g) Drugs used to treat or cure
alopecia (hair loss/baldness), and anabolic steroids used for body building or
any other reason other than wasting syndrome;
h) Anorectics- drugs used for
the purpose of suppressing appetites and weight loss control;
i)
Fertility agents or sexual enhancements drugs, such as but not limited
to Parlodel, Pergonal, Clomid, Profasi, Metrodin, Serophene, or Viagra;
j)
Growth hormones;
k) Refills in excess of the
number specified or those dispensed after one (1) year of the date of the
original prescription;
l)
Any drug that can be acquired in any form over-the-counter without a
written order from a licensed physician or other clinical licensed practitioner;
m) Vitamins, minerals, herbs
and or other nutritional supplements;
n) Medications other than those
taken for chronic conditions may only be dispensed in limits up to thirty (30)
days or the prescribed amount whichever is less. Medications for chronic conditions may be
dispensed up to a sixty (60) day supply only after a Member has first received
a trial dose up to but not exceeding a thirty (30) day supply and consumed by
the Member. Two (2) co-payments will be
charged for each sixty (60) day supply;
o) Medications reflecting
amounts above the generally accepted pharmaceutical guidelines, manufacturer’s
packaging, and/or FDA guidelines;
p) Medication refills before at
least seventy-five (75) % of the previously filled prescription has been
consumed and not more than thirty (30) day supply beyond the Term of coverage.
13. Fertility/Infertility
Services
Including, but not limited to birth control; family planning; fertility tests; infertility (male or female), including any services or supplies rendered for the purpose or with the intent of inducing conception. Examples of fertilization procedures are: ovulation induction procedures, in vitro fertilization, embryo transfer or similar procedures that augment or enhance your reproductive ability; premarital examinations; impotence, organic or otherwise, the reversal of tubal ligations or vasectomy; sexual reassignment surgery.
14. Prescription Medicine and supplies related to or intended for treatment of nicotine or alcohol addiction or any other potentially addictive substances or conditions.
15. Biofeedback
treatment, services and supplies related to biofeedback
16. Elective Surgery and treatment
Services and any related charges including facility charges.
17. Routine
physical examination and testing
Routine physical examination and routine testing, preventative testing or treatment, screening exams or testing in absence of Injury or Sickness except as specifically provided for within Covered Services.
18. Injections
and Immunizations
Immunization needed to meet educational requirements such as college entrance clerkships, internships, residencies, etc., and/or injections needed for planned travel.
19. Workers’
Compensation
Injury or sickness for which benefits are paid or payable under Workers’ Compensation or Occupational Disease Law or Act, or similar legislation.
20. Foot
Care
Services and supplies for foot care including care of corns, bunions (except capsular or bone surgery), or calluses.
21. Transfer
Policy
Refusing to transfer to another Hospital or health care facility for other than medical reasons, as requested by CampusCare will result in loss of benefits for any and all days and charges at the non-approved facility from the date of refusal.
22. Exhaustion
of Benefits/Eligibility
Services ordered or authorized beyond the benefit limitation or eligibility period are the responsibility of the Member without regard to whether or not services are initiated during an eligible period.
23. High
Risk physical activities
a) Medical Services needed as a
result of injuries or sickness caused by including, but not limited to
skydiving, parachuting, hang gliding, glider flying, parasailing, sail
planning, bungee jumping, or flight in any kind of aircraft, except while
riding as a passenger on a regularly scheduled flight of a commercial airline;
24. Vision Services
a) Services and supplies
related to eye examinations, eyeglasses or contact lens or prescriptions or
fitting of eyeglasses, except when due to a disease process.
b) Services and supplies
related to myopia, astigmatism, or normal aging processes of the eye or
surgical or laser correction of the conditions.
25. Weight Management
Services and supplies related to weight reduction
programs, weight management programs, related nutritional supplies, treatment
for obesity, and surgery for removal of excess skin or fat.
26. Services and supplies
received outside of the continental
E. Rates
Undergraduate, Graduate, Health Professional
students and others enrolled in sponsored student programs and Dependents fee/premium
per Term.
Fall Spring Summer
Student
$401.00 $401.00 $264.00
Spouse* $1,068.00 $1,068.00 $710.00
All Children *
$538.00 $538.00 $355.00
* Student must
also be insured.
F.
2008-2009 Important Dates
Fall Term Spring Term Summer Term
Coverage
Periods: 8/25/08- 1/11/09 1/12/09- 5/25/09 5/26/09-
8/23/09
Enrollment/
Change Periods: 8/25/08-9/21/08 1/12/09-2/8/09 5/26/09-6/9/09
Exemptions/
Reinstatements/
Dependent Periods
and
Deadlines: 8/25/08-9/21/08 1/12/09-2/8/09 5/26/09-6/9/09
Deadlines are dates by which exemptions, extensions
or enrollment of Dependents must be accomplished.
Dates are based on the University Academic Year and
are subject to change.
G.
Excess Provision
This Plan contains an “Excess Provision”. No benefits are payable under this coverage for any incurred Injury or Sickness expenses that are payable or paid by other valid and collectible group insurance.
H.
Third Party Liability
Services
and supplies covered under this Certificate of Coverage are provided for you if
you are injured by acts of omissions of a third party. You must require the third party to pay for
the services and/or to reimburse CampusCare
immediately upon collecting any damages, whether by action of law, settlement,
or otherwise, to the extent of the expenses incurred by CampusCare.
CampusCare shall have a lien, to the
extent of the expenses incurred by CampusCare. The lien may be filed with the third party
whose act(s) caused the injuries, his agent or a court having jurisdiction in
the matter.
Section VI
Informal and Formal Grievance Procedures
The
following procedures have been developed to resolve informal and formal Member
request, concerns, or complaints with respect to CampusCare issues and operations.
Customer Service and Claim Representatives are required to maintain a
written encounter, which identifies the general nature and disposition of the
request, concern, or complaint.
A.
Informal Procedures
1.
A member should discuss his/her request, concerns, or complaints with
his/her
2.
If the Member is not satisfied with the resolution, he/she should
discuss and resolve the matter with the assistance of a CampusCare representative.
3.
If the resolution is not satisfactory, the Member should discuss and
resolve the matter with a CampusCare
Customer Service Supervisor.
4.
If the resolution is not satisfactory, the Member should discuss and
resolve the matter with the assistance of the Director or Medical Director.
5.
If the resolution is not satisfactory, after following the above
procedures, the member has the right to file a formal grievance with the
chairperson of the Grievance Committee.
B.
Formal
Procedures
1.
A formal grievance must be in writing, list the facts and circumstance
giving rise to the grievance, and be filed within 90 days from the date the
Member reasonably should have known of the occurrence of the
circumstances.
2.
No grievance may be filed:
a) Concerning any allegation or
implication of professional liability or unusual injury due to negligence;
b) Which challenges or disputes
established written policies of CampusCare,
the Board, or any state or federal action, regulation, or procedure, except
that the Grievance Committee may hear grievances challenging written CampusCare or Board policies for the
sole purpose of advising CampusCare
of requested changes;
c) Which request relief not
within the power of CampusCare or Board to grant, except that the
Grievance Committee may hear grievances requesting such actions for the sole
purpose of advising CampusCare of the requested changes;
d) Which challenges or disputes
any part of any contractual arrangement entered into by the Board, CampusCare,
or any agent of CampusCare including employment contracts, and Provider
or service agreements; or
e) Which challenges or disputes
any programmatic decision made by the Board or CampusCare.
3.
The Grievance Committee chairperson shall review the formal grievance
and in consultation with CampusCare Administration render the resolution
requested by the Member or convene the Grievance Committee to resolve the
grievance.
4.
The Chairperson will issue a written receipt to the member within ten
(10) business days of receiving the grievance.
5.
After discussing the matter with the Member, the Committee will
deliberate in private to render the resolution by majority vote. This resolution will be made within sixty
(60) days after the grievance is filed.
An additional thirty (30) day extension is available in the event of a
delay in obtaining the documents or records necessary for resolution. All requests for documents or records
necessary for the resolution shall be maintained in CampusCare's grievance file.
6.
The Member will receive a written notification of the determination
within five (5) business days of that determination.
7.
The decision of the Grievance Committee shall be final.
Section
How to File a Claim
If you receive a bill for any type of service that
you believe is a covered benefit you should send the bill to:
CampusCare
440 Quadrangle Drive Suite B
Claims over one (1) year old will not be paid.
You can also check the status of any claim by
logging on to:
http://www.uic.edu/hsc/campuscare/chicago/
http://www.uic.edu/hsc/campuscare/peroria/
http://www.uic.edu/hsc/campuscare/rockford/
Please visit our web site listed above for:
Brochures, Enrollment Cards, Claim Status, Dental
and Vision plan benefits and other important information.
Question regarding claims or benefits should be
directed to customer service at 312-996-4915.