Payment & Reimbursement Responsibility pay a Non-Plan Provider because the claim was denied, you could be liable to the Non-Plan Provider for the cost of service.
Liability of Subscriber or Enrollee for Payment Plan Members are not liable for charges for Covered Services authorized by their PCP or VHP. A Copayment may be required for some services. The specific Copayment or other charges for your Benefit Plan can be found in the “Benefits Description Table” and in the Group Service Agreement available from your employer. If you receive care that is not performed by your PCP or authorized by VHP, you will be financially responsible for the cost of care provided. (This does not apply if you receive Emergency Services or Out of Network/ Service Area Urgent Services that are Covered Services and you have notified your PCP or VHP.) If you receive care that is a non-Covered Service or if you receive services of a non-VHP Provider that have not been authorized by VHP, you will be financially liable for such services. Non-Covered Services are listed in the “Exclusions and Limitations” section, “Benefits Descriptions” section and in the “Benefits Description Table.” Members may be responsible for charges by a provider for appointments that are missed without notice to the provider.
Coordination of Benefits Reimbursement The Covered Services under this EOC are subject to Coordination of Benefits (COB) rules. You must notify VHP if you have health care coverage with another health plan or insurance company, VHP will coordinate benefits for Members who are covered under two (2) or more health plans. When there is a Coordination of Benefits, health care plans share the costs of authorized services. Members may be able to receive up to one hundred percent (100%) coverage. Valley Health Plan will pay for Covered Services provided by Plan Providers and authorized by VHP. If appropriate, you should submit claims to VHP for review. You must notify VHP if you or your enrolled Dependent(s) are covered under another health care plan, including government health care programs such as the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS), Medi-Cal, and Medicare. VHP will not cover Benefits that duplicate the other benefits to which a Member is entitled. VHP has the right to recover any overpayments made for Covered Services. In certain circumstances, Members may be required to assist VHP with the necessary documentation.
Third Party Reimbursement / Liability In cases of injuries caused by any act or omission of a third party (including, without limitation, motor vehicle accidents and injuries, and illnesses covered by Workers’ Compensation) and complications incident thereto, Plan will furnish Covered Services. However, you must inform VHP or your Provider when services performed are covered through workers’ compensation laws, automobile, accident, or other liability coverage. The Plan will not duplicate coverage for such services. When a legitimate dispute exists as to third party liability, Plan will furnish Covered Services until the 77 V A L L E Y H E A L T H P L A N E V I D E N C E O F C O V E R A G E A N D D I S C L O S U R E F O R M
