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SURGERY-RELATED
BENEFITS
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Through the Fund’s Fee-for-Service Plan, the physician’s fee for inpatient
surgery, surgery done at the doctor's
office, or surgery done on an outpatient basis will
be paid at 70% of the amount listed in the
SURGICAL SCHEDULE,
after satisfaction of the Calendar Year Deductible, if applicable. Follow-up
care is included in the surgery charge if applicable.
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EXAMPLE: |
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Surgeon's Charge |
$
1,000.00 |
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Allowed Amount |
800.00 |
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Fund's Payment |
560.00 |
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Employee's Out-of-Pocket
Expense |
440.00 |
The
complete SURGICAL SCHEDULE
is too lengthy to publish. If you
require information on a specific surgery, please call or write the Fund Office
for the details you require. You
must have the Current Procedural
Terminology (CPT) code or the Health Care Financing Administration's Common
Procedure Coding System (HCPCS) code of the procedure performed. The complete SURGICAL
SCHEDULE is available from the Fund Office upon request.
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ANESTHESIA |
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Through the Fund’s Fee-for-Service Plan, fees for anesthesia services will be
reimbursed at
70% of the Surgical Schedule.
The Fund’s allowed amount is based on the procedure performed, complications,
and the amount of time involved after satisfaction of the
Calendar Year Deductible, if applicable.
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EXAMPLE: |
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Anesthesiologist's Charge |
$ 700.00 |
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Allowed Amount from Schedule |
600.00 |
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Fund's Payment |
420.00 |
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Employee's Out-of-Pocket
Expense |
280.00 |
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ASSISTANT
SURGEON
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If
the procedure REQUIRES one
or more assistant surgeons, the assistant surgeon will be reimbursed through
the Fund's Fee-for-Service Plan with a total payment for all assistant
surgeons at 20%
of the amount allowed for the primary surgeon,
after satisfaction of the Calendar Year Deductible, if applicable.
If the only assistant is a Registered Nurse First Assistant (RNFA) or
Physician’s Assistant (PA), reimbursement will be at a total of 10% of the
allowed amount for the surgery,
after satisfaction of the Calendar Year Deductible, if applicable.
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EXAMPLE: |
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Surgery Allowance |
$
1,000.00 |
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Assistant Surgeon's Charge |
500.00 |
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Allowed Amount |
200.00
(20% of Surgery Allowance) |
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Fund's Payment |
140.00 |
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Member's Out-of-Pocket Expense |
860.00 |
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COSMETIC
SURGERY
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| The term "Cosmetic
Surgery" means surgery which is performed merely for the purpose of
improving the appearance of an individual.
The Fund does NOT cover Cosmetic Surgery
unless the surgery is being done to repair or alleviate disfigurement resulting from an
accident which occurred while the patient was eligible in the Plan, or for the correction of
a congenital defect in a Dependent child, or for breast reconstruction following
cancer-related mastectomy.
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FOR
A BETTER BENEFIT
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Eligible employees and their eligible dependents can obtain surgical services,
when prescribed by a physician, from PPO contract providers at several locations
in Southern California and Nevada. Under the PPO contract provisions, the Plan
will pay 90% of the contract amount (minus any copayment) after satisfaction of
the Calendar Year Deductible, if applicable.
Simply present your Health & Welfare Identification Card along with your
doctor’s prescription.
Providers under contract with Anthem Blue Cross are listed in the Anthem Blue
Cross Directory or at
www.anthem.com .
Providers under contract with AHF are listed in the AHF Directory of
Participating Hospitals and Physicians
which is available
via their website at
www.AHFONLINE.org |
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