|
|
|
SURGERY-RELATED
BENEFITS
|
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 100% of the amount listed on
the SURGICAL SCHEDULE,
after satisfaction of the calendar year deductible, if applicable. Follow-up care is included in the surgery charge if applicable.
|
EXAMPLE: |
|
|
|
Surgeon's Charge |
$ 500.00 |
|
Allowed Amount |
400.00 |
|
Fund's Payment |
400.00 |
|
Employee's Out-of-Pocket
Expense |
100.00 |
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.
|
|
ANESTHESIA |
|
Through the Fund’s Fee-for-Service Plan, fees for anesthesia
services will be reimbursed at 100% of the Scheduled Benefit. 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.
|
EXAMPLE: |
|
|
|
Anesthesiologist's Charge |
$ 700.00 |
|
Allowed Amount from Schedule |
600.00 |
|
Fund's Payment |
600.00 |
|
Employee's Out-of-Pocket
Expense |
100.00 |
|
|
ASSISTANT
SURGEON
|
|
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 any applicable calendar
year deductible. 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 deductible if applicable.
|
EXAMPLE: |
|
|
|
Surgery Allowance |
$ 500.00 |
|
Assistant Surgeon's Charge |
125.00 |
|
Allowed Amount |
100.00
(20% of Surgery Allowance) |
| |
Fund's Payment |
100.00 |
|
Member's Out-of-Pocket Expense |
25.00 |
|
|
COSMETIC
SURGERY
|
| 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.
|
|
FOR
A BETTER BENEFIT
|
|
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 the contracted rate which the provider has agreed
to accept. You have no co-payment.
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 from the Fund Office.
|
 |
|
