2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Balance (PPO) Chapter 7: Asking us to pay our share of a bill you have received for covered medical services or drugs 175 Section 1 Situations in which you should ask us to pay our share of the cost of your covered services or drugs Sometimes when you get medical care or a prescription drug, you may need to pay the full cost. Other times, you may find that you have paid more than you expected under the coverage rules of the plan. Or you may receive a bill from a provider. In these cases, you can ask our plan to pay you back (paying you back is often called “reimbursing” you). It is your right to be paid back by our plan whenever you’ve paid more than your share of the cost for medical services or drugs that are covered by our plan. There may be deadlines that you must meet to get paid back. Please see Section 2 of this chapter. There may also be times when you get a bill from a provider for the full cost of medical care you have received or possibly for more than your share of cost-sharing as discussed in the document. First try to resolve the bill with the provider. If that does not work, send the bill to us instead of paying it. We will look at the bill and decide whether the services should be covered. If we decide they should be covered, we will pay the provider directly. If we decide not to pay it, we will notify the provider. You should never pay more than plan-allowed cost-sharing. If this provider is contracted you still have the right to treatment. Here are examples of situations in which you may need to ask our plan to pay you back or to pay a bill you have received: 1. When you’ve received medical care from a provider who is not in our plan’s network When you received services from a provider in the United States who is not part of our network, you are only responsible for paying your share of the cost. Ask the provider to bill the plan for our share of the cost. · If you pay the entire amount yourself at the time you receive the care, ask us to pay you back for our share of the cost. Send us the bill, along with documentation of any payments you have made. · You may get a bill from the provider asking for payment that you think you do not owe. Send us this bill, along with documentation of any payments you have already made. - If the provider is owed anything, we will pay the provider directly. - If you have already paid more than your share of the cost of the service, we will determine how much you owed and pay you back for our share of the cost. · Please note: While you can get your care from an out-of-network provider, the provider must be eligible to participate in Medicare. Except for emergency care, we cannot pay a provider who has opted out of or been excluded or precluded from the Medicare Program. If the provider is not eligible to participate in Medicare, you will be responsible for the full cost of the services you receive. · You can also receive emergency or urgently needed services from a provider outside the United States. If you receive emergency or urgently-needed services outside of the United States, the provider may require that you pay for the cost of the services in full. Ask for a written, detailed bill or receipt showing the specific services provided to you. Send a copy of