2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 4: Medical Benefits Chart (what is covered and what you pay) 136 · Routine chiropractic care · Routine acupuncture services · Naturopathic services Refer to the Routine hearing services benefit section below for more details on your routine hearing benefit. These are covered health services when you follow the coverage rules in the Evidence of Coverage. These services are in addition to Medicare-covered benefits outlined in the Evidence of Coverage. The provisions of this section are incorporated into and made a part of your Evidence of Coverage. Copayments or coinsurance for these covered health services do not apply toward the annual out- of-pocket maximum (if applicable to your plan) described earlier in this chapter. Further details on the benefits available as part of your additional benefit(s) (if applicable) are detailed in the section titled: Covered services. Submit a claim or request reimbursement When you obtain services, the service provider normally submits a claim on your behalf. If the service provider is unwilling to do so, you can ask us for reimbursement. Refer to Chapter 7 Section 2 How to ask us to pay you back or to pay a bill you have received. Hearing aids ordered through providers other than UnitedHealthcare Hearing are not covered. Limitation of liability We will not reduce or deny a claim for failure to furnish such proof within the time required, provided a claim is furnished as soon as reasonably possible. Except in the absence of legal capacity, we will not accept a claim more than one (1) year from the date of service. Access your benefits You may see doctors and other health care professionals, medical groups, hospitals, and other health care facilities that are not contracted with UnitedHealthcare, as long as they accept the plan, and have not opted out of or been excluded or precluded from the Medicare Program, and as long as the services are covered benefits and are medically necessary. Unlike most PPO plans, with this plan you pay the same cost share in-network and out-of-network. You may receive covered services from a provider anywhere in the United States by taking the following steps: · Locate a provider of your choice. · Call your selected provider’s office to schedule your services. · Pay the appropriate cost shares at the time of your service, if applicable. · When you go to the provider’s office for services, you may be asked to show your UnitedHealthcare member ID card. It is important to note that the provider has the right to decide whether or not he or she will agree to submit the bill for covered services directly to us for payment at the time he or she furnishes covered services to you. If the provider does not wish to submit the bill directly to us please follow the instructions under “Submit a claim or request reimbursement”.