2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Balance (PPO) Chapter 11: Legal notices 242 1) Our payments are less than the recovery amount. If our payments are less than the total recovery amount from any third party (the “recovery amount”), then our reimbursement is computed as follows: a) First: Determine the ratio of the procurement costs to the recovery amount (the term “procurement costs” means the attorney fees and expenses incurred in obtaining a settlement or judgment). b) Second: Apply the ratio calculated above to our payment. The result is our share of procurement costs. c) Third: Subtract our share of procurement costs from our payments. The remainder is our reimbursement amount. 2) . If our payments equal or exceed the Our payments equal or exceed the recovery amount recovery amount, our reimbursement amount is the total recovery amount minus the total procurement costs. 3) We incur procurement costs because of opposition to our reimbursement. If we must bring suit against the party that received the recovery amount because that party opposes our reimbursement, our reimbursement amount is the lower of the following: a) Our payments made on your behalf for services; or b) the recovery amount, minus the party’s total procurement cost. Subject to the limitations stated above, you agree to grant us an assignment of, and a claim and a lien against, any amounts recovered through settlement, judgment or verdict. You may be required by us and you agree to execute documents and to provide information necessary to establish the assignment, claim, or lien to ascertain our right to reimbursement. Section 5 Member liability Note: This section only applies to you if you are required by your plan rules to obtain a referral before seeing non-network providers. Please see the chapter entitled Using the plan’s coverage for your medical services to see if your plan requires referrals to non-network providers. You will be liable if you receive services from non-network providers without authorization or a referral. In the event we fail to reimburse provider’s charges for covered services, you will not be liable for any sums owed by us. Neither the plan nor Medicare will pay for non-covered services except for the following eligible expenses: · Emergency services · Urgently needed services · Out-of-area and routine travel dialysis (must be received in a Medicare Certified Dialysis Facility within the United States) · Post-stabilization services If you enter into a private contract with a provider, neither the plan nor Medicare will pay for those services.