Benefits and services included in, and excluded from, coverage
Chorus Community Health Plans (CCHP) contract is for an Exclusive Provider Organization (EPO). As an EPO, our plan is designed to cover in-network services only. Except as specifically stated in our contract, services received from an out-of-network provider will not be covered. In addition, certain services that members wish to receive from in-network providers require prior authorization. If services are obtained from an out-of-network provider that are covered under this contract, the maximum allowable amount will be determined based on this contract’s fee schedule, usual and customary charges, or other method as defined in our contract.
The fact that a healthcare practitioner has performed or prescribed a medically necessary procedure, treatment, or supply, or the fact that it may be the only available treatment for a bodily injury or illness, does not mean that the procedure, treatment or supply is covered under our contract. Individual and family plans are designed to cover medically necessary services which are performed at an in-network provider. Medically necessary items would include any medical service, supply or treatment authorized by a practitioner for preventive or screening purposes or to diagnose and treat a member’s illness or injury which:
- Is consistent with the symptoms or diagnosis;
- Is provided according to generally accepted medical practice standards;
- Is not custodial care;
- Is not solely for the convenience of the practitioner or the covered person;
- Is not experimental or investigational treatment;
- Is provided in the most cost effective care facility or setting;
- Does not exceed the scope, duration, or intensity of that level of care that is needed to provide safe, adequate, and appropriate diagnosis or treatment; and
- When specifically applied to a hospital confinement, it means that the diagnosis and treatment of your medical symptoms or conditions cannot be safely provided at an outpatient setting.
Covered services
We provide benefits for the following medically necessary covered services, within the categories below:
- Ambulance services
- Autism intensive/non-intensive level services
- Breast reconstruction
- Chiropractic care
- Clinical trials
- Cochlear implants
- Contraceptive coverage and family planning
- Dental services – accident only
- Dental / anesthesia services
- Diabetes services
- Diagnostic services
- Durable medical equipment and supplies
- Emergency health services – outpatient
- Enteral nutrition in the home
- Genetic testing and counseling
- Habilitative services
- Hearing aids
- Home health care
- Hospice care
- Hospital – Inpatient stay
- Inpatient rehabilitation
- Kidney disease services
- Laboratory services
- Medical Nutrition Education
- Medical supplies
- Mental health and substance abuse disorders
- Outpatient services
- Pharmaceutical products
- Podiatry services
- Pregnancy – maternity services
- Preventive care services
- Prosthetic devices
- Reconstructive procedures
- Rehabilitate services
- Skilled nursing facility
- Telehealth services
- Temporomandibular joint disorder services
- Transplant services: organ and tissue
- Urgent care Urinary catheters
- Vision care services – pediatric
Exclusions and Limitations
In addition to medically necessary covered benefits, there are also certain benefits that have been deemed as not medically necessary and would not be covered under this contract. Those exclusion are included within the categories below:
- Alternative treatments
- Assisted fertilization
- Autism spectrum disorder – certain services excluded
- Bariatric surgery
- Blood
- Cosmetic surgery and services
- Court-ordered care
- Custodial care
- Dental services
- Devices, appliances, and prosthetics
- Employment-related or employer-sponsored
- Employment, school, and travel related services
- Engaged in an illegal act or occupation
- Experimental / Investigational Food supplements / vitamins
- Foot care
- Genetic counseling and testing
- Growth hormones
- Habilitative services
- Home care
- Maintenance therapy
- Maternity services
- Medical services / supplies not provided in this contact
- Medically unnecessary services
- Mental health and substance use disorder services
- Military service
- Nutritional supplements
- Oral surgery
- Out-of-network / non-participating providers
- Over the counter drugs
- Other prescription drugs
- Personal care, comfort, or convenience
- Private duty nursing
- Reproduction
- Transplants
- Transportation
- Treatment outside the USA
- Type of care
- Vision
- Weight reduction and weight modification
- Workers compensation
- Any services, supplies, or treatments not specifically listed in the contract, unless preventive
Charges incurred for treatment that is not medically necessary are not eligible service expenses.
Out-of-network providers or outside of the service area.
There is no coverage available outside of the service area, unless it is an emergency or if prior authorization has been obtained. If a member is outside of the service area, or if a member is in the service area, but is seeking coverage by an out-of-network provider, and it is not an emergency, and prior authorization has not been obtained, that member will be responsible for all related fees and expenses. This may result in additional out-of-pocket expense or being Balance Billed by the provider. For more information, see the "When Coverage Begins and Ends" section of the Evidence of Coverage at the link below.
Please see your Evidence of Coverage for additional details.