How Benefits Are Determined
Customary and Reasonable (C&R) Charges
Customary and Reasonable Charges are those charges for services rendered by or on behalf of a non-network physician, for an amount not to exceed the amount determined by Anthem Blue Cross in accordance with the applicable fee schedule.
A Customary and Reasonable Charge is a charge which falls within the common range of fees billed by a majority of physicians for a procedure in a given geographic region. If it exceeds that range, the expense must be justified based on the complexity or severity of treatment for a specific case.
Covered Health Services
Covered Health Services are those health services, supplies or equipment provided for the purpose of preventing, diagnosing or treating a sickness, injury, covered medical condition, or their symptoms.
A Covered Health Service is a Medically Necessary health care service or supply described under "What the ROP Covers" as a Covered Health Service and which is not excluded under "What the ROP Does Not Cover", including experimental or investigational services or unproven services as well as custodial services.
Covered Health Services must be provided:
  • when the Plan is in effect;
  • prior to the effective date of any of the individual termination conditions set forth in this Summary Plan Description; and
  • only when the person who receives services is a covered person and meets all eligibility requirements specified in the Plan.
Decisions about whether to cover new technologies, procedures and treatments will be determined by Anthem Blue Cross.
Medically Necessary Services
Medically Necessary Services are those procedures, supplies, equipment or services which the Claims Administrator, Anthem Blue Cross on behalf of Anthem Blue Cross Life & Health, determines to be:
  • Appropriate and necessary for the diagnosis or treatment of the medical condition;
  • Provided for the diagnosis or direct care and treatment of the medical condition;
  • Within standards of good medical practice within the organized medical community;
  • Not primarily for your convenience, or for the convenience of your physician or another provider; and
  • The most appropriate procedure, supply, equipment or service which can safely be provided. The most appropriate procedure, supply, equipment or service must satisfy the following requirements:
    • There must be valid scientific evidence demonstrating that the expected health benefits from the procedure, supply, equipment or service are clinically significant and produce a greater likelihood of benefit, without a disproportionately greater risk of harm or complications, for you with the particular medical condition being treated than other possible alternatives; and
    • Generally accepted forms of treatment that are less invasive have been tried and found to be ineffective or are otherwise unsuitable; and
    • For hospital stays, acute care as an inpatient is necessary due to the kind of services you are receiving or the severity of your condition, and safe and adequate care cannot be received by you as an outpatient or in a less intensified medical setting.
The fact that a physician, licensed professional or other provider may prescribe, order, recommend, or approve a service or supply does not, in itself, make it Medically Necessary, even though it is not specifically listed as an exclusion or limitation. The services or supplies must be ordered by the attending physician or licensed professional for the direct care and treatment of a covered illness, injury or condition. Services must be standard medical practice where received for the illness, injury or condition being treated and must be legal in the United States.
Emergency Care
If you or a covered family member experiences a medical emergency, seeking prompt care should be the first priority. Under the ROP, emergency care is provided 24 hours a day, seven days a week, anywhere in the world. A medical emergency is defined as a sudden and unforeseeable illness or injury of such a nature that failure to get immediate medical care could be life-threatening or cause serious harm to bodily function.
Examples of medical emergencies include:
  • Apparent heart attack
  • Severe or multiple injuries
  • Severe shortness of breath
  • Severe bleeding
  • Allergic reactions accompanied by swelling of the face and lips or wheezing in the chest
  • Apparent poisoning
  • Sudden loss of consciousness
  • Obvious fractures
  • Convulsions
  • Sudden vision loss
What to Do In Case of Emergency
In case of a medical emergency, you should go immediately to the nearest hospital emergency room. The ROP will cover 70% of the Eligible Expenses for the emergency room visit after you have met your annual deductible.
It is important to understand that symptoms such as colds, earaches, sprains and rashes, although potentially serious, are not immediately life-threatening, and thus, may not require a visit to the emergency room. In these cases, you should always call your regular physician first.