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Consent Form. The reason for the request of personal health information will be stated on the Consent Form. At any point in time, the Covered Individual may revoke consent. If the consent is revoked, the Covered Individual may request how the personal health information has been used and the outcome of the use of the information. TML Intergovernmental Employee Benefits Pool will maintain documentation of consent requestors, responses and revocations. A Federal regulation, called the "Privacy Rule," requires TML Intergovernmental Employee Benefits Pool to protect the privacy of each Covered Individual's identifiable health information. Under the Privacy Rule, TML Intergovernmental Employee Benefits Pool may use and disclose a Covered Individual's identifiable health infonnation only for certain permitted purposes, such as the payment of claims under the health plan. If TML Intergovernmental Employee Benefits Pool needs to use or disclose a Covered Individual's health information for a purpose not pennitted under the Privacy Rule, TML Intergovernmental Employee Benefits Pool must first obtain a written authorization signed by the Covered Individual. In addition to restrictions on how TML Intergovernmental Employee Benefits Pool may use and disclose a Covered Individual's identifiable health information, the Privacy Rule gives each Covered Individual certain rights. These include the right of a Covered Individual to access his or her health information, to amend his or her health information, and to receive an accounting of certain disclosures of his or her health information. Important Disclaimer The information presented in this Schedule of Benefits IS NOT a guarantee of payment. The benefits described are subject to all plan limitations, preexisting information, filing deadlines, exclusions and eligibility requirements. All benefits are based on the plan document language. If a Covered Individual is on continuation of coverage (COC), coverage could tenninate retroactively if the individual's contribution is not made within the COC payment timeframe. Requests for reimbursement for a covered benefit should be sent to the Group Benefits Administrator within ninety (90) days of the date of service but not later than twelve (12) months. All inpatient and outpatient facilities are required to be JCAHO/Medicare accredited for the bill to be considered for payment. Precertification is the determination only on the medical necessity of a proposed treatment based on the information provided at the time the precertification is issued. Precertification does not verify or certify: I. eligibility of any individual for coverage; 2. benefit coverage for services rendered pursuant to the precertification; or 3. network status of the provider(s). Exclusions and Limitations applicable to aU Benefits Benefits are not provided for injury or sickness of a covered person which results directly or indirectly, wholly or partly, fi'om: I. Insurrection, rebellion, participation in a riot, commission of or attempting to connnit an assault, battery, felony, or act of aggression; War or any act of war, whether declared or undeclared, or sickness contracted or accidental bodily injury occurring while on full-time active duty in the Armed Forces of any country or combination of countries; . Occupational injury or sickness or any injury or sickness otherwise covered by any Workers' Compensation Act, Occupational Disease Law or similar law; Operating a motor vehicle under the influence of alcohol as evidenced by a blood alcohol level in excess of the state legal intoxication limit; Care or treatment related to intentionally self-inflicted injury or self-induced sickness; Charges for which there is no legal obligation to pay, or no charge is made, or in the absence of coverage no charge would be made; Charges incurred after tennination of coverage; Charges for care or services furnished by any agency or program funded by federal, state or local government except Medicaid; Charges which are not medically necessary for treatment of sickness or injury; Unless specifically provided for in the plan, charges for routine physicals or exams or routine immunizations when no injury or sickness is present; , Charges for medical care, services or supplies which are not furnished or prescribed by a doctor; . Charges for experimental or investigational treatment, procedures for research purposes or practices when not generally recognized as accepted medical practices; . Charges for care, treatment, services or supplies that are not approved or accepted as essential to the treatment of an injury of sickness by any of the following: a. The American Medical Association, b. The U.S. Surgeon General, 2. 3. 4. s. 6. 7. 8. 9. 10. II. 12. 13. C:\Docwnents and Scttings\ganderson\Local Settings\TCß1)Orary Internet Files\OLKS\EarlyRetdoc: