UNITE HERE HEALTH. Summary Plan Description Los Angeles Plan Plan 178. July 2012

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1 UNITE HERE HEALTH Summary Plan Description Los Angeles Plan Plan 178 July 2012 This Summary Plan Description supercedes and replaces all materials previously issued.

2 The Plan Administrator and the agent for service of legal process is the Chief Executive Officer (CEO) of UNITE HERE HEALTH. Service of legal process may also be made on any Plan Trustee. The CEO s address and phone number are: UNITE HERE HEALTH Chief Executive Officer P. O. Box 6020 Aurora, IL (630)

3 INTRODUCTION UNITE HERE HEALTH (the Fund) was created to provide benefits for you and your covered dependents. UNITE HERE HEALTH serves participants working for employers in the hospitality industry and is governed by a Board of Trustees composed of an equal number of union and employer trustees. Each employer contributes to UNITE HERE HEALTH according to a specific contract, called a Collective Bargaining Agreement, between the employer and the union. Your Plan, Plan 178, has been adopted by the Trustees for the payment of Medical and other health and welfare benefits from UNITE HERE HEALTH. This booklet is your Summary Plan Description (SPD). It is a summary of the Plan s rules and regulations and describes: How you become eligible; When your dependents are covered; What benefits you have; Limitations and exclusions; How to file claims; and How to appeal denied claims. If information contained in the SPD is inconsistent with those rules and regulations, the rules and regulations will govern. If information contained in the SPD is inconsistent with any insurance contract governing benefits, those insurance contracts will govern. No contributing employer, employer association, labor organization, or any individual employed by one of these organizations has the authority to answer questions or interpret any provisions of this Summary Plan Description on behalf of UNITE HERE HEALTH. 3

4 ABOUT PLAN FINANCES Who Pays for Your Benefits? Employers participating in the Plan are required to make contributions for their employees. These contributions are controlled by the terms of the Collective Bargaining Agreements negotiated by your local union. Depending on the plan of benefits you select and your Collective Bargaining Agreement, you may also be required to contribute towards the cost of Employee Coverage. The Plan is supported by employer contributions and any required contributions you make. What Benefits Are Provided Through Insurance Companies? The Plan insures HMO benefits, including benefits available to certain retirees. The HMO benefit options are funded and administered under group contracts underwritten by Kaiser Permanente (Kaiser). Retiree HMO benefits are provided through a contract with UnitedHealthcare. The Plan also insures Life Insurance Benefits. They are funded and guaranteed under group contracts underwritten by Dearborn National. However, the Plan provides the following self-funded benefits: PPO Plan Comprehensive Major Medical Coverage, PPO Plan Prescription Drug Benefits, and benefits provided through the Dental Center. Self-funded means that none of these benefits are funded by insurance contracts. Benefits and associated administrative expenses are paid directly by UNITE HERE HEALTH. The Plan also maintains contracts to help administer certain benefits. The PPO Plan Prescription Drug Benefits are administered by Catalyst Rx, and the Dental Center is staffed and operated by Dr. Roger Fieldman, DDS, Inc. In addition, precertification and utilization review services for the PPO Plan s Medical and Surgical Benefits are provided by Medical Cost Management (MCM). 4

5 IMPORTANT PHONE NUMBERS Kaiser HMO Plans Only For HMO Benefit Questions and to Find a Kaiser Permanente Doctor or Hospital (800) Kaiser Advice Nurse (888) PPO Plan Only For PPO Benefit Questions (855) Find a Blue Cross Blue Shield of Illinois Network Doctor or Hospital PPO Plan Mandatory Precertification: MCM For hospital admissions and certain procedures (see page 20), call Medical Cost Management (MCM) before treatment. For emergency hospital treatment, call the first business day following admission. $150 benefit reduction if you do not call to precertify. (800) (800) Find a Catalyst Rx Network Pharmacy (866) Dental Center Both HMO and PPO Plan Members To Make an Appointment (213) To request claim forms, enrollment or election forms, report changes in your employment or family status, inquire about self-payments or request additional information, contact the Los Angeles UNITE HERE HEALTH office: 130 South Alvarado Street Los Angeles, California (213) or (855) Visit our website at Set up an account on the UNITE HERE HEALTH website to check eligibility, update address information, add dependent information, and make COBRA payments online. 5

6 TABLE OF CONTENTS This Table of Contents is designed to help you find specific benefit information easily and quickly. Look for the question that best describes what you want to know. Where Does the Money to Pay Benefits Come From? About Plan Finances Who Pays for Your Benefits? What Benefits Are Provided Through Insurance Companies? What Health and Welfare Benefits Does the Plan Provide? Benefits at a Glance Who s Covered by the Plan? Who s Eligible Employees Dependents Who Your Dependents Are Enrollment Requirements Choice of Coverage Options Employees Dependents Dependent Documentation How Do I Use Kaiser HMO Coverage? Kaiser HMO Options How to Use Kaiser HMO Coverage The Effect of Choosing Kaiser HMO Coverage Is Precertification of Hospital and Other Services Required Under the PPO Plan? PPO Plan Medical Management Review Medical and Surgical Treatment Hospital Admissions Outpatient Surgeries & Diagnostic Tests Processing Requests for Precertification of Benefits If More Time Is Needed If Additional Information Is Needed

7 TABLE OF CONTENTS Special Rules for Decisions Involving Concurrent Care If a Request for Precertification Is Denied Appealing the Denial of Benefit Certification How Does the Plan Decide How Much to Pay for PPO Plan Benefits? How PPO Plan Benefits Are Determined Injuries and Sicknesses Allowable Charges Medically Necessary Care and Treatment Treatment by Network or Non-Network Doctors and Hospitals Experimental, Investigational, or Unproven Procedures Definition of Doctor Emergency Medical Treatment What Medical or Surgical Services Does the PPO Plan Cover? PPO Plan Comprehensive Major Medical Benefits What the PPO Plan Pays What You Pay Copayments About the Deductibles Family Deductible Limit Out-of-pocket Spending Limit (Network Services Only) Annual Maximum Benefit What s Covered Preventive Health Care Services Covered at 100% When Network Providers Are Used What s Not Covered Does the PPO Plan Cover Prescription Drugs? PPO Plan Prescription Drug Benefits What You Pay Generic Drug Policy What s Covered Drugs Requiring Preauthorization Dispensing Limitations Mail Order Refills What s Not Covered Processing Requests for Pre-authorization

8 TABLE OF CONTENTS If More Time Is Needed If Additional Information Is Needed If a Request for Pre-authorization Is Denied Appealing the Denial of a Request for Preauthorization What Dental Services Does the Plan Cover? Dental Benefits What You Pay What s Covered What s Not Covered Pre-Estimate of Dental Needs Dental Benefits After Eligibility Ends Retiree Self-Pay Dental Program What Services and Supplies Are Not Covered at All? General Exclusions and Limitations What If I m Also Covered Under Another Health Care Plan? Coordination of PPO Plan Benefits Which Plan Pays First Order of Payment COB and Precertification Special Rules for Medicare Husband and Wife, or Domestic Partner, Employees Under This Plan When Must Plan Payments Be Returned? Subrogation The Plan s Right to Recover Payments When Injury Is Caused by Someone Else Statement of Facts and Repayment Agreement What If I Die? Life Insurance Benefit Benefit Amount Naming a Beneficiary Continuation If You Become Totally Disabled Converting to Individual Life Insurance Coverage

9 TABLE OF CONTENTS Filing a Claim Additional Life Insurance Benefits How Do I Become Eligible For and Then Continue Coverage? Eligibility for Coverage Monthly Employee Contributions When Your Coverage Begins Hotel Group Employees Cafeteria Group Employees Event Center Group Employees Restaurant Group Employees Continuing Eligibility Hotel Group Employees Cafeteria Group Employees Event Center Group Employees Restaurant Group Employees Eligibility for Employees Who Work for More than One Employer Eligibility for Employees Who Work in More than One Employee Group Vacation Hours Disability Credit Hours Extended Disability Credits for Hotel Group Employees Self-payments Self-payments to Continue Coverage Self-payments During a Work Place Closing Self-payments During a Strike When Dependent Coverage Begins Enrollment Periods Open Enrollment Periods Special Enrollment Periods Retiree Eligibility When Does Coverage end? Termination of Coverage When Employee Coverage Ends When Dependent Coverage Ends Certificate of Creditable Coverage If You Are Disabled When Coverage Ends

10 TABLE OF CONTENTS The Effect of Severely Delinquent Employer Contributions When Your Employer s Collective Bargaining Agreement Expires Remedies for Fraud Limited Retroactive Terminations of Coverage Allowed What If I Lose Coverage and Then Return to Work? Re-establishing Eligibility Portability Family and Medical Leave Act The Effect of Uniformed Service How Can Coverage Be Continued? COBRA Continuation Coverage Who Can Elect COBRA Coverage? What Is a Qualifying Event? What Coverage Can Be Continued? How Long Can Coverage Be Continued? Termination of COBRA Coverage Notifying UNITE HERE HEALTH When Qualifying Events Occur Election and Payment Deadlines How Do I File a Claim and What Do I Do If It s Denied? General Claim Provisions Filing a Benefit Claim Health Care Claims Under the PPO Plan All Other Benefit Claims Deadlines for Filing a Benefit Claim Individuals Who May File a Benefit Claim Who Is an Authorized Representative? Payment of Claims Concurrent Care Decisions Life Insurance Benefit Claims Health Care Claims Not Involving Concurrent Care Decisions If a Benefit Claim Is Denied Special Rules for Denials of PPO Prescription Drug Card Benefits Appealing the Denial of a Claim

11 TABLE OF CONTENTS Claims Subject to Two Levels of Appeal First Level of Appeal Final Level of Appeal Claims Subject to One Level of Appeal Appeals to UNITE HERE HEALTH Involving Urgent Care Claims Appeals Under the Sole Authority of the Plan Administrator Review of Appeals Notice of the Decision on Your Appeal Independent External Review Procedures for the PPO Plan What Else Do I Need to Know? Other Important Information Interpretation of Plan Provisions Kaiser HMO Benefits Dental Benefits Independent Review Organization All Other Authority Rests with the Board of Trustees Amendment or Termination of the Plan Providers Workers Compensation Type of Plan Employer and Employee Organizations Plan Administrator Employer Identification Number Plan Number Plan Year Your Rights Under ERISA Receive Information About Your Plan and Benefits Continue Group Health Plan Coverage Creditable Coverage Prudent Actions by Plan Fiduciaries Enforce Your Rights Assistance With Your Questions Board of Trustees Provider Organization Phone Numbers and Addresses

12 BENEFITS AT A GLANCE HMO Benefit through Kaiser Permanente (Kaiser) UNITE HERE HEALTH has contracted with Kaiser to give you the opportunity to choose health care coverage under one of the Kaiser HMO options instead of under the PPO plan. Kaiser uses area hospitals, physicians, and other providers to provide covered services. Except in an emergency, all treatment must be received from a primary care physician or from a provider he or she refers you to. See the Kaiser Enrollment Book or contact Kaiser to find a doctor, or with questions about your Kaiser HMO benefits. (800) PPO Plan Please call (855) if you have specific questions about covered services. In general, Plan benefits distinguish between treatment provided by network providers and treatment provided by nonnetwork providers, as shown below. The PPO Plan pays a percentage of the Plan s allowable charges for covered medical expenses. You are responsible for paying copayments, your share of allowable charges the Plan doesn t pay, any amount over the maximum benefits, and any expenses that are not covered by the Plan. Annual Maximum 2012 $1,250,000 per person 2013 $2,000,000 per person 2014 Total annual dollar maximum will no longer apply Annual Deductible Individual $300 Family $600 The deductible applies to most covered services, even if there is a copayment. See pages for a list of what it does not apply to. Major Medical Plan Payments BCBS NETWORK NON-NETWORK Physician Office Visits other than for preventive health care services; not including psychiatrists, chiropractors, or podiatrists 90% 50% Preventive Health Care Services for example: routine physical exams, immunizations, well-child visits, pap smear, diabetes, cholesterol, and blood pressure screening 100% 50% (see pages for complete list) Hospital Inpatient Treatment 90% 50% Hospital Outpatient Treatment 90% 50% Hospital Emergency Room Emergency care to prevent serious and permanent physical impairment or death; copay waived if admitted to the hospital 100% after $100 copay 100% after $100 copay Non-emergency care 50% after $100 copay 50% after $100 copay Urgent Care Facility 90% 50% Professional Ambulance 80% 80% X-ray and Laboratory Services 90% 50% Mental Health Treatment Inpatient up to 30 days per calendar year, combined network/non-network 90% 50% Outpatient up to 75 group or individual visits per calendar year, combined network/non-network 90% 50% Alcohol/Substance Abuse Inpatient up to 30 days per calendar year, combined network/non-network 90% 50% Outpatient up to 75 group or individual visits per calendar year, combined network/non-network 90% 50% 12

13 BENEFITS AT A GLANCE Major Medical Plan Payments BCBS NETWORK NON-NETWORK Chiropractic Services 40-visit maximum per person each calendar year combined network/non-network 90% 50% Podiatric Services no coverage for routine 90% 50% Durable Medical Equipment and Oxygen Services 80% 80% Certified Diabetes Educator $200 calendar year maximum 100% Not Covered Registered Dietitian Services $200 calendar year maximum 100% Not Covered Skilled Nursing Facility up to 60-day maximum per calendar year, combined network/non-network Home Health Care Services up to 60-day maximum per calendar year, combined network/non-network Hospice Care up to 60-day maximum per calendar year, combined network/non-network Physical, Occupational and Speech Therapy 60-visit maximum per calendar year; combined network/non-network Acupuncture 40-visit maximum by licensed acupuncturist, combined network/non-network, limited to $50 per visit 100% 50% 100% 50% 100% 100% 90% 50% 80% 50% All Other Covered Expenses 90% 50% Out-of-pocket Spending Limit once $5,000 in network benefits have been paid on a person s behalf (through December 31, 2012), or once you pay $700 per person in network out-of-pockets costs (on or after January 1, 2013), during a calendar year (excluding certain charges see page 31 for more information), network benefits will be paid at 100% for the rest of the calendar year. 100% n/a Prescription Drug Benefit Benefits only available at participating Catalyst Rx Pharmacies What you pay for retail 34-day supply or mail order 60-day supply through Catalyst Mail Certain Drugs and Supplements see page 41 $0 Generic Drugs 10% of the cost, minimum $5, maximum $20 Brand-Name Drugs on the Catalyst Rx Formulary 20% of the cost, minimum $25, maximum $45 Brand-Name Drugs not on the Catalyst Rx Formulary 30% of the cost, minimum $50, no maximum Dental Benefit Dental Benefits are only paid for services and supplies provided by the Dental Center, 130 South Alvarado Street, Los What You Pay Angeles, CA 90057, (213) Dental+ Dental2+ Routine Exams, emergency palliative services, diagnostic X-ray services 0% 0% Minor Restorative Services, fillings 15% 10% Major Restorative Services, crowns, root canals 25% 15% Life Insurance Benefit Enrolled Employee $10,000 Enrolled Dependent $10,000 PPO Plan Utilization Review/Medical Management Utilization Review includes hospital pre-admission certification, emergency admission review, and precertification of certain medical procedures and treatments. Call MCM toll free (800) $150 Benefit Reduction if you don t call as required (see page 20 for more information). 13

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15 IN THIS SECTION 15 EMPLOYEES 15 DEPENDENTS 16 ENROLLMENT REQUIREMENTS WHO S ELIGIBLE Employees You are eligible for coverage if: You work for an employer who is required by a Collective Bargaining Agreement to contribute to UNITE HERE HEALTH on your behalf; The necessary contributions are received by UNITE HERE HEALTH; You make any required monthly employee contributions or self-payments (sometimes called cash payments) to UNITE HERE HEALTH; and You satisfy the Plan s eligibility rules. If you are required to make any payment toward the cost of providing coverage for you and your family, you must arrange with your employer to make those payments by payroll deduction. If your employer does not permit payroll deductions, you must send any payment owed to the Los Angeles UNITE HERE HEALTH office. Dependents Your dependents become eligible for coverage on the date you become eligible or on the date you acquire the dependent, whichever happens last. Who Your Dependents Are For benefit purposes, your dependents are: Your husband or wife, but only if there is a valid marriage license or marriage certificate; Your opposite-sex or same-sex domestic partner, under certain circumstances, and his or her children contact UNITE HERE HEALTH for details; The information beginning on page 64 will help you figure out when you are eligible for benefits. If your employer does not permit payroll deductions, send your applicable monthly employee contribution to: 130 S. Alvarado Street 2nd Floor P.O. Box Los Angeles, CA This office also accepts walk-in payments. Coverage for your dependents can not begin before your coverage begins. Your children, including: natural children, step-children, adopted children, children placed with you for adoption and for whom you are legally required to provide support until the adoption is finalized, children entitled to coverage because of a Qualified Medical Child Support Order, or children for whom you are awarded legal guardianship or sole custody pursuant to state domestic relations law, who are under age 26; 15

16 WHO S ELIGIBLE For more information on termination of Dependent Coverage or on continuing coverage for your children over 26, see page 73. To be covered on or after their 26th birthday, your unmarried children must be unable to support themselves because of a mental or physical handicap that began before age 19 and while covered by the Plan on the day prior to their 19th birthday. Your unmarried grandchild under age 19, provided he or she lives with you, and you provide his or her principal support. Enrollment Requirements Choice of Coverage Options UNITE HERE HEALTH offers several coverage options. Your coverage options depend on your employee group: Hotel Group Employee, Cafeteria Group Employee, Event Center Group Employee, or Restaurant Group Employee. Your employee group is determined by the terms in the Collective Bargaining Agreement between your employer and the Union. Please contact the Los Angeles regional office if you need more information about your employee group. Plan benefits will not be paid until you and your eligible dependents are enrolled. You will be given an opportunity to enroll once you become initially eligible. After you become initially eligible, and during open enrollments, you can enroll yourself or any dependents at any time. However, if you do not enroll when first eligible to do so, you will only be able to enroll yourself and your dependents in the Kaiser+ with Dental+ option until either the next Open Enrollment, or the occurrence of a Special Enrollment period (see page 71). The coverage options for each employee classification are shown below. Contact UNITE HERE HEALTH with questions about your coverage options or required monthly employee contributions. Employee Group Medical and Dental Options Employee Group Kaiser+ with Dental+ Kaiser2+ with Dental2+ Kaiser3+ with Dental2+ PPO Plan with Dental2+ Hotel Group Employee Available Available Available Available Cafeteria Group Employee Available Available Event Center Group Employee Available Available Option not available Option not available Available Available Restaurant Group Employee (No coverage available for dependents) Available Option not available Option not available Option not available Monthly employee contributions may be required for the above medical and dental options. The amount of the contribution is determined by the Trustees and/or the terms of the Collective Bargaining Agreement between your employer and the Union and may change from time to time. 16

17 WHO S ELIGIBLE Employees You need to fill out an Enrollment Form, whether or not you are required to contribute to the cost of coverage. The Enrollment Form must be completed and submitted to UNITE HERE HEALTH by the enrollment due dates. Plan benefits will not be paid until a completed Enrollment Form is submitted. Once you have Dependent Coverage, you must still enroll newly acquired dependents and submit the required proof to the Aurora, Illinois UNITE HERE HEALTH Office. Dependents The Enrollment Form identifies the dependents you want covered and requests: your name, Social Security number, birth date, home address, telephone number, employer s name and address, and the dependent s name, sex, birth date, and Social Security number. Benefits will not be paid on behalf of your dependent until he or she is enrolled. Restaurant Group Employees are not eligible for Dependent Coverage. Dependent Documentation In order to verify a person s dependent status for benefit purposes, in addition to the completed Enrollment Form, you must also provide, as appropriate, at least one of the following: A certified copy of your marriage license or marriage certificate; Kaiser may have different rules governing dependent documentation. If you enroll in Kaiser, you may need to provide additional documentation. A commemoration of marriage issued by a generally recognized denomination of organized religion; A certified copy of the birth certificate; Baptismal certificate; Hospital birth records; Written proof of adoption or legal guardianship; Copies of court decrees that obligate an employee to provide medical benefits for a dependent child; Notarized copies of a participant s most recent Federal Income Tax return (Form 1040 or its equivalents). If you are enrolling a grandchild, the most recent Federal Income Tax return should show that you claimed the grandchild as a dependent; Certificates of Creditable Coverage issued in accordance with the provisions of the Health Insurance Portability and Accountability Act of 1996, as amended; Federal law requires UNITE HERE HEALTH to honor Qualified Medical Child Support Orders. UNITE HERE HEALTH has established procedures for determining whether a divorce decree or a support order meets federal requirements and for enrollment of any child named in the Qualified Medical Child Support Order. To obtain a copy of these procedures at no cost, or for more information, contact UNITE HERE HEALTH. Documentation of dependent status issued and certified by the United States Immigration and Naturalization Service; or Documentation of dependent status issued and certified by a foreign embassy. If any of the above documents are used to verify the dependent status of a child, they must contain the names of the child s parents. English translations for all documents must be provided as required. 17

18 IN THIS SECTION 18 HOW TO USE KAISER HMO COVERAGE? 18 THE EFFECT OF CHOOSING KAISER HMO COVERAGE KAISER HMO OPTIONS If you elect to choose a primary care physician, you may choose any Kaiser physician available. You may also choose a Kaiser pediatrician as the primary care physician for a child. UNITE HERE HEALTH has contracted with Kaiser Permanente (Kaiser) to provide health maintenance organization (HMO) benefits for you and your enrolled dependents. When you become eligible to enroll in UNITE HERE HEALTH, you will receive an enrollment packet highlighting the Kaiser benefit options available to you. In order to enroll, you must complete the forms included in the enrollment packet. If you choose to enroll in Kaiser, you will get a Kaiser booklet (a certificate of coverage) describing your Kaiser benefits. However, Restaurant Group Employees may only enroll in the Kaiser+ coverage option. How to Use Kaiser HMO Coverage If you enroll in one of the Kaiser options, you should choose a primary care doctor. Your primary care doctor will help you get care through Kaiser. For example, you will need a referral from a Kaiser provider to see most specialists. Your primary care doctor can do this for you. You do not need a referral or prior authorization to receive obstetrical or gynecological care from a Kaiser-contracted health care professional who specializes in obstetrics or gynecology. Except in emergencies, you will usually be required to use a Kaiser doctor, Kaiser hospital, or Kaiser facility in order to receive benefits. You can get more information about your Kaiser benefits by calling Kaiser, or from your Kaiser enrollment materials. For more information about your HMO benefits call Kaiser Permanente (800) The Effect of Choosing Kaiser HMO Coverage The contract between UNITE HERE HEALTH and Kaiser Permanente will govern how Kaiser benefits are paid. If there is any discrepancy between any information about the Kaiser benefits provided by UNITE HERE HEALTH and the Kaiser contract, the Kaiser contract will govern. 18

19 KAISER HMO OPTIONS In addition, the contract between UNITE HERE HEALTH and Kaiser governs how benefits are paid and administered. That means that the Kaiser certificate of coverage you get when you enroll in one of the Kaiser options will explain the rules that apply to your benefits. Several sections of this SPD do not apply to you if you are enrolled in one of the Kaiser options, including: PPO Plan Medical Management Review; How PPO Plan Benefits are Determined; PPO Plan Comprehensive Major Medical Benefits; PPO Plan Prescription Drug Benefits; and Coordination of Benefits under the PPO Plan; In addition, if you are enrolled in one of the Kaiser HMO options, the following sections only apply to those benefits not provided through Kaiser. General Exclusions and Limitations; Subrogation; and General Claim Provisions. The Kaiser certificate of coverage will give you more information about your medical management programs, your medical and prescription drug benefits, coordination of benefits, exclusions and limitations, subrogation, and claims provisions, including filing claim appeals. 19

20 IN THIS SECTION 21 MEDICAL AND SURGICAL TREATMENT 22 PROCESSING REQUESTS FOR PRECERTIFICATION OF BENEFITS 23 SPECIAL RULES FOR DECISIONS INVOLVING CONCURRENT CARE 23 IF AREQUEST FOR PRECERTIFICATION IS DENIED PPO PLAN MEDICAL MANAGEMENT REVIEW Depending on your employee group, you may have the choice of enrolling in the PPO Plan or in one of the Kaiser HMO options. This section only applies to members enrolled in the PPO Plan option. If you are enrolled Kaiser, see your Kaiser booklet for more information about medical management review. Medical Management Review is a mandatory program requiring precertification as well as review of certain treatments and procedures. UNITE HERE HEALTH has contracted with Medical Cost Management (MCM) to provide the following medical and surgical utilization review services: hospital pre-admission certification, emergency admission review, precertification of certain outpatient medical and/or diagnostic procedures and treatments, and retrospective review when precertification or authorization is not obtained as required. To certify medical and surgical treatment, call Medical Cost Management (MCM) toll free (800) Certification or authorization under Medical Management Review does not guarantee eligibility for benefits or that benefits will be payable for treatment or services provided. Medical Management Review is not intended as and does not constitute medical advice. The necessity for treatment, the length of hospitalization, or any other recommendations regarding medical matters is solely determined by you and your doctor. UNITE HERE HEALTH is not responsible for any consequences resulting from decisions you or your doctor make based on the certification or determination of benefits UNITE HERE HEALTH will pay. 20

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