Individual and Family Plans

Premier HealthOne Processes and Policies

Premier Health Plan offers comprehensive, doctor-led health plans to fit your individual needs and meet your budget. We are a local insurer, so when you need assistance or have a question, we are right in your communities when you need us.

Premier Health Plan helps gives you access to the information you need to properly navigate through all of the benefits our health plans have to offer. Whether you want to know more about billing of claims or how you can apply for coverage of a certain medication, Premier Health Plan has the information for you here. Learn more about submitting claims, in-network care, and grace periods. Find out how overpayments are reimbursed, how to obtain prior authorization, and read more about explanation and coordination of benefits.

We bring information to your fingertips so you are better able to make informed decisions that matter to you, just one of the ways that shows our dedication to Premier Health’s mission to create healthier communities, one patient at a time.

Learn more:

  • Out-Of-Network Liability and Balance Billing
  • Enrollee Claim Submission
  • Grace Periods and Claims Pending
  • Retroactive Denials
  • Enrollee Recoupment of Overpayments
  • Prior Authorization Timeframes and Enrollee Responsibilities
  • Drug Exception Timeframes and Enrollee Responsibilities
  • Explanation of Benefits
  • Coordination of Benefits

Balance Billing

What is Balance Billing?
Balance billing occurs when an Out-of-Network provider bills you for the difference between his/her total billed charges (i.e., the amount that your doctor or other provider charged for a service or procedure you received) and the allowed and paid amount paid by your health insurance plan. Balance billing does not include your doctor or other provider charging or collecting out-of-pocket expenses associated with your plan such as deductibles, copayments or coinsurance required under your health benefit plan or billing you for non-covered services.

Does Premier Health Plan Allow Providers to Balance Bill?
Premier Health Plan strives to process claims efficiently, and to work with providers and members toward that goal. Participating Premier Health Plan doctors and facilities are contractually prohibited from sending you a bill in excess of your required out-of-pocket expenses (e.g., deductible, coinsurance amounts or copayments) for services covered under your plan. Participating network providers agree to accept Premier Health Plan’s network rate as payment in full for covered services and shall not balance bill. Out-of-Network or non-participating providers are not held to the same contractual billing requirements because they have not chosen to participate as an in-network provider with Premier Health Plan. In the absence of any state-mandated limitations, these out-of-network providers are free to collect up to the amount billed for services rendered. We will only “allow” and pay up to a certain amount of charges and any remaining balance beyond the paid amount will be the member’s responsibility.

Are There Any Exceptions to Out-of-network Liability?
Yes, in the event that a covered service is not available from an In-Network provider, you may obtain those covered services from an Out-of-Network provider if you receive Prior Authorization from Premier Health Plan or if the service qualifies as an emergency service. In such situations, you will not be balanced billed for covered services that are medically necessary. You may be liable for the complete bill or balance if you receive an Out-of-Network service or procedure that is not an emergency or has not received prior approval from Premier Health Plan.

How to Avoid Balance Billing
The best way to prevent receiving a bill from a provider that may be inappropriate is to make sure that you understand Premier Health Plan’s rules. You can minimize your chances of balance billing by:

  • Only using In-Network participating doctors, facilities, and other providers (such as laboratory and radiology facilities);
  • Knowing what services and procedures are covered under your health benefits plan; and
  • Ensuring that you obtain Prior Authorization for medical services or procedures, if required.

Should you have any questions, you can always contact Member Services at (855) 572-2159 or TTY at (855) 250-5604, Monday - Friday, 7:00 am – 7:00 pm Eastern Standard Time and Saturday, 8:00 am – 3:00 pm Eastern Standard Time.

How to Submit a Claim

In-Network Provider
If you receive care from an In-Network Provider, you do not have to submit a claim. We will pay the In-Network Provider directly. In the instance that you do pay an In-Network Provider directly you may submit a claim for reimbursement in accordance with the process set forth under Out-of-Network Providers below.

If you are required to pay out of pocket for health care costs provided by an In-Network Provider or pharmacy, the amount you are required to pay to the provider or pharmacy will not exceed the amount your Premier Health Plan would pay under the applicable reimbursement rates negotiated with the provider or pharmacy.

Out-of-Network Providers
In general, Premier Health Plan offers no coverage for services provided by Out-of-Network Providers, unless you have received Prior Authorization from us for these services or unless emergency services were provided. If you are unsure whether your provider is In-Network, you should call Member Services and verify. If you have received our Prior Authorization to receive Medically Necessary Covered Services from an Out-of-Network Provider, you may have to file a claim for yourself. To submit a claim, follow the steps below.

STEP 1: Review your Certificate of Coverage (COC) to make sure that the services you received are covered under your Plan.

STEP 2: Get an itemized bill from the Provider. It must be an original bill and contain all of the following information:

  • The Member’s full name
  • The name and address of the Provider/Facility that provided the services
  • A description of the service provided
  • The date of service
  • The amount charged
  • The diagnosis or nature of illness or injury
  • For private duty nursing, the shifts worked, charge per day, nurse’s license number, and signature of the ordering Provider
  • For durable medical equipment, the certification of the ordering Provider
  • If you have already made payment, please enclose proof of payment or a receipt

Make sure that you make copies, as the original itemized bills will not be returned. Note that we cannot accept cancelled checks and cash register receipts as bills.

STEP 3: Complete a claim form (In-Network or out-of-network) Claim forms are also available from Member Services. Make sure that you sign and date the claim form.

STEP 4: Mail the claim form and itemized bill to the address below within 20 days of the date you saw the provider for care (also referred to as date of service), or as soon thereafter as is reasonably possible. We will not accept any claims for reimbursement more than one year after the end of the year that benefits were paid.

Mail your completed claim form and itemized bill to:
Premier Health Plan, Inc. PO Box 3076 Pittsburgh, PA 15230-3076

Should you have any questions, you can always contact Member Services at (855) 572-2159 or TTY at (855) 250-5604, Monday - Friday, 7:00 am – 7:00 pm Eastern Standard Time and Saturday, 8:00 am – 3:00 pm Eastern Standard Time.

Remember, claims will not be reviewed and no payment will be made unless all required information has been sent to us. We have the right to require more information to support your claim if necessary.

Timeliness of Filing and Payment of Claims
If you submit a claim, a completed claim form with any necessary reports and records must be filed within 20 days of the date of service, or as soon thereafter as is reasonably possible. We will not accept any claims for reimbursement more than one year after the end of the year that benefits were paid. Payment of claims will be made within 30 days following receipt of the claim, unless we need additional information. There may be delays if there is incomplete or missing information. In that case, we will notify you within 15 working days of receipt of the claim. We will provide you with a list of all data needed to continue processing your claim. After we receive this information, claims will be processed during the next 30 working days. We will pay interest at the rate required by applicable law to you or the assigned Provider if we do not meet these requirements.

Affordable Care Act Grace Period for Payment of Premium

Premier Health Plan knows that our members sometimes encounter unexpected delays. Under a provision of the Affordable Care Act (ACA), insurers are required to allow a 90 day grace period for non-payment of premiums before discontinuing coverage for certain enrollees who purchase their health plan on the Health Insurance Marketplace and qualify for the federal advance payment of the premium tax credit. Enrollees not covered under the Health Insurance Marketplace (“Exchange”) have a grace period of 31 days from the premium due date in order to remit the required premium payment.

The required health insurance premium payment for the next month of coverage is due no later than the first day of the month. This is the due date. Members will receive a bill before the due date for the next month. If the full premium amount is not received on or before the due date, the member will be considered delinquent, a late notice will be sent and the grace period described below will begin.

The grace period applies after the enrollee has paid at least one month’s premium within the benefit year and the next payment is not received by the due date for the following month. Therefore, if an enrollee receives an advance premium tax credit and does not pay his or her health insurance premiums in full, he or she enters a 90 day “grace period”.

  • During the first 30 days of the grace period, the enrollees will continue to have health insurance coverage, and the insurer will pay claims for health care services provided to the patient during that period of time.
  • However, days 31 to 90 of the grace period, the health insurer may “pend” claims for services provided to the patient during that time.
    • If the enrollee pays his or her premiums in full before the end of the grace period, the insurer will process the pended claims for payment in accordance with the enrollee’s benefits under the plan.
    • If the enrollee does not pay his or her health insurance premium in full before the end of the grace period, the health insurer will not extend coverage for days 31 to 90 of the grace period and will retroactively terminate coverage as of the last day of the period for which health insurance premium was paid (or the last day of the first month of the grace period if the enrollee purchased coverage through the Exchange and received advance payment of the premium tax credit) and deny claims for services rendered during that time. If this retroactive termination happens, the enrollee/patient is responsible for paying the entire bill for services rendered during days 31 to 90 of the grace period.

How Premier Health Plan Handles the Grace Period for Members Who Receive an Advance Premium Tax Credit

In situations when the enrollee becomes delinquent on their health insurance premiums, Premier Health Plan will take the following steps, as defined by the ACA:

  • Premier Health Plan will process claims for services received during the first 30 days of the grace period and will pay all appropriate medical and pharmacy claims for Covered Services rendered to the enrollee during this time period.
  • Premier Health Plan will “pend” claims for services received from days 31 to 90 during the grace period until the full premium for the 90-day grace period is received. If the full premium owed is received during the 90 day grace period, claims for services provided during the 90 day grace period will automatically be processed.
  • Premier Health Plan will notify HHS and the Member of the non-payment of premiums, as well as Providers of the possibility of denied claims when the Member is in the second and third months of the grace period.
  • Premier Health Plan will notify members regarding unpaid premiums and grace period status by sending a notice of non-receipt of premium and ending of coverage (“late notice”). The late notice will include the following:
    • A statement that the full premium payment has not been received by the due date and that coverage will end for nonpayment under the plan if the required premiums are not received prior to the end of the grace period as described in the late notice;
    • The amount of premiums due; and
    • The specific date and time when the enrollee’s membership will end if the premium is not received.
  • Premier Health Plan will continue to collect advance premium tax credits on behalf of the Member from the Department of the Treasury during the grace period.
  • If the health insurance premium is not paid in full within 90 days, the member’s health plan will be cancelled, effective back to day 31 of the grace period, and the pended claims will be denied. The member will be responsible for payment of services received during this time. Premier Health Plan will not recover or retract payment for Covered Services with dates of service within the first month of the grace period.
  • Premier Health Plan will return the advance premium tax credits on behalf of the Member for the second and third months of the grace period if the Member exhausts their grace period as described.

Retroactive denials

A retroactive denial is a reversal of a previously paid claim, through which you then become responsible for the payment.

If you or your Dependents have a claim for damages or a right to repayment from a third party for any condition, illness, or injury for which benefits are paid under this Plan, we have a right of recovery for payment. Our right of recovery will be limited to the amount of any benefits we paid for covered medical expenses under this Plan, but will not include nonmedical items. Money received for future medical care or pain and suffering may not be recovered by the Plan. Our right of recovery will include compromise settlements. You or your attorney must inform us of any legal action 10 days prior to settlement or trial. We will then notify you of the amount we seek and the amount of your legal expenses we will pay.

Whenever payment has been made in error, we will have the right to recover such payment from you or, if applicable, the Provider. In the event we recover a payment made in error from the Provider, except in cases of fraud, we will only recover payment from the Provider within 24 months of the date we made the payment to the Provider. We reserve the right to deduct or offset any amounts paid in error from any pending or future claim. The cost share amount shown in your Explanation of Benefits (EOB) is our final determination; you will not receive notice of an adjusted cost share due to any recovery activity.

We have a responsibility for compliance oversight with Provider and vendor contracts. We may enter into a settlement or compromise about contract enforcement and may retain any recoveries made from a Provider or vendor due to these audits.

We have set recovery policies to decide which recoveries are to be pursued, when to incur costs and settle, or when to compromise recovery amounts. We will not pursue recoveries for overpayments if the cost of collection exceeds the overpayment amount. We may not provide you with notice of overpayments if the recovery method makes providing such notice difficult.

To help prevent retroactive claims payment denials you are advised to pay all monthly health insurance premiums by the requested due date.

Enrollee Recoupment of Overpayments

Premier Health Plan has established a process to help members get reimbursed for overpayments in a timely manner. Members may submit a request for a reimbursement of overpayment by calling Member Services at 1-855-572-2159 or TTY at (855) 250-5604, Monday - Friday, 7:00 am – 7:00 pm and Saturday, 8:00 am – 3:00 pm Eastern Standard Time. Members who have had their insurance policy cancelled or terminated, and who have made payments for a coverage period beyond their cancellation or termination date, will be refunded after the next premium billing cycle. Requests from members for recoupment of other types of overpayments, such as making a duplicate monthly premium payment, will also be processed in a timely manner.

Prior Authorization

Prior Authorization
At Premier Health Plan, we want to help you get the care you need, when you need it. Prior Authorization is a prospective review determination process through which Premier Health Plan approves a request to access a covered service or procedure before the member actually has the service or procedure performed. Under your plan, certain services require review and authorization (“Prior Authorization”) by our clinical team before services are rendered in order to be covered by Premier Health Plan. Based on your plan, your Provider is responsible for obtaining the Prior Authorization from Premier Health Plan on your behalf.

Prior Authorization determinations are made within 2 business days after Premier Health Plan receives all the necessary information regarding the proposed admission, procedure, or health care service. When Premier Health Plan approves or denies a Prior Authorization request, we send a notification letter to you and your Provider. If your Provider does not obtain Premier Health Plan’s Prior Authorization for a service or procedure that requires it, the service, procedure or medication may not be covered.

If you are unsure as to whether a service requires Prior Authorization, call Member Services and they will help you. Except for emergency or urgent care, your provider (e.g., Primary Care Provider or Specialist) must get Prior Authorization from the Plan before you receive certain services. Prior Authorization is required for select services and procedures, such as:

  • Inpatient Hospital Admissions
  • Skilled Nursing Facility Admissions
  • Behavioral Health Services / Substance Abuse Admissions
  • Home Care Services
  • Private Duty Nursing
  • Outpatient Services – Physical Therapy, Occupational Therapy and Speech Therapy
  • Surgical Procedures
  • Durable Medical Equipment
  • Clinical Trials
  • Transplants including travel and lodging

Note: The above list is a representative sample of services requiring Prior Authorization and is not all-inclusive. Please call for detailed information on services requiring Prior Authorization

  • Phone: (855) 869-7140 / (855) 250-5604 (TTY)
  • Hours: Monday – Friday, 8:00 am – 5:00 pm Eastern Standard Time

Prescription Drugs Exception Process

Premier Health Plan covers thousands of brand-name and generic medications. Members or their authorized representatives can submit a request for an exception to the formulary (list of covered medications) to Premier Health Plan using one of the methods below:

  • Phone: Contact member services at (855) 572-2159.
  • Email: Complete the Member Exception Request form and send via email to ExchangeRX@evolenthealth.com. Exception request sent by email which contain Protected Health Information (PHI) should be sent securely. All requests submitted by email are immediately received by Premier Health Pharmacy Services for processing.

Premier Health Plan has a prescription drug exception process which allows enrollees to request and gain access to prescription drugs that are not listed on our drug formulary. You, your designee, your prescribing physician, or other prescriber can ask for coverage of clinically appropriate drugs that are not covered by the Plan or are covered through utilization management. Either you, your designee, or your physician may submit the request in writing, electronically, or telephonically. A request for a non-formulary medication must include a justification supporting the need for the non-formulary drug to treat your condition, including a statement that all covered formulary drugs on any tier will be or have been ineffective, would not be as effective as the non-formulary drug, or would have adverse effects.

We will make our coverage determination on an expedited review request based on extreme circumstances and notify you or your designee, or your prescribing physician (or other prescriber, as appropriate) of our coverage determination no later than 24 hours after we receive the request. For standard requests, we will notify you or your designee, or your prescribing physician (or other prescriber, as appropriate) of our coverage determination no later than 72 hours after we receive the request. Any exceptions that are granted will be treated as a covered item or service. Any cost-sharing will be applied towards the Plan’s annual limitation on cost-sharing. All exceptions will be granted for the duration of the prescription, including refills. If a request is expedited based on circumstances, the drug will be approved for the duration of the necessity. You, your designee, or your prescribing physician can request for a denied exception to be reviewed by an independent review organization. Please refer to the External Review process below for further information.

Right to External Review
Under certain circumstances, you have a right to request an External Review of our adverse benefit decision by an Independent Review Organization or by the Superintendent of Insurance, or both. If you have filed internal claims and appeals according with the procedures of this Plan, and we have denied or refused to change our decision, or if we have failed, because of our actions or our failure to act, to provide you with a final determination of your appeal within the time permitted, or if we waive, in writing, the requirement to exhaust the internal claims and appeals procedures, you may make a request for an External Review of an Adverse Benefit Determination.

If our failure to comply with our obligations under the internal claims and appeals procedures was considered: (i) minor, (ii) not likely to cause prejudice or harm to you (claimant), (iii) because we had a good reason or our failure was caused by matters beyond our control, (iv) in the context of an ongoing good- faith exchange of information between us and you (claimant) or your Authorized Representative, and (v) not part of a pattern or practice of our not following the internal claims and appeals procedures, then you will not be deemed to have exhausted the internal claims and appeals requirements. You may request an explanation of the basis for us asserting that our actions meet this standard.

All requests for an External Review must be made within 180 days (six months) of the date of the notice of our Final Adverse Benefit Determination. Standard requests for an External Review must be provided in writing; requests for expedited External Reviews, including experimental / investigational Services, may be submitted orally or electronically. When an oral or electronic request for review is made, written confirmation of the request must be submitted to us no later than 5 days after the initial request was made. Written confirmation will be sent to you when all of the request information has been received and is completed.

You may file the request for an External Review by completing a Member Exception Request form and sending it via email to ExchangeRX@evolenthealth.com or contacting us:

Premier HealthOne
Premier Health Plan, Inc.,
PO Box 3605
Pittsburgh, PA 15230-3605

Toll-free: (855) 572-2159
TTY: (855) 250-5604
Fax: (855) 862-6518
PremierHealthPlan.org

Non-urgent request for an External Review

Unless the request is for an expedited External Review, we will initiate an External Review within 5 days receipt of complete written request. We will provide you with notice that we have initiated the External Review that includes:

  • The name and contact information for the assigned Independent Review Organization or the Superintendent of Insurance, as applicable; and
  • Except for when an expedited request is made, a statement that you may submit, in writing, additional information for either the Independent Review Organization or the Superintendent of Insurance to consider when conducting the External Review within 10 business days after the date when notice is received.

If your request is not complete, we will notify you in writing and include information about what is needed to complete the request.

If we deny your request for an External Review on the basis that the adverse benefit determination is not eligible for an External Review, we will notify you, in writing. The notification will include the reasons for the denial and that you have a right to appeal the decision to the Superintendent of insurance.

If we deny your request for an External Review because you have failed to exhaust the Internal Claims and Appeals Procedure, you may request a written explanation. The written explanation will be provided to you within 10 days of receipt of your request. It will explain the specific reasons for our assertion that you were not eligible for an External Review because you did not comply with the required procedures.

Explanation of Benefits

What is an Explanation of Benefits?
An Explanation of Benefits ( EOB) is a notice we send you that lists the recent medical treatments and/or services you received. It reflects how we processed your claim for payment and what, if anything, you may owe. At a high level, the EOB includes information on if the claim has been paid, the amount of the health plan’s payment, and the member’s financial responsibility in accordance with the member’s coverage. You will only receive an EOB if you have a financial responsibility in accordance with your coverage. The EOB is not a bill.

What Information is contained in My Explanation of Benefits?
Your EOB contains a lot of useful information that may assist you in tracking your healthcare services and expenditures. A typical EOB has been included below, and definitions of the information it contains have been provided. 

 

Premier HealthOne Processes and Procedure

Date of Service: The beginning and end date of the service you received from the provider.

Provider: The name of the provider who performed the services for you or your dependent. This may be the name of the doctor, hospital, laboratory or radiology facility, or other healthcare provider.

Billed Amount: The amount your provider billed Premier Health Plan for the service.

Additional information may include your spending summary for the benefit year (e.g., the amount of deductible and out-of-pocket maximum met) and amount of payment made to the provider. 

Why your Explanation of Benefits (EOB) is Important
Your EOB is important because it is a record of your claims billing history. You should carefully read and review the EOB because it provides a list of services that the provider is stating have been provided to the patient. The EOB is just one way to help you verify services and control costs. Sometimes errors can occur. Simple errors can often be corrected by contacting the provider’s office or facility who rendered the services. However, if the EOB contains inaccuracies or discrepancies that cause you to question whether a claim for payment has been honestly submitted on your behalf, you should contact Premier Health Plan’s anti-fraud department to report this concern.

Coordination of Benefits

Coordination of Benefits (“COB”) with other contracts

Coordination of benefits is a process whereby two or more health plans or entities determine allocation of primary and secondary responsibility for payment of a claim for health care services provided to a member when he or she has overlapping coverage. The Coordination of Benefits (“COB”) provision applies when you have healthcare coverage under more than one Plan. Plan is defined below.

The order of benefit determination rules govern the order in which each Plan will pay a Claim for benefits. The Plan that pays first is called the Primary Plan. The Primary Plan must pay benefits in accordance with its policy terms without regard to the possibility that another Plan may cover some expenses. The Plan that pays after the Primary Plan is the Secondary Plan. The Secondary Plan may reduce the benefits it pays so that payments from all Plans do not exceed 100 percent of the total Allowable Expense.

The following terms have the meanings set forth below solely for the purpose of this Coordination of Benefits (COB) Section:

  • A “Plan” is any of the following that provides benefits or services for medical or dental care or treatment. If separate contracts are used to provide coordinated coverage for members of a group, the separate contracts are considered parts of the same Plan and there is no COB among those separate contracts.
    • A Plan includes: group and non-group insurance contracts, health insuring corporation (“HIC”) contracts, Closed Panel Plans or other forms of group or group-type coverage (whether insured or uninsured); medical care components of long-term care contracts, such as skilled nursing care; medical benefits under group or individual automobile contracts; and Medicare or any other federal governmental Plan, as permitted by law.
    • A Plan does not include: hospital indemnity coverage or other fixed indemnity coverage; accident only coverage; specified disease or specified accident coverage; supplemental coverage as described in the Ohio Revised Code sections 3923.37 and 1751.56; school accident type coverage; benefits for non-medical components of long-term care policies; Medicare supplement policies; Medicaid policies; or coverage under other federal governmental Plans, unless permitted by law.
    • Each contract for coverage is a separate Plan. If a Plan has two parts and COB rules apply only to one of the two, each of the parts is treated as a separate Plan.
  • “This Plan” means the part of the contract providing the healthcare benefits to which the COB provision applies and which may be reduced because of the benefits of other Plans. Any other part of the contract providing healthcare benefits is separate from This Plan. The COB may not necessarily coordinate all benefits the same. The contract may coordinate similar benefits you have by applying a certain COB provision to a specific benefit (e.g. Dental), but may apply another COB provision to coordinate other specific benefits you may have (e.g. Prescription Drugs).
    • The order of benefit determination rules determine whether This Plan is a “Primary Plan” or “Secondary Plan” when you have healthcare coverage under more than one Plan.
    • When This Plan is primary, it determines payment for its benefits first before those of any other Plan without considering any other Plan's benefits. When This Plan is secondary, it determines its benefits after those of another Plan and may reduce the benefits it pays so that all Plan benefits do not exceed 100 percent of the total Allowable Expense.
  • The “Allowable Expense” is a healthcare expense, including Deductibles, Coinsurance and Copayments, that is covered at least in part by any Plan covering you. When a Plan provides benefits in the form of services, the reasonable cash value of each service will be considered an Allowable Expense and a benefit paid. An expense that is not covered by any Plan covering you is not an Allowable Expense. In addition, any expense that a Provider by law or in accordance with a contractual agreement is prohibited from charging you is not an Allowable Expense.

    The following are examples of expenses that are not Allowable Expenses:
    • The difference between the cost of a semi-private hospital room and a private hospital room is not an Allowable Expense, unless one of the Plans provides coverage for private hospital room expenses.
    • If you are covered by two or more Plans that compute their benefit payments on the basis of usual and customary fees or relative value schedule reimbursement methodology or other similar reimbursement methodology, any amount in excess of the highest reimbursement amount for a specific benefit is not an Allowable Expense.
    • If you are covered by two or more Plans that provide benefits or services on the basis of negotiated fees, an amount in excess of the highest of the negotiated fees is not an Allowable Expense.
    • If you are covered by one Plan that calculates its benefits or services on the basis of usual and customary fees or relative value schedule reimbursement methodology or other similar reimbursement methodology and another Plan that provides its benefits or services on the basis of negotiated fees, the Primary Plan's payment arrangement must be the Allowable Expense for all Plans. However, if the Provider has contracted with the Secondary Plan to provide the benefit or service for a specific negotiated fee or payment amount that is different than the Primary Plan's payment arrangement and if the Provider's contract permits, the negotiated fee or payment must be the Allowable Expense used by the Secondary Plan to determine its benefits.
    • The amount of any benefit reduction by the Primary Plan because you have failed to comply with the Plan provisions is not an Allowable Expense. Examples of these types of Plan provisions include second surgical opinions, precertification of admissions, and preferred Provider arrangements.