Medical Mutual - Health Plans for Life

Corporate Reimbursement Policies

Medical Mutual Corporate Reimbursement Policies Disclaimer

Medical Mutual has certain Corporate Reimbursement Policies (the “Reimbursement Policies”) that offer guidance for payment determinations for a service or guidance for the way a service should be billed to Medical Mutual. The provider is responsible for submission of accurate claims.

The Reimbursement Policies have been developed to assist in administering proper payment under benefit plans. Benefit plans vary in coverage and some plans may not provide coverage for some services discussed in these Reimbursement Policies. Benefit determinations, coverage decisions, and payment determinations are subject to all terms and conditions of the applicable benefit plan, including definitions, specifically stated benefits, exclusions and benefit limitations, applicable state or federal laws, and other Reimbursement Policies and Medical Mutual Corporate Medical Policies. Reimbursement Policies are not intended to address every issue related to reimbursement of health care services, and Medical Mutual may use reasonable discretion in interpreting and applying Reimbursement Policies to particular cases.

Reimbursement Policies are considered guidelines and are not intended to infer or eliminate benefits or coverage for a specific member. Payment determinations are based on the specific facts regarding the service provided and how that service is billed.

Reimbursement Policies do not constitute medical advice or medical care. The healthcare provider treating the member is solely responsible for the medical advice and treatment rendered to the member. Only the treating provider can deliver medical care and be responsible for the quality or appropriateness of the medical care and the skill with which it is provided.

Medical Mutual coverage decisions are benefit decisions only. Medical Mutual is not responsible for, does not provide and does not represent itself as a provider of medical care. If a service or supply is not eligible for benefits as determined by Medical Mutual, a member and the treating provider may proceed with that service or supply; however, benefits will not be available under the member’s plan.

Reimbursement Policies are regularly reviewed, updated, withdrawn or added and therefore, subject to change. Payment determinations are made in the context of Reimbursement Policies and other Medical Mutual policies, including Corporate Medical Policies, existing at the time the determination is made and are not subject to later revision as a result of a change in Reimbursement Policy.

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