Single Case Agreement Harvard Pilgrim

Single Case Agreement Harvard Pilgrim

To determine the extent of mental health benefits available, the plan`s performance manual (sometimes referred to as the Summary Plan Description or SPD) is reviewed. (See Administrative Data Set (CA) 00040, 00029-00031 (2016); AR 00221, 00211-00213 (2015).) For the case of J.O., the most relevant language that defines benefits and exclusions includes: UBH told her what she needed to know, but Nancy and UBH and J.O.s suppliers did not follow. Although Nancy was informed three times of the potential of an agreement on a case-by-case basis, there is no evidence that she communicated this request to Uinta. There is no evidence that Uinta seized UBH to seek an agreement on a case-by-case basis, let alone that Uinta made a reasonable effort to obtain one. The appeal letter was also accompanied by a letter from James Meyer, the education advisor, in which he stated his recommendation that J.O. should visit Uinta. (See AR 01169 (cited as of January 24, 2016, attached as ex.14 for brief appeal).) Mr. Meyer is not a physician and his letter did not support the conclusion that J.O. treatment at Uinta was medically necessary or that no network provider would be sufficient to treat J.O. Nancy also cited (and beif├╝ge) a letter dated January 26, 2016 from Russ Pryor, LCSW and Associate Executive Director of Uinta explaining why he believed J.O.

needed treatment at Uinta. (AR 01183-01184.) As in Mr Meyer`s letter, Mr Pryor did not support the medical decision of necessity or the conclusion that J.O.`s needs could not be met by a network provider. In that ERISA case, the applicants Robert O. and Nancy S., residents of Massachusetts, and J.O.`s parents, appealed pending the rejection of their entitlement to health insurance for the costs incurred in the treatment of J.O. at uinta Academy in Utah. The defendants Harvard Pilgrim Health Care (Harvard Pilgrim or HPHC) and United Behavioral Health dba Optum (UBH) assert that the costs of J.-O. are not covered by Robert`s health plan because (1) the plan does not cover emergency services from a non-state provider without pre-authorization that the applicants have not received; (2) treatment at Uinta Academy was not medically necessary, and (3) Uinta primarily provided educational services that the plan does not cover. . . .


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