'96 05/08
`
`13:39
`
`FAX
`
`LASKY—M&G—2
`
`002
`
`FROM ALLINA-LEGAL-DEPT
`-| I
`
`_
`
`{ AU
`.
`
`5. 08' 96 12:28/ST. 12:27/N0. 3560~co5201 P
`
`2
`
`
`
`’96 05/08
`
`13:39
`
`FAX
`
`LASKY~ M&G — 2
`
`FROM ALLINA—LEGAL~DEPT
`
`J05. 0895 12:28/ST. 12:27/NO. 3550::uI32Ul P
`L.
`MEDICA CHOICE SELECT
`CERTIFICATE OF COVERAGE
`("Certificate")
`
`003
`
`3
`
`Benefits:
`
`Providers:
`
`Referrals:
`
`Emergen cy
`Services:
`
`Exclusions:
`
`Continuation;
`Conversion:
`
`Cancellation:
`
`Mental Health
`and Substance
`Abuse:
`
`Important Consumer Inforrnation
`about
`Health Maintenance Organization ("HMO") Benefits
`
`HMO health care services will he covered by Medics Choice only if such service: are
`Provided In participating providers or authorized by Medical Choice. Your Certificate
`describes the health care services [or which you have coverage and the procedure: you
`must follavr to obtain HMO coverage.
`
`Enrolling in Medic: Choice does not guarantee that a particular provider on the list of
`provider: will remain a participating provider or that a particular participating provider
`will provide you with health care services. When aprnvider no longer participate: with
`Medic: Choice, you must choose to receive your health care services from among the
`remaining participating providers. You must verify that your provider participate: with
`Medics Choice each time you receive services.
`
`Certain health care services are covered only upon referral. Read your Certificate for
`referral requirement :5. All referrals to narr—parn‘cIpan'ng providers and certain types of
`participating providers must be prior approved by Medic: Choice to be eligible for
`coverage.
`
`Emergency services Iran nan—paru'cz'pan’ng provider: will be covered only if you follow
`proper procedures. Your Certificate explains these procedures and benefits associated
`with emergency core.
`
`Certain health care services are not covered. Read. your Certificate for I detailed
`explanation of all exclusions.
`
`You may convert to an Individual conversion plan or continue coverage under certain
`circumstances. These continuation and conversion rights are explained fully in your
`Certificate.
`
`Your coverage may be cancelled only under certain conditions- Your Certificate
`describes all reasons for cancellation of coverage.
`
`United. Beha-vioro! Systems, Inc. ("UB5") uses in limited network of hospital: for the
`provision of mental health and rubstnnce abuse benefits.
`Except for emergencies:
`
`1.
`2.
`
`All mental health and substance heuefit: are provided and arrgnged by
`UBS; and
`2. treatment plan, including any canfinernents, must be prior npproved. by
`UB5 to be eligible for coverage.
`
`
`
`‘96 05/08
`
`13:39
`
`AK
`F \
`
`‘
`‘
`«
`LASKY M&G 2
`
`004
`
`FROM ALLINA"LEGAL"DEPT
`
`(l.
`
`}U5. US' 95 12:28/ST. 12:27/N0. 355Uu...>2U1 P
`
`4
`
`Important Consumer information
`about
`
`Insurance Benefits
`
`In so rauce
`Benefit;-;
`
`Maximum
`Amount:
`Exclusion:-.
`
`Claims:
`
`Conversion:
`
`and prior approved
`obtain insurance benefit .
`referrals to nan-participating providers are covereai as HMO benefit: and are 113
`considered ins: rance benefits. some benefit: are provided only as HMO benefits. Read
`your Certificate for I detailed explanation of HMO and insurance benefits.
`Insurance benefit: are subject to a maximum amount payable by Physicians Insurance
`Company. Read your Certificate for a detailed explanation of the maximum amount.
`
`when you use nan-participating providers, you will be réspoosihle for filing clainu in
`order to be reimbursed for usual charges. See Section XXII for details.
`'
`plan under certain circumstances. See
`ights.
`
`The laws of the State of Min
`including the right to:
`
`Member Bill of Rights
`
`1.
`
`2.
`
`Available and acce-csi
`.1 day, 7 days a week.
`
`Information about your health condition, treatment options and risks so you can make an informed
`choice about your health cure.
`
`Refuse treatment recomeuded to you by Medic: Choice or any provider.
`Privacy of your medieafand flnancia
`provider. This will be done according to existing law.
`
`oice (the complaint process is described in your Certificate) and
`t’ Health for issues related to I-[M0 benefit: or Minnesota’: Commissioner
`of Commerce for issues related to insurance benefits.
`In accordance with Section XXVIIL you may
`begin a legal proceeding if you have 1 problem with Medic: Choice or any provider. For information,
`at: Department of Health at (612) 623-5365 or 1-800-657-3916 And request I-[MO
`information or the Minnesota Department of Commerce at (611) 296-2488 and request insurance
`information.
`'
`
`It is the policy of Medic-a Choice and Physicians lnsunlncc Company to treat all persons alike. without
`distinctions based. on race, color, religion, national origin, handicap, sex or age. If you have qngslions about
`this policy, contact Member Service at (612) 945-8000 (locally) or 1-800-952-3455
`impaired members with a. TDD phone. contact Member Service at (6
`(outstate).
`
`#310 (I/I31
`
`
`
`05/08/96
`Vj:
`
`15:41
`
`13703 308 7193
`
`PTO-LAW OFC. 13
`
`:i4:!'=!::!<H<'«l<E:3::-}:=i::k:1<>H=H==Z<>i::}::»i::{:2XH!::{::}=##3##}:
`$ ~
`ACTIVITY REPORT
`* m
`:i=*=§::H==%=:i¢:HHH=%€=E<>l:=iH}:>I:=H:é::H::l:=!4=£==H':=IH}4
`
`RECEPTION OK
`
`TX/RX N0,
`
`CONNECTION TEL
`
`CONNECTION ID
`
`START TIME
`
`USAGE TIME
`
`PAGES
`
`RESULT
`
`LASKY—M&G—2
`
`05/08 15:38
`
`02'33
`
`4
`
`OK
`
`
`
`'95 05/03
`
`13:39
`
`FAX
`
`LASKY-WG-2
`
`MERCHANT & GOULD
`3100 Norwest Center Minneapolis, Minnesota 55402 USA
`
`FAX TRANSMISSION
`
`FROM: Michael B. Lasky
`
`DIRECT FAX: +612-371-5224 (USA)
`
`DIRECT TEL: + 612-336-4634 (USA)
`Central Tel: + 612-332-5300 (USA)
`Internet: xIasky@mai|merchant-gould.com
`
`8 May 1996
`
`Local Time: 14:36
`
`TO:
`
`Jeff Look £-
`
`Law off 108
`
`YOUR REF: sn 74 592862
`
`FAX NUMBER: 703308 7193
`
`PHONE NUMBER:
`
`Informal submission of specimens for Class 42. Please call me back when you have
`considered the attachment
`
`
`
`
`
`
`
`Why a Service Center?
`You told us it was important to you to have a relationship with Medica statt who know you —
`“V9 V°iCe5: “oi V°lC9 mall Wl"e" Y°U Cull — Gnd °"9 Place Where 7°” ‘3°" °lW°')’5 rel)’ °“ Ele"i"‘Q
`5°"‘e°"e l° 'e5°lV° Y°“" l55”e5- l" "55P°"5e '0 )’°U’ "eqUe5i5/ We 5'9 Ple°9e'J l° °""°'J”Ce 'l‘e
`°Pe“l"S °l ll"e Medic“ Service Ce"l9"-
`
`Key Components of the Service Center
`An additional staff ol eight senionlevel representatives who will respond to your inquiries regarding
`billing, enrollment, claims and benefits.
`0
`Immediate response to requests related to claims ocliustments, benefit requests, billing corrections,
`enrollment additions/terminations, material requests, etc. Ninety-five percent of the inquiries
`received in the Service Center will be resolved within 24 hours!
`
`Service Center Phone Numbers and Hours
`In the past, you may have been calling the account service line, 936-6880.
`Starting Oct. "I7, 1994, you should call the Service Center at the numbers listed below.
`METRE CALLEH5
`NUN-METRE CALLEH5
`992—2200*
`l-800-936-6880*
`- When you call, you will be asked to enter ~i ~ st ~2~ let’ your dedicated service statt.
`it you are d smallrgroup business with two to 29 employees. Enter 2 eds dn other businesses.
`Enter 1
`The Service Center was created especially for employers and brokers. in order to make sure our
`representatives are able to serve you consistently, please direct your employees to the Customer
`Service lines listed below. These numbers will not change an Oct. 17.
`MEDICA CUSTOMER SERVICE NUMBERS
`612945-8000 (metro) or l-800-952-3455 (toll-tree non-metro]
`
`Medica Account Teams
`tn SEI'ViCE Excellence
`Your Medico account team is structured to support our commitment to service
`excellence. We do so through a responsive and knowledgeable team ol experienced
`service representatives. Your account team and their general responsibilities include:
`
`Amumfixemm
`Overall account responsibility and monaages most of new and renewal business.
`
`Account Service Representative
`Medicds primary Service comod for employer groups and brokers Assures rho.
`adminismfive Operations mes. you’ needs
`
`Micl< Hannalin — 992-3759
`AC°‘“"” E"3C”‘l"5
`Acmum Sewme Rewesenmme
`Steve Helm ~ 9923752
`Account Cvmdmatov
`Connie Griebel — 9923753
`ifezlé-E;fi::1ET992_22O0
`Nonwewo cane“ _ ]_800_936_688o
`
`4‘?
