Humana Gold Choice is a Medicare+Choice private fee-for-service plan that is authorized by the Centers for Medicare and Medicaid Services (CMS), formerly the Health Care Financing Administration (HCFA). It is being offered in DuPage County, Illinois, to Medicare beneficiaries by Employers Health Insurance Company (EHI), a subsidiary of Humana Inc.

Humana Gold Choice is a unique program because a member is not restricted to a particular provider network and no referrals to specialists or other services are required. There is no traditional provider network or contracts, applications, or other documents to complete. Humana Gold Choice payment for covered services is the Medicare allowable, less any member cost-sharing amounts that are described below. Also, Humana Gold Choice will comply with Medicare’s prompt payment of claims requirements for all clean claims.

You will not have a contract with Humana Gold Choice, but you are deemed a participating provider if:

• You have knowledge that your patient is enrolled as a Member in Humana Gold Choice. Humana Gold Choice will provide Members with an identification or enrollment card.

• You have a reasonable opportunity to obtain the Terms and Conditions for participation in Humana Gold Choice that are set out herein;

• You provide services to a Humana Gold Choice Member.

In addition, you:

• Must be licensed or certified by the state and be acting within the scope of that license or certification, and not be sanctioned or have opted out of Medicare.

• Must comply with all Medicare and other federal health care program laws, regulations and program instructions that apply to the services furnished to Members.

• Agree not to balance bill Members and collect from Members only the 2002 cost-sharing amounts as follows:

Physician Services
• Primary Care Physician office visit - $10 copayment
• Specialist office visit - $20 copayment

Hospital Services
• Emergency room visit - $50 copayment
• Inpatient hospitalization - $200 a day for days one through five of each admission
• Outpatient hospital visit - $50 copayment

Other health care services:
• No copayment for skilled nursing facility (SNF) care days one through 100 (three-day hospital stay required)
• 50-percent coinsurance for durable medical equipment (DME) and prosthetics
• Ambulatory center visits - $25 copayment
• Outpatient mental health visits - $20 copayment
• Home health visits - $10 per date of service
• Outpatient prescription drugs - $5 allowance per each prescription at designated pharmacies
• $250 annual deductible for worldwide emergency and urgently needed services for Medicare covered services, plus 20-percent coinsurance applied to charges after the deductible, up to a $25,000 annual maximum.

• Submit claims within 365 days of providing services to Humana Gold Choice Members. Claims should be submitted to:

PGBA Claims & Customer Service
Humana Gold Choice
P.O. Box 202047
Florence, SC 29502-2047

Claims Customer Service telephone number is (877) 511-5000

• Agree that in no event, including, but not limited to nonpayment by Humana Gold Choice, Humana Gold Choice's insolvency or breach of this Agreement, shall you or your assignees and/or subcontractors bill, charge, collect a deposit from, seek compensation, remuneration or reimbursement from, or have any recourse against Members of Humana Gold Choice or persons other than Humana Gold Choice acting on their behalf, for covered services provided to Member by you. This provision shall not prohibit collection of payments for any noncovered services or Member cost-share amounts set for the above. You further agree that: (i) this provision supersedes any oral or written contrary agreement now existing or hereafter entered into between you and a Member or persons acting on their behalf and (ii) this provision shall apply to all of your employees, agents, trustees, assignees and subcontractors, and you shall obtain from such persons specific agreement to this provision.

• Shall comply with all Humana Gold Choice appeal and grievance procedures. Copies of those procedures are available upon request from the provider relations department, by calling (312) 441- 5056.

• Agree that if you do not agree to accept the Terms and Conditions stated herein, you may not provide services to a Humana Gold Choice Member.

Federal health care providers are not eligible for payment for services to Humana Gold Choice Members, except for emergency services.

If you have any questions or concerns about your payment or if you would like more information about Humana Gold Choice, please call PGBA Claims & Customer Service at (877) 511-5000.