These rules apply if a charge is made to a Member for any service or supply with respect to which benefits would be provided under the Group Health Care Coverage.

1. REIMBURSEMENT PROVISIONS FOR NON-PARTICIPATING PROVIDERS OR OUT-OF-AREA CLAIMS

   Only Emergency Care is covered outside of Community First’s network and/or Service Area, except in the case of Court-Ordered Dependent coverage, or unless Medically Necessary Covered Services are not available through Participating Providers.  In these situations Community First will reimburse the Non-participating Provider at the negotiated or usual and customary rate for Medically Necessary Covered Services, requested by Participating Providers and approved by Community First within forty-five (45) days of Community First's receipt of a claim with the documentation reasonably necessary to process the claim, unless a different time frame is provided for by written agreement between the parties.  Non-Participating Providers may require immediate payment for their services and supplies. If You pay a bill for Covered Services, submit a copy of the paid bill along with a completed claim form to Community First’s Member Services Department requesting reimbursement (Claim forms may be obtained from the Member Services Department or on the Web site at www.ers.state.tx.us).  Include all of the following information on Your request:

   1. The patient's name, address and the identification number and Group number and Your relationship to the Subscriber from Your identification card.
   2. Name and address of the provider of Your service (if not on the bill).
   3. If You receive a bill for authorized Covered Services from a Non-Participating Provider, You may ask Community First to pay the provider directly. Send the bill to Community First according to the procedures listed above.

   Any bill or invoice submitted to Community First for payment or
   reimbursement will be evaluated and if Community First is obligated to pay the bill under this Certificate or applicable law, then Community First will pay the bill or reimburse Member for payments already made at the allowable rate. However, submitting a bill to Community First does not guarantee payment or reimbursement and Community First will only pay or reimburse what it is obligated to pay or reimburse.
   

2. PROOF OF LOSS

   Community First must be given written proof of the loss for which claim is made under the Coverage. This proof must cover the occurrence, character and extent of that loss. It must be furnished within sixty (60) days after the date of the loss. However, it may not be reasonably possible to do so. In that case, the claim will still be considered valid if the proof is furnished as soon as reasonably possible.

3. WHEN BENEFITS ARE PAID

   Benefits are paid when Community First receives written proof of the loss.

   Allowed charges for a covered service or supply with respect to which benefits would be provided under the Group Health Care Coverage generally will be paid by Community First to the provider of the service or supply, except as stated below. If You furnish Community First satisfactory evidence that You have made payment to a provider with respect to allowed charges that are covered under this Certificate and are the obligation of Community First, reimbursement for those charges will be paid to You.
   
   Any claims submitted by Member to Community First for reimbursement will be processed as follows:

   1. Fifteen (15) days after receipt of claim, Community First shall:
      1. Acknowledge receipt of claim;
      2. Commence investigation of claim; and
      3. Request all information from claimant as deemed necessary by Community First. Subsequent additional requests may be necessary.
   2. No later than fifteen (15) business days after receipt of all
      information reasonably necessary for Community First to process the claim Community First will:
      1. Notify claimant in writing of acceptance or rejection of claim. If the claim is rejected, the notice will state the reasons for the rejection; or
      2. Notify claimant in writing of the reasons Community First needs additional time.
   3. No later than the 45th day after claimant has been notified of the need for additional time to make a decision, Community First will accept or reject the claim.
   4. If Community First notifies claimant that claim will be paid, claim will be paid no later than five (5) Working Days after notice was made.
   5. All claims must be submitted to Community First within sixty (60) calendar days from the date expenses are incurred or as soon as is reasonably possible to do so. Any claim submitted after sixty (60) days, will not be eligible for reimbursement, unless a written statement requesting additional time (not to exceed forty-five (45) days) is received.

      A benefit that is payable to You in accordance with the above paragraph but remains unpaid at the time of Your death will be paid to Your estate.

4. DAMAGES

   If delaying payment of a claim following receipt of information required by Community First exceeds the period allowed above, Community First shall pay the claim amount and eighteen percent (18%) per annum of the amount of such claim as damages, together with reasonable attorney fees as may be required by the trier of fact.

5. PHYSICAL EXAM

   Community First, at its own expense, has the right to examine the person whose loss is the basis of claim. Community First may do this when and as often as is reasonable while the claim is pending.

6. LEGAL ACTION

   No action at law or in equity will be brought to recover on the Coverage until sixty (60) days after the written proof described above is furnished. No such action will be brought more than three (3) years after the end of the time within which proof of loss is required.