§ 135-45.8. (See Editor's Note for temporary provision) General limitations and exclusions. - North Carolina Statutes

§ 135‑45.8.  (SeeEditor's Note for temporary provision) General limitations and exclusions.

The following shall in noevent be considered covered expenses nor will benefits described in G.S. 135‑45.6through G.S. 135‑45.11 be payable for:

(1)        Charges for anyservices rendered to a person prior to the date coverage under this Planbecomes effective with respect to such person.

(2)        Charges for care ina nursing home, adult care home, convalescent home, or in any other facility orlocation for custodial or for rest cures.

(3)        Charges to theextent paid, or which the individual is entitled to have paid, or to obtainwithout cost, in accordance with any government laws or regulations exceptMedicare. If a charge is made to any such person which he or she is legallyrequired to pay, any benefits under this Plan will be computed in accordancewith its provisions, taking into account only such charge. "Anygovernment" includes the federal, State, provincial or local government,or any political subdivision thereof, of the United States, Canada or any othercountry.

(4)        Charges for servicesrendered in connection with any occupational injury or disease arising out ofand in the course of employment with any employer, if (i) the employerfurnishes, pays for or provides reimbursement for such charges, or (ii) theemployer makes a settlement payment for such charges, or (iii) the personincurring such charges waives or fails to assert his or her rights respectingsuch charges.

(5)        Charges for anycare, treatment, services or supplies other than those which are certified by aphysician who is attending the individual as being required for the medicallynecessary treatment of the injury or disease and are deemed medically necessaryand appropriate for the treatment of the injury or disease by the ExecutiveAdministrator and Board of Trustees upon the advice of the Claims Processor.This subdivision shall not be construed, however, to require certification byan attending physician for a service provided by an advanced practiceregistered nurse acting within the nurse's lawful scope of practice.

(6)        Charges for anyservices rendered as a result of injury or sickness due to an act of war,declared or undeclared, which act shall have occurred after the effective dateof a person's coverage under the Plan.

(7)        Charges for personalservices such as barber services, guest meals, radio and TV rentals, etc.

(8)        Charges for anyservices with respect to which there is no legal obligation to pay. For thepurposes of this item, any charge which exceeds the charge that would have beenmade if a person were not covered under this Plan shall, to the extent of suchexcess, be treated as a charge for which there is no legal obligation to pay;and any charge made by any person for anything which is normally or customarilyfurnished by such person without payment from the recipient or user thereofshall also be treated as a charge for which there is no legal obligation topay.

(9)        Charges during acontinuous hospital confinement which commenced prior to the effective date ofthe person's coverage under this Plan.

(10)      Charges in excess ofeither the allowed amount or the reasonable amount, or the fair and reasonablevalue of the services or supply which gives rise to the expense; provided thatin each instance the extent that a particular charge is usual, customary andreasonable or fair and reasonable shall be measured and determined by comparingthe charge with charges made for similar things to individuals of similar age,sex, income and medical condition in the locality concerned, and the result ofsuch determination shall constitute the maximum allowable as covered medicalexpenses unless the Claims Processor finds that considerations of fairness andequity in a particular set of circumstances require that greater or lessercharges be considered as covered medical expenses in that set of circumstances.

(11)      Charges for or inconnection with any dental work or dental treatment except to the extent thatsuch work or treatment is specifically provided for under the Plan. Excluded ispayment for surgical benefits for tooth replacement, such as crowns, bridges ordentures; orthodontic care; filling of teeth; extraction of teeth (whether ornot impacted); root canal therapy; removal of root tips from teeth; treatmentfor tooth decay, inflammation of gingiva, or surgical procedures on diseasedgingiva or other periodontal surgery; repositioning soft tissue, reshapingbone, and removal of bony projections from the ridges preparatory to fitting ofdentures; removal of cysts incidental to removal of root tips from teeth andextraction of teeth; or other dental procedures involving teeth and their bonesor tissue supporting structure.

(12)      Charges incurred forany medical observations or diagnostic study when no disease or injury isrevealed, unless proof satisfactory to the Claims Processor is furnished that(i) the claim is in order in all other respects, (ii) the covered individualhad a definite symptomatic condition of disease or injury other than hypochondria,and (iii) the medical observation and diagnostic studies concerned were notundertaken as a matter of routine physical examination or health checkup.

(13)      Charges for routineeye examinations, eyeglasses or other corrective lenses (except for cataractlenses certified as medically necessary for aphakia persons) and hearing aidsor examinations for the prescription or fitting thereof.

(14)      Charges for cosmeticsurgery or treatment except that charges for cosmetic surgery or treatmentrequired for correction of damage caused by accidental injury sustained by thecovered individual while coverage under this plan is in force on his or heraccount or to correct congenital deformities or anomalies shall not be excludedif they otherwise qualify as covered medical expenses. Reconstructive breastsurgery following mastectomy, as those terms are defined in G.S. 58‑51‑62,is not "cosmetic surgery or treatment" for purposes of this section.

(15)      Admissions fordiagnostic tests or procedures which could be, and generally are, performed onan outpatient basis and inpatient services or supplies which are not consistentwith the diagnosis, for which admitted.

(16)      Costs denied by theClaims Processor as part of its overall program of claim review and costcontainment.

(17)      Charges in excess ofnegotiated rates allowed for preferred providers of institutional andprofessional medical care and services, when such preferred providers arereasonably available to provide institutional and professional medical care.

(18)      If a covered servicebecomes excluded from coverage under the Plan, the Executive Administrator andClaims Processor may, in the event of exceptional situations creating unduehardships or adverse medical conditions, allow persons enrolled in the Plan toremain covered by the Plan's previous coverage for up to three months after theeffective date of the change in coverage, provided the persons so enrolled hadbeen undergoing a continuous plan of specific treatment initiated within threemonths prior to the effective date of the change in coverage.

(19)      Charges for servicesunless a claim is filed within 18 months from the date of service.

(20)      Any service,treatment, facility, equipment, drug, supply, or procedure that is experimentalor investigational as defined by the Plan. Clinical trial phases III and IV arecovered by the Plan as is clinical trial phase II when approved by the Plan.Regardless of the type of trial phases covered by the Plan, all covered trialsmust involve the treatment of life‑threatening medical conditions, mustbe clearly superior to available noninvestigational treatment alternatives, andmust have clinical and preclinical data that shows the trials will be at leastas effective as noninvestigational alternatives. Trials must also involvedeterminations by treating physicians, relevant scientific data, and opinionsof experts in relevant fields of medicine. Covered trials must be approved bythe National Institutes of Health, a National Institutes of Health cooperativegroup or center, the U.S. Food and Drug Administration, the U.S. Department ofDefense, or the U.S. Department of Veterans Affairs. The Plan may also coverclinical trials sponsored by other entities. Trials must also be approved byapplicable qualified institutional review boards. All covered trials must beconducted in and by facilities and personnel that maintain a high level ofexpertise because of their training, experience, and volume of patients. To becovered by the Plan, patients participating in clinical trials must meetsubstantially all protocol requirements of the trials and exercise informedconsent in the trials. Only medically necessary costs of health care servicesinvolved in treatments provided to patients for the purpose of the trials arecovered by the Plan to the extent that such costs are not customarily funded bynational agencies, commercial manufacturers, distributors, or other suchproviders. Clinical trial costs not covered by the Plan include, but are notlimited to, the costs of services that are not health care services and costsassociated with managing research in the trials. The Plan shall not excludebenefits for covered clinical trials if the proposed treatment is the onlyappropriate protocol for the condition being treated.

(21)      Complications arisingfrom noncovered services.

(22)      Charges related to anoncovered service, even if the charges would have been covered if rendered inconnection with a covered service.

(23)      Charges for servicescovered by the long‑term care benefit provisions of Part 4 of thisArticle.

(24)      Charges disallowed bythe Plan's pharmacy benefits manager.  (1981 (Reg. Sess., 1982), c. 1398, s. 6; 1983, c.922, ss. 15, 21.4; 1985 (Reg. Sess., 1986), c. 1020, ss. 16, 20, 21, 25, 26;1987, c. 282, s. 35; 1991, c. 427, ss. 16, 30, 40; 1993, c. 464, s. 7; 1995, c.535, s. 29; 1997‑456, s. 55.9; 1997‑468, s. 6; 1997‑512, ss.4, 13; 1998‑212, s. 28.29(c); 2000‑141, s. 5; 2007‑323, ss.28.22A(j), (k); 2008‑168, ss. 1(a), 3(a), (m), (v); 2009‑16, s.2(d).)