Rev 6-10 31
EXCLUSIONS – WHAT IS NOT COVERED BY CHIP
CHIP will not pay for any expense or charge:
1. for any services or supplies which are not, in the judgment of our Administrator, medically necessary or not recommended by a physician. Our Administrator will make the decision whether hospitalization or health care services or supplies were not medically necessary and therefore not eligible charges under the terms of your CHIP coverage;
2. for room and board or for services rendered or articles prescribed by a physician, dentist, or other provider that exceeds the usual and customary fee;
3. incurred prior to the effective date of your CHIP coverage or after your CHIP coverage ends;
4. for services and supplies which are primarily to provide rest or convalescence, are for custodial care services, or are for educational or domiciliary purposes;
5. requiring prior approval under the terms of your CHIP coverage if such prior approval is not obtained;
6. relating to a hospital admission for diagnostic services that may be performed on an outpatient basis;
7. which is incurred while you are on active duty or training in the Armed Forces, National Guard or Reserves of any state or country; and for which any governmental body or its agencies are liable;
8. for personal supplies or services provided by a hospital or skilled nursing facility or any other service, drug or supply which is non-medical in nature or can be obtained without a prescription;
9. for services of any blood donors, any fee for failure to replace the first 3 pints of blood provided to you for each calendar year, and blood derivatives which are not classified as drugs in the official formularies;
10. for maternity services, including related services and supplies, for the Traditional and Medicare plans, except for complications of pregnancy (Maternity services are covered under the Section 15 Plans);
11. for obtaining an abortion, induced miscarriage or induced premature birth unless in the opinion of the attending physician:
a) such procedures are necessary for the preservation of life of the woman seeking such treatment; or
b) an induced premature birth is intended to produce a live viable child and such procedure is necessary for the health of the mother or the unborn child;
12. for services or articles the provision of which is not within the scope of licensure of the institution or individual providing the services or articles;
13. for: (a) routine extraction or repair of teeth; (b) procedures, including orthodontics and prosthetics, necessary for craniofacial or maxillofacial conditions; (c) services relating to the diagnosis, treatment and appliance of temporomandibular joint disorders or syndromes (TMJ) and other myofunctional disorders; or (d) dental services, including dental care, dental surgery, dental treatment, any other dental procedure involving the teeth or periodontium or any
