Table of Contents (continued) iv Part 8 Other Health Plan Provisions........................................................................................78 Access to and Confidentiality of Medical Records..............................................................................78 Acts of Providers..................................................................................................................................78 Assignment of Benefits........................................................................................................................79 Authorized Representative and Legal Representative .........................................................................79 Changes to Health Plan Coverage........................................................................................................79 Charges for Non-Medically Necessary Services .................................................................................80 Clinical Guidelines and Utilization Review Criteria ...........................................................................80 Continuity of Care Access for Cancer and Pediatric Facilities............................................................81 Disagreement with Recommended Treatment.....................................................................................81 Mandates for Residents or Services Outside of Massachusetts ...........................................................82 Member Cooperation ...........................................................................................................................82 Pre-Existing Conditions.......................................................................................................................82 Quality Assurance Programs................................................................................................................82 Services Furnished by Non-Preferred Providers..................................................................................83 Services in a Disaster...........................................................................................................................84 Time Limit for Legal Action................................................................................................................84 Part 9 Filing a Claim ................................................................................................................85 When the Provider Files a Claim .........................................................................................................85 When the Member Files a Claim .........................................................................................................85 Timeliness of Claim Payments ............................................................................................................86 Part 10 Appeal and Grievance Program...............................................................................87 Inquiries and/or Claim Problems or Concerns.....................................................................................87 Appeal and Grievance Review Process ...............................................................................................87 Internal Formal Review ..................................................................................................................87 External Review..............................................................................................................................91 Part 11 Group Policy................................................................................................................94 Eligibility and Enrollment for Group Coverage ..................................................................................94 Eligible Employee...........................................................................................................................94 Eligible Spouse ...............................................................................................................................94 Eligible Dependents........................................................................................................................95 Enrollment Periods for Group Coverage .............................................................................................96 Initial Enrollment............................................................................................................................96 Special Enrollment..........................................................................................................................96 Qualified Medical Child Support Order .........................................................................................98 Open Enrollment Period .................................................................................................................98 Other Membership Changes ...........................................................................................................98 Termination of Group Coverage..........................................................................................................98 Loss of Eligibility for Group Coverage..........................................................................................98 Termination of Group Coverage by the Subscriber........................................................................99 Termination of Group Coverage by Blue Cross Blue Shield HMO Blue ......................................99 Continuation of Group Coverage.......................................................................................................100 Family and Medical Leave Act.....................................................................................................100 Limited Extension of Group Coverage under State Law..............................................................100 Continuation of Group Coverage under Federal or State Law.....................................................101 Medicare Program..............................................................................................................................102 Under Age 65 with End Stage Renal Disease (ESRD).................................................................102