American Health Shield - Temporary Health Insurance
American Health Shield - Short Term Health Insurance provides
benefits for Covered Medical Expenses related to covered Injury or
Sickness, which are: 1) not in excess of Usual and Customary
Charges; 2) not in excess of a maximum benefit amount; 3) made for
services and supplies which are a Medical Necessity and listed as Covered
Medical Expenses in the Policy or Certificate issued by FSG - Fairmont
and Customary Charges
means the lesser of: 1) the actual charge; 2) what the provider would
accept for the same service or supply in the absence of insurance; or 3)
the reasonable charge as determined by Fairmont Specialty Group, based on
factors such as: a) the most common charge for the same or comparable
service or supply in a community similar to where the service or supply is
furnished; b) the amount of resources expended to deliver the treatment
rendered; c) charging protocols and billing practices generally accepted
by the medical community or specialty groups; or d) inflation trends by
plan requires a Pre-Admission Certification by a Professional
Review Organization prior to in-patient Hospitalization or surgery.
A Covered Person or
their Attending Physician must call the Professional
Review Organization: 1. For elective or non-emergency
Hospitalization or surgery, at least 10-days prior to the date of proposed
Hospitalization; 2. Within 48-hours of an emergency admission; or 3.
Within 48-hours of delivery for complicated childbirth.
Non-compliance with the Pre-Admission Certification procedure will
result in a reduction in benefits of 50%, unless the Covered
Person is incapacitated and unable to contact the Professional
Review Organization. In such cases, the Covered
Person must contact us as soon as possible.
Covered Medical Expenses and Benefits vary by state. Detailed information about these and additional Covered Medical Expenses is listed in the Policy or Certificate issued by Fairmont Specialty Group to approved applicants