Participating Outpatient Providers
To maximize your benefits, mental health care or chemical dependency treatment must be both authorized by MHN and provided by an MHN contracted network provider. To access these benefits call MHN at1-800- WTWT-008 (1-800-989-8008). You can call any time of the day or night. A specially trained MHN staff member will be there to take your call. Calls can also be made to MHN on your behalf by your medical doctor or family member if you choose to have them call.

If you need to talk to a counselor when you call, you will be connected to one of MHN’s staff counselors for immediate help. Otherwise MHN will arrange for you to see an MHN contracted provider in your area. The assessor will help you evaluate your problem and try to help you solve it. The assessment may take one, two or three visits. Assessment sessions are provided at no cost to all eligible participants and their eligible dependents. If you need help or treatment beyond the assessment sessions, the assessor will refer you to an MHN contracted network provider in your area for treatment. Only medically necessary and clinically appropriate services will be authorized. In the event you would like to change to another participating provider, please contact MHN for authorization and the name of another MHN network provider in your area.

If there is not an MHN network provider in your area, MHN will refer you to an appropriate non-network provider. Call MHN at 1-800-WTWT-008 (1-800-989-8008) for assistance in locating a provider. You must go through the MHN system in order to receive benefits at the higher level.

You need not complete or submit a claim form if you use an network provider. You are responsible only for any applicable co-payment.

If an network provider is terminated, breaks his/her contract, or is unable to perform his/her duties, will provide written notice to you and to WTWT within a reasonable time. Upon termination of an network provider, remains liable for medically necessary and clinically appropriate Covered Services undertaken by the provider (other than for copayments) until such services have been completed. However, may make reasonable and medically appropriate provisions for the assumption of such services by another network provider.

Every contract between and network providers and facilities states that in the event that fails to pay the involved network provider or network facility, you and your dependents will not be responsible to the provider or facility for any sums owed by .

Non-Participating Outpatient Providers
Alternately, you may elect to obtain medically necessary and clinically appropriate outpatient services from a non- network provider, but you will receive a substantially lower level of benefits.

If you obtain care from a non- Network provider, you must pay for services and file a claim form with in order to be reimbursed for the benefits which are payable to you under this program. Call the Access Line at 1-800-WTWT-008 (1-800-989-8008) and request a “Non-Contracting Claim Form”. The completed claim form should then be returned to for processing and benefit application. If the claim is in order, you will receive a reimbursement check from . When using a non-participating provider or facility, you are responsible for the difference between the billed amount and the amount paid by MHN.

Inpatient or Alternate Care Treatment
The program provides benefits for inpatient hospitalization and alternate care treatment. You will receive the maximum benefit if you both access the needed treatment through and obtain such treatment from an network facility. However, you may elect to obtain inpatient hospitalization or alternate care treatment from a non-participating facility provider, but at a lower level of benefits. Pre-authorization from is required for all non-emergency inpatient or alternate care treatment, whether provided by an network facility or non- network facility. Failure to obtain pre-authorization from prior to entering a hospital or alternate care facility will result in no benefits being payable. Only medically necessary and clinically appropriate services will be authorized.

To obtain pre-authorization for an inpatient or alternate care program admission call the Access Line at 1-800-WTWT-008 (1-800-989-8008).

Special Provision Where Network is Not Available
The Network of contracted providers and facilities is available throughout the nation and can be expanded as a need for services in a particular location arises. However, should you or a dependent need care, and is unable to refer you to a network provider or facility provider located in your area (within a 30 minute driving distance or 20 mile radius from your home), you may use the services of a non- network provider or facility provider, and benefits will be paid as if a network provider or facility had been used, provided that such treatment has been pre-authorized by MHN.

This provision applies only if you first call the Access Line and give an opportunity to refer you to a provider or facility situated in your area who is already a network member, or who is willing to become a network member for the particular services that you or your dependent may require. Remember, these special situations must be reviewed and approved in advance by .

Emergency Services
Payment for Covered Services provided through inpatient hospitalization or alternate care treatment is conditioned on pre-notification and authorization by , except in cases of emergency. In an emergency, will pay for Covered Services rendered by the involved facility only for the first 48 hours following the emergency admission.

Coverage for treatment rendered after the 48 hour period for emergency admissions is subject to immediate notification to and continuing authorization by of all such treatment.

To obtain reimbursement for emergency treatment by a non- network facility, the eligible participant must send a copy of the report of the emergency, a copy of the itemized bill, and a copy of the receipt for the eligible participant’s payment to the Claims Department of .

Out-of-Pocket Expenses Not Applicable to Your Medical Plan
The copayments and other out-of-pocket expenses incurred under this program do not accrue to the satisfaction of the deductibles or other out-of-pocket maximums of the WTWT Medical Plan.