[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-1-en-105":3,"doc-seo-302169-105":53,"doc-detail-302169-en":126},{"code":4,"msg":5,"data":6},0,"success",[7,14,19,24,29,34,39,44,49],{"id":8,"doc_module":9,"doc_module_name":10,"category_name":11,"show_sort_weight":12,"slug":13},11,1,"Template","Presentations",90,"presentations",{"id":15,"doc_module":9,"doc_module_name":10,"category_name":16,"show_sort_weight":17,"slug":18},12,"Resumes",80,"resumes",{"id":20,"doc_module":9,"doc_module_name":10,"category_name":21,"show_sort_weight":22,"slug":23},14,"Invoices",70,"invoices",{"id":25,"doc_module":9,"doc_module_name":10,"category_name":26,"show_sort_weight":27,"slug":28},15,"Posters",60,"posters",{"id":30,"doc_module":9,"doc_module_name":10,"category_name":31,"show_sort_weight":32,"slug":33},16,"Social Media",50,"social-media",{"id":35,"doc_module":9,"doc_module_name":10,"category_name":36,"show_sort_weight":37,"slug":38},17,"Forms",40,"forms",{"id":40,"doc_module":9,"doc_module_name":10,"category_name":41,"show_sort_weight":42,"slug":43},18,"Letters",30,"letters",{"id":45,"doc_module":9,"doc_module_name":10,"category_name":46,"show_sort_weight":47,"slug":48},21,"Paper Templates",5,"papers-templates",{"id":50,"doc_module":9,"doc_module_name":10,"category_name":51,"show_sort_weight":4,"slug":52},158,"General","general-158",{"code":4,"msg":54,"data":55},"ok",{"site_id":56,"language":57,"slug":58,"title":59,"keywords":60,"description":61,"schema_data":62,"social_meta":119,"head_meta":121,"extra_data":123,"updated_unix":125},105,"en","evidence-of-coverage-clarksville-montgomery-county-employees-insurance-trust-2024-preferred-planstandard-plan","Evidence of Coverage - Clarksville Montgomery County Employees Insurance Trust 2024 - Preferred Plan/Standard Plan","","Evidence of Coverage document for Clarksville Montgomery County Employees Insurance Trust (2024) detailing the Preferred Plan and Standard Plan health benefit coverage administered by BlueCross BlueShield of Tennessee, Inc. Includes a nondiscrimination notice, accessibility and language assistance information, and instructions for filing a nondiscrimination grievance or a civil rights complaint. Provides the table of contents covering benefit administration, eligibility, when coverage begins and ends, prior authorization and care management, claims and payment, coordination of benefits, and definitions and attachments such as covered services and schedules of benefits.",{"@graph":63,"@context":118},[64,80,101],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/evidence-of-coverage-clarksville-montgomery-county-employees-insurance-trust-2024-preferred-planstandard-plan/302169/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/evidence-of-coverage-clarksville-montgomery-county-employees-insurance-trust-2024-preferred-planstandard-plan/302169.png","ImageObject",442,249,{"name":88,"@type":89},"Theodora","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-09-23","2026-09-19",true,{"@type":98,"interactionType":99,"userInteractionCount":9},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"Who administers the health benefits described in this Evidence of Coverage?","Question",{"text":108,"@type":109},"BlueCross BlueShield of Tennessee, Inc. administers the benefits referenced in the document as “Administrator,” “We,” “Us,” “Our,” or “BlueCross.”","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"What should members do if they need language or accessibility assistance?",{"text":113,"@type":109},"Members can request free language services and free aids and services for disabilities by contacting the consumer advisor or using the member service number on the back of their ID card (TTY and other contact options are provided).",{"name":115,"@type":106,"acceptedAnswer":116},"How can a member file a nondiscrimination grievance?",{"text":117,"@type":109},"A member can file a nondiscrimination grievance in person or by mail, fax, or email, addressed to the Nondiscrimination Compliance Coordinator as specified in the notice.","https://schema.org",{"og:url":78,"og:type":120,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":122,"canonical":78},"index,follow",{"doc_id":124,"site_id":56},302169,1790196562,{"code":4,"msg":5,"data":127},{"doc_id":124,"user_id":128,"nickname":88,"user_avatar":129,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":9,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":135,"language":136,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":61,"update_tm":140,"read_time":141},687197207919,"https://ap-avatar.wpscdn.com/avatar/a000253d6f5f7c60be?x-image-process=image/resize,m_fixed,w_180,h_180&k=1779446848396160552","| Evidence of Coverage\u003Cbr>Health Benefit Plan\u003Cbr>Clarksville Montgomery County Employees Insurance Trust – 2024\u003Cbr>Preferred Plan\u003Cbr>Standard Plan\u003Cbr>|  |\n| --- | --- |\n| | |\n\nBlueCross BlueShield of Tennessee 1 Cameron Hill Circle | Chattanooga, [TN 37402 | bcbst.com](TN 37402 | bcbst.com)  \nBlueCross BlueShield of Tennessee, Inc., an Independent Licensee of the BlueCross BlueShield Association COM M-662 (1/ 2021)  \nNONDISCRIMINATION NOTICE  \nBlueCross BlueShield of Tennessee (BlueCross) complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability or sex. BlueCross does not exclude people or treat them differently because of race, color, national origin, age, disability or sex.  \nBlueCross:  \n• Provides free aids and services to people with disabilities to communicate effectively with us, such as: (1) qualified interpreters and (2) written information in other formats, such as large print, audio and accessible electronic formats.  \n• Provides free language services to people whose primary language is not English, such as: (1) qualified interpreters and (2) written information in other languages.  \nIf You need these services, contact a consumer advisor at the Member Service number on the back of Your ID card or call 1-800-565-9140 (TTY: 1-800-848-0298 or 711) .  \nIf You believe that BlueCross has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability or sex, You can file a grievance (“Nondiscrimination Grievance”). For help with preparing and submitting Your Nondiscrimination Grievance, contact a consumer advisor at the Member Service number on the back of Your ID card or call 1-800-565-9140 (TTY: 1-800- 848-0298 or 711). They can provide You with the appropriate form to use in submitting aNondiscrimination Grievance. You can file a Nondiscrimination Grievance in person or by mail, fax or email. Address Your Nondiscrimination Grievance to: Nondiscrimination Compliance Coordinator; c/o Manager, Operations, Member Benefits Administration; 1 Cameron Hill Circle, Suite 0019, Chattanooga, TN 37402-0019; (423) 591-9208 (fax); [Nondiscrimination_OfficeGM@bcbst.com](Nondiscrimination_OfficeGM@bcbst.com) (email).  \nYou can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at [https://ocrportal.hhs.gov/ocr/portal/lobby.jsf](https://ocrportal.hhs.gov/ocr/portal/lobby.jsf), or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, 1–800– 368–1019, 800–537–7697 (TDD) . Complaint forms are available at  \n[http://www.hhs.gov/ocr/off](http://www.hhs.gov/ocr/off)ice/file/index.html.  \nNOTICE  \nPLEASE READ THIS EVIDENCE OF COVERAGE CAREFULLY AND KEEP IT IN A SAFE PLACE FOR FUTURE REFERENCE. IT EXPLAINS YOUR BENEFITS AS ADMINISTERED BY BLUECROSS BLUESHIELD OF TENNESSEE, INC. IF YOU HAVE ANY QUESTIONS ABOUT THIS EVIDENCE OF COVERAGE OR ANY OTHER MATTER RELATED TO YOUR MEMBERSHIP IN THE PLAN, PLEASE WRITE OR CALL US AT:  \nCUSTOMER SERVICE DEPARTMENT  \nBLUECROSS BLUESHIELD OF TENNESSEE, INC.  \nADMINISTRATOR  \n1 CAMERON HILL CIRCLE  \nCHATTANOOGA, TENNESSEE 37402  \n(800) 565-9140  \nTABLE OF CONTENTS  \nINTRODUCTION...............................................................................................................1  \nBENEFIT ADMINISTRATION ERROR..........................................................................1  \nNOTIFICATION OF CHANGE IN STATUS ...................................................................2  \nELIGIBILITY.....................................................................................................................3  \nWHEN COVERAGE BEGINS...........................................................................................7  \nW","cbCaihOCpmzjuXV8","https://ap.wps.com/l/cbCaihOCpmzjuXV8","pdf",1450390,89,"English","# Introduction\n## Benefit Administration Error\n## Notification of Change in Status\n## Eligibility\n## When Coverage Begins\n## When Coverage Ends\n## Continuation of Coverage\n## Prior Authorization, Care Management, Medical Policy and Patient Safety\n## Health and Wellness Services\n## Inter-Plan Arrangements\n## Claims and Payment\n## Coordination of Benefits\n## Grievance Procedure\n## Definitions\n## Attachment A: Covered Services and Exclusions\n## Attachment B: Other Exclusions\n## Attachment C: Schedule of Benefits – Preferred Plan\n## Attachment C: Schedule of Benefits – Standard Plan\n## General Provisions\n## Privacy Practices","[{\"question\":\"Who administers the health benefits described in this Evidence of Coverage?\",\"answer\":\"BlueCross BlueShield of Tennessee, Inc. administers the benefits referenced in the document as “Administrator,” “We,” “Us,” “Our,” or “BlueCross.”\"},{\"question\":\"What should members do if they need language or accessibility assistance?\",\"answer\":\"Members can request free language services and free aids and services for disabilities by contacting the consumer advisor or using the member service number on the back of their ID card (TTY and other contact options are provided).\"},{\"question\":\"How can a member file a nondiscrimination grievance?\",\"answer\":\"A member can file a nondiscrimination grievance in person or by mail, fax, or email, addressed to the Nondiscrimination Compliance Coordinator as specified in the notice.\"}]","Evidence of Coverage - Clarksville Montgomery County Employees Insurance Trust 2024 - Preferred Plan/Standard Plan | PDF",1789789884,31]