Designated Transplant. Network Provider Any licensed hospital, health care provider, group or association of health care providers that satisfies the quality, outcome, and accessibility needs of PIC and its members, and has contracted to participate as a designated transplant provider in the specific PIC participating provider network designated by PIC to provide benefits for organ or bone marrow transplant or stem cell support and all related services and aftercare for you. Dressing Putting on and taking off all items of clothing and any necessary braces, fasteners, or artificial limbs. Eating Feeding oneself by getting food into the body from a receptacle, such as a plate, cup, or table, or by a feeding tube or intravenously. Educational A service or supply: (1) that is primarily intended to provide training in the activities of daily living, instruction in scholastic skills such as reading and writing; preparation for an occupation; or treatment for learning disabilities; or (2) that is provided to promote development beyond any level of function previously demonstrated, except in the case of a child with congenital, developmental, or medical conditions that have significantly delayed speech or motor development as long as progress is being made towards functional goals set by the attending health care professional. Effective Date The date you become eligible for health care benefits under this contract and complete all enrollment requirements. Eligible Charges A charge for health care services, subject to all of the terms, conditions, limitations and exclusions of the contract and for which PIC or you will pay. Eligible Individual An individual whom PIC determines has met the eligibility requirements for enrolling in this contract, which requirements include, but are not limited to, residency in a Minnesota service area served by this contract. Such residency requirement does not apply to dependents. Emergency (Also Emergency Medical Condition) See definition of emergency medical condition. Emergency Department of a Hospital A hospital outpatient department that provides emergency services. Emergency Medical Condition (Also Emergency) A medical condition, including a mental health condition or substance use disorder, manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in: i. placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy; ii. serious impairment to bodily functions; or iii. serious dysfunction of any bodily organ or part.
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Samples: www.preferredone.com, www.preferredone.com, www.preferredone.com
Designated Transplant. Network Provider Any licensed hospital, health care provider, group or association of health care providers that satisfies the quality, outcome, and accessibility needs of PIC and its members, and has contracted to participate as a designated transplant provider in the specific PIC participating provider network designated by PIC to provide benefits for organ or bone marrow transplant or stem cell support and all related services and aftercare for you. Dressing Putting on and taking off all items of clothing and any necessary braces, fasteners, or artificial limbs. Eating Feeding oneself by getting food into the body from a receptacle, such as a plate, cup, or table, or by a feeding tube or intravenously. Educational A service or supply: (1) that is primarily intended to provide training in the activities of daily living, instruction in scholastic skills such as reading and writing; preparation for an occupation; or treatment for learning disabilities; or (2) that is provided to promote development beyond any level of function previously demonstrated, except in the case of a child with congenital, developmental, or medical conditions that have significantly delayed speech or motor development as long as progress is being made towards functional goals set by the attending health care professionalphysician. Effective Date The date you become eligible for health care benefits under this contract and complete all enrollment requirements. Eligible Charges A charge for health care services, subject to all of the terms, conditions, limitations and exclusions of the contract PIC and for which PIC or you will pay. Eligible Individual An individual whom PIC determines has met the eligibility requirements for enrolling in this contract, which requirements include, but are not limited to, residency in a Minnesota service area served by this contract. Such residency requirement does not apply to dependents. Emergency (Also Emergency Medical Condition) See definition The onset of emergency medical condition. Emergency Department of a Hospital A hospital outpatient department that provides emergency services. Emergency Medical Condition (Also Emergency) A medical condition, including a mental health condition or substance use disorder, manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in a medical condition manifesting itself by acute symptoms of sufficient severity (severity, including severe pain) , such that the absence of immediate medical attention could reasonably be expected by a prudent layperson to result in: i. placing the 1. Placing your health of the individual (or, with respect to if you are a pregnant womanindividual, the health of the woman you or her your unborn child) in serious jeopardy; ii2. serious Serious impairment to bodily functions; or iii3. serious Serious dysfunction of any bodily organ or part. Emergency Services A medical screening examination that is within the capability of the emergency department of a hospital, including ancillary services routinely available to the emergency department, to evaluate such emergency medical condition and such further medical examination and treatment required to stabilize the patient. Essential Health Benefits The categories of covered services this contract is required to cover under the Affordable Care Act. Fee-for-Service Method of payment for provider services based on each visit or service rendered. Fee Schedule The amount that the participating provider has contractually agreed to accept as reimbursement in full for covered services and supplies. This contracted amount may be less than the provider’s usual charge for the service. If health care services are delivered to you via telemedicine by a distant site participating provider who is not a designated participating provider for web based (online) care, PIC will reimburse such participating provider on the same basis and using the same fee schedule as would apply if the covered services had been delivered in person by the distant site participating provider. Formulary A list, which may change from time to time, of prescription drugs which PIC, in its sole discretion, after consideration of recommendations from PIC’s Pharmacy and Therapeutics Quality Management Subcommittee, has established for use with this contract. Habilitative Therapy Therapy provided to develop initial functional levels of movement, strength, daily activity, or speech. Health Care Services Medical or behavioral services including pharmaceuticals, devices, technologies, tests, treatments, therapies, supplies, procedures, hospitalizations, or provider visits. Health Plan Health insurance coverage offered in the individual market or a small group health plan offered in the small group market, that provides essential health benefits, all within the meaning of the Affordable Care Act. A health plan does not include coverage that is excepted benefits under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Homebound When you are unable to leave home without considerable effort due to a medical condition. Lack of transportation does not constitute homebound status. Hospital A facility that provides diagnostic, medical, therapeutic, and surgical services by or under the direction of physicians and with 24-hour registered nursing services. The hospital is not mainly a place for rest or custodial care, and is not a nursing home or similar facility. Incurred Services and supplies rendered to a member are considered to be “incurred” at the time or date the service or supply was actually purchased or provided. Infertility Inability to become pregnant after the following periods of time of regular unprotected intercourse or therapeutic donor insemination: 1. One year, if you are a female under age 35 or a male of any age, or 2. Six months, if you are a female age 35 or older, provided that your infertility is not related to voluntary sterilization or failed reversal of voluntary sterilization, Injury Bodily damage other than sickness, including all related conditions and recurrent symptoms. Investigative As determined by PIC, a drug, device or medical treatment or procedure is investigative if reliable evidence does not permit conclusions concerning its safety, effectiveness, or effect on health outcomes. XXX will consider the following categories of reliable evidence, none of which shall be determinative by itself: 1. Whether there is a final approval from the appropriate government regulatory agency, if required. This includes whether a drug or device can be lawfully marketed for its proposed use by the FDA; or if the drug, device or medical treatment or procedure is under study or if further studies are needed to determine its maximum tolerated dose, toxicity, safety or efficacy as compared to standard means of treatment or diagnosis; and 2. Whether there are consensus opinions or recommendations in relevant scientific and medical literature, peer-reviewed journals, or reports of clinical trial committees and other technology assessment bodies. This includes consideration of whether an oncology treatment is included in the applicable National Comprehensive Cancer Network (NCCN) guideline, as appropriate for its proposed use, or whether a drug is included in any authoritative compendia as identified by the Medicare program such as, the National Comprehensive Cancer Network Drugs and Biologics Compendium, as appropriate for its proposed use; and 3. Whether there are consensus opinions of national and local health care providers in the applicable specialty as determined by a sampling of providers, including whether there are protocols used by the treating facility or another facility, studying the same drug, device, medical treatment or procedure. Maintenance Care Care that is not habilitative or rehabilitative therapy and there is lack of documented significant progress in functional status over a reasonable period of time. Medical Literature Articles from major peer reviewed medical journals that have recognized the drug or combination of drugs’ safety and effectiveness for treatment of the indication for which it has been prescribed. Each article shall meet the uniform requirements for manuscripts submitted to biomedical journals established by the International Committee of Medical Journal Editors or be published in a journal specified by the United States Secretary of Health and Human Services pursuant to United States Code, title 42, section 1395x, paragraph (t), clause (2), item (B), as amended, as acceptable peer review medical literature. Each article must use generally accepted scientific standards and must not use case reports to satisfy this criterion. Medically Necessary Any health care services, preventive health care services, and other preventive services that PIC, in its discretion and on a case by case basis, determines are appropriate and necessary in terms of type, frequency, level, setting, and duration, for the diagnosis or condition; and the care must: 1. Be consistent with the medical standards and generally accepted practice parameters of providers in the same or similar general specialty as typically manages the condition procedure or treatment at issue; and 2. Help restore or maintain your health; or 3. Prevent deterioration of your condition; or 4. Prevent the reasonably likely onset of a health problem or detect an incipient problem. Member A subscriber or dependent who is enrolled under this contract. Minimum Essential Coverage Health care coverage as defined by the Affordable Care Act and codified in the Internal Revenue Code § 5000A(f), and any related regulations as they may be amended from time-to-time; which includes, but is not limited to, certain government-sponsored programs including a standard basic health plan (BHP) within the meaning of the Affordable Care Act, employer-sponsored plans, health plans offered in the individual market in a state; and which, if it is an employer-sponsored plan, provides minimum value, meaning that the plan’s share of the total allowed costs of benefits provided under the plan is at least 60 percent of such costs. Net Price PIC's cost for insulin, including any rebates or discounts received by or accrued directly or indirectly to PIC from a drug manufacturer or pharmacy benefit manager. Non-Participating Provider A clinic, physician, provider, or facility that is licensed but is not a participating provider. Non-Participating Provider Benefits Coverage for health care services provided by licensed providers other than participating providers. With non-participating provider benefits, you are financially responsible for a deductible, coinsurance, and any amount in excess of the PIC non-participating provider reimbursement value. Out-of-Pocket Limit The maximum amount of money you must pay in copayments, coinsurance and deductibles before PIC pays remaining eligible charges. If you reach benefit, day, or visit maximums, you are responsible for amounts that exceed the out-of-pocket limit. Orthognathic Surgery Surgical manipulation of the elements of the facial skeleton to restore the proper anatomic and functional relationship in patients with dentofacial skeletal anomalies. Participating Provider A licensed clinic, physician, provider or facility that is directly contracted to participate in the specific PIC participating provider network designated by PIC to provide benefits to members enrolled in this PIC contract. The participating status of providers may change from time to time. Participating providers may also be offered from other Preferred Provider Organizations that have contracted with PIC. Participating Provider Benefits Coverage for health care services provided through participating providers. Pediatric acute-onset neuropsychiatric syndrome (PANS) A class of acute-onset obsessive compulsive or tic disorders or other behavioral changes presenting in children and adolescents that are not otherwise explained by another known neurologic or medical disorder. Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS) A condition in which a streptococcal infection in a child or adolescent causes the abrupt onset of clinically significant obsessions, compulsions, tics, or other neuropsychiatric symptoms or behavioral changes, or a relapsing and remitting course of symptom severity. Physical Disability A condition caused by a physical injury or congenital defect to one or more parts of your body that is expected to be ongoing for a continuous period of at least two years from the date the initial proof is supplied to PIC and as a result you are incapable of self-sustaining employment and are dependent on the subscriber for a majority of support and maintenance. An illness by itself will not be considered a physical disability unless adequate separate proof is furnished to PIC for PIC to determine that a physical disability also exists as defined in the preceding sentence. Physician A licensed Doctor of Medicine, Doctor of Osteopathy, Doctor of Podiatry, Doctor of Optometry, or Doctor of Chiropractic. PIC PreferredOne Insurance Company.
Appears in 1 contract
Samples: www.preferredone.com
Designated Transplant. Network Provider Any licensed hospital, health care provider, group or association of health care providers that satisfies the quality, outcome, and accessibility needs of PIC and its members, and has contracted to participate as a designated transplant provider in the specific PIC participating provider network designated by PIC to provide benefits for organ or bone marrow transplant or stem cell support and all related services and aftercare for you. Dressing Putting on and taking off all items of clothing and any necessary braces, fasteners, or artificial limbs. Eating Feeding oneself by getting food into the body from a receptacle, such as a plate, cup, or table, or by a feeding tube or intravenously. Educational A service or supply: (1) that is primarily intended to provide training in the activities of daily living, instruction in scholastic skills such as reading and writing; preparation for an occupation; or treatment for learning disabilities; or (2) that is provided to promote development beyond any level of function previously demonstrated, except in the case of a child with congenital, developmental, or medical conditions that have significantly delayed speech or motor development as long as progress is being made towards functional goals set by the attending health care professionalphysician. Effective Date The date you become eligible for health care benefits under this contract and complete all enrollment requirements. Eligible Charges A charge for health care services, subject to all of the terms, conditions, limitations and exclusions of the contract PIC and for which PIC or you will pay. Eligible Individual An individual whom PIC determines has met the eligibility requirements for enrolling in this contract, which requirements include, but are not limited to, residency in a Minnesota service area served by this contract. Such residency requirement does not apply to dependents. Emergency (Also Emergency Medical Condition) See definition The onset of emergency medical condition. Emergency Department of a Hospital A hospital outpatient department that provides emergency services. Emergency Medical Condition (Also Emergency) A medical condition, including a mental health condition or substance use disorder, manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in a medical condition manifesting itself by acute symptoms of sufficient severity (severity, including severe pain) , such that the absence of immediate medical attention could reasonably be expected by a prudent layperson to result in: i. placing the 1. Placing your health of the individual (or, with respect to if you are a pregnant womanindividual, the health of the woman you or her your unborn child) in serious jeopardy; ii2. serious Serious impairment to bodily functions; or iii3. serious Serious dysfunction of any bodily organ or part. Emergency Services A medical screening examination that is within the capability of the emergency department of a hospital, including ancillary services routinely available to the emergency department, to evaluate such emergency medical condition and such further medical examination and treatment required to stabilize the patient. Essential Health Benefits The categories of covered services this contract is required to cover under the Affordable Care Act. Fee-for-Service Method of payment for provider services based on each visit or service rendered. Fee Schedule The amount that the participating provider has contractually agreed to accept as reimbursement in full for covered services and supplies. This contracted amount may be less than the provider’s usual charge for the service. If health care services are delivered to you via telemedicine by a distant site participating provider who is not a designated participating provider for web based (online) care, PIC will reimburse such participating provider on the same basis and using the same fee schedule as would apply if the covered services had been delivered in person by the distant site participating provider. Formulary A list, which may change from time to time, of prescription drugs which PIC, in its sole discretion, after consideration of recommendations from PIC’s Pharmacy and Therapeutics Quality Management Subcommittee, has established for use with this contract. Habilitative Therapy Therapy provided to develop initial functional levels of movement, strength, daily activity, or speech. Health Care Services Medical or behavioral services including pharmaceuticals, devices, technologies, tests, treatments, therapies, supplies, procedures, hospitalizations, or provider visits. Health Plan Health insurance coverage offered in the individual market or a small group health plan offered in the small group market, that provides essential health benefits, all within the meaning of the Affordable Care Act. A health plan does not include coverage that is excepted benefits under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Homebound When you are unable to leave home without considerable effort due to a medical condition. Lack of transportation does not constitute homebound status. Hospital A facility that provides diagnostic, medical, therapeutic, and surgical services by or under the direction of physicians and with 24-hour registered nursing services. The hospital is not mainly a place for rest or custodial care, and is not a nursing home or similar facility. Incurred Services and supplies rendered to a member are considered to be “incurred” at the time or date the service or supply was actually purchased or provided. Infertility Inability to become pregnant after the following periods of time of regular unprotected intercourse or therapeutic donor insemination: 1. One year, if you are a female under age 35 or a male of any age, or 2. Six months, if you are a female age 35 or older, provided that your infertility is not related to voluntary sterilization or failed reversal of voluntary sterilization, Injury Bodily damage other than sickness, including all related conditions and recurrent symptoms. Investigative As determined by PIC, a drug, device or medical treatment or procedure is investigative if reliable evidence does not permit conclusions concerning its safety, effectiveness, or effect on health outcomes. XXX will consider the following categories of reliable evidence, none of which shall be determinative by itself: 1. Whether there is a final approval from the appropriate government regulatory agency, if required. This includes whether a drug or device can be lawfully marketed for its proposed use by the FDA; or if the drug, device or medical treatment or procedure is under study or if further studies are needed to determine its maximum tolerated dose, toxicity, safety or efficacy as compared to standard means of treatment or diagnosis; and 2. Whether there are consensus opinions or recommendations in relevant scientific and medical literature, peer-reviewed journals, or reports of clinical trial committees and other technology assessment bodies. This includes consideration of whether an oncology treatment is included in the applicable National Comprehensive Cancer Network (NCCN) guideline, as appropriate for its proposed use, or whether a drug is included in any authoritative compendia as identified by the Medicare program such as, the National Comprehensive Cancer Network Drugs and Biologics Compendium, as appropriate for its proposed use; and 3. Whether there are consensus opinions of national and local health care providers in the applicable specialty as determined by a sampling of providers, including whether there are protocols used by the treating facility or another facility, studying the same drug, device, medical treatment or procedure. Maintenance Care Care that is not habilitative or rehabilitative therapy and there is lack of documented significant progress in functional status over a reasonable period of time. Medical Literature Articles from major peer reviewed medical journals that have recognized the drug or combination of drugs’ safety and effectiveness for treatment of the indication for which it has been prescribed. Each article shall meet the uniform requirements for manuscripts submitted to biomedical journals established by the International Committee of Medical Journal Editors or be published in a journal specified by the United States Secretary of Health and Human Services pursuant to United States Code, title 42, section 1395x, paragraph (t), clause (2), item (B), as amended, as acceptable peer review medical literature. Each article must use generally accepted scientific standards and must not use case reports to satisfy this criterion. Medically Necessary Any health care services, preventive health care services, and other preventive services that PIC, in its discretion and on a case by case basis, determines are appropriate and necessary in terms of type, frequency, level, setting, and duration, for the diagnosis or condition; and the care must: 1. Be consistent with the medical standards and generally accepted practice parameters of providers in the same or similar general specialty as typically manages the condition procedure or treatment at issue; and 2. Help restore or maintain your health; or 3. Prevent deterioration of your condition; or 4. Prevent the reasonably likely onset of a health problem or detect an incipient problem. Member A subscriber or dependent who is enrolled under this contract. Minimum Essential Coverage Health care coverage as defined by the Affordable Care Act and codified in the Internal Revenue Code § 5000A(f), and any related regulations as they may be amended from time-to-time; which includes, but is not limited to, certain government-sponsored programs including a standard basic health plan (BHP) within the meaning of the Affordable Care Act, employer-sponsored plans, health plans offered in the individual market in a state; and which, if it is an employer-sponsored plan, provides minimum value, meaning that the plan’s share of the total allowed costs of benefits provided under the plan is at least 60 percent of such costs. Net Price PIC's cost for insulin, including any rebates or discounts received by or accrued directly or indirectly to PIC from a drug manufacturer or pharmacy benefit manager. Non-Participating Provider A clinic, physician, provider, or facility that is licensed but is not a participating provider. Non-Participating Provider Benefits Coverage for health care services provided by licensed providers other than participating providers. With non-participating provider benefits, you are financially responsible for a copayment, deductible, coinsurance, and any amount in excess of the PIC non- participating provider reimbursement value. Out-of-Pocket Limit The maximum amount of money you must pay in copayments, coinsurance and deductibles before PIC pays remaining eligible charges. If you reach benefit, day, or visit maximums, you are responsible for amounts that exceed the out-of-pocket limit. Orthognathic Surgery Surgical manipulation of the elements of the facial skeleton to restore the proper anatomic and functional relationship in patients with dentofacial skeletal anomalies. Participating Provider A licensed clinic, physician, provider or facility that is directly contracted to participate in the specific PIC participating provider network designated by PIC to provide benefits to members enrolled in this PIC contract. The participating status of providers may change from time to time. Participating providers may also be offered from other Preferred Provider Organizations that have contracted with PIC. Participating Provider Benefits Coverage for health care services provided through participating providers. Pediatric acute-onset neuropsychiatric syndrome (PANS) A class of acute-onset obsessive compulsive or tic disorders or other behavioral changes presenting in children and adolescents that are not otherwise explained by another known neurologic or medical disorder. Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS) A condition in which a streptococcal infection in a child or adolescent causes the abrupt onset of clinically significant obsessions, compulsions, tics, or other neuropsychiatric symptoms or behavioral changes, or a relapsing and remitting course of symptom severity. Physical Disability A condition caused by a physical injury or congenital defect to one or more parts of your body that is expected to be ongoing for a continuous period of at least two years from the date the initial proof is supplied to PIC and as a result you are incapable of self-sustaining employment and are dependent on the subscriber for a majority of support and maintenance. An illness by itself will not be considered a physical disability unless adequate separate proof is furnished to PIC for PIC to determine that a physical disability also exists as defined in the preceding sentence. Physician A licensed Doctor of Medicine, Doctor of Osteopathy, Doctor of Podiatry, Doctor of Optometry, or Doctor of Chiropractic. PIC PreferredOne Insurance Company.
Appears in 1 contract
Samples: www.preferredone.com
