Medical Emergency A medical condition which manifests 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 attention to result in 1) 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; 2) serious impairment to bodily functions; or 3) serious dysfunction of any bodily organ or part. Examples of a medical emergency are severe pain, suspected heart attacks and fractures. Examples of a non- medical emergency are minor cuts and scrapes. Medically Necessary and Medical Necessity Services a physician, exercising prudent clinical judgment, would use with a patient to prevent, evaluate, diagnose or treat an illness or injury or its symptoms. These services must: Agree with generally accepted standards of medical practice Be clinically appropriate in type, frequency, extent, site and duration., They must also be considered effective for the patient’s illness, injury or disease Not be mostly for the convenience of the patient, physician, or other healthcare provider. They do not cost more than another service or series of services that are at least as likely to produce equivalent therapeutic or diagnostic results for the diagnosis or treatment of that patient’s illness, injury or disease. For these purposes, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer reviewed medical literature. This published evidence is recognized by the relevant medical community, physician specialty society recommendations and the views of physicians practicing in relevant clinical areas and any other relevant factors. Member Any person covered under this plan. Mental Condition A condition that is listed in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM). This does not include conditions and treatments for chemical dependency. Mental Health Services Medically necessary outpatient and inpatient services provided to treat mental conditions. State and federal law require that the copays and coinsurance for mental health services will be no more than the copays and coinsurance for medical and surgical services. Prescription drugs for mental conditions are covered under the same terms and conditions as other prescription drugs covered under this plan.
