Common use of GENERAL ANESTHESIA SERVICES Clause in Contracts

GENERAL ANESTHESIA SERVICES. Covered Services must be Medically Necessary and ordered by the attending Physician and administered by another Physician who customarily bills for such services. The Covered Services must be connected to a procedure that is also a Covered Service. Anesthesia services administered by a Certified Registered Nurse Anesthetist (CRNA) are also covered. Such anesthesia service includes the following procedures which are given to cause muscle relaxation, loss of feeling, or loss of consciousness: • Spinal or regional anesthesia; • Injection or inhalation of a drug or other agent (local infiltration is excluded). HABILITATIVE SERVICES We cover Medically Necessary habilitative services. Habilitative services are defined as health care services and devices that are designed to assist individuals acquiring, retaining or improving self-help, socialization, and adaptive skills and functioning necessary for performing routine activities of daily life successfully in their home and community-based settings. These services include physical therapy, occupational therapy, speech therapy, and Durable Medical Equipment. These services have calendar year visit limits. Plan limits are outlined in the Summary of Benefits and Coverage. HEARING AIDS Hearing Aid means any nonexperimental and wearable instrument or device offered to aid or compensate for impaired human hearing that is worn in or on the body. The term Hearing Aid includes any parts, ear molds, repair parts, and replacement parts of such instrument or device, including, but not limited to, nonimplanted bone anchored hearing aids, nonimplanted bone conduction hearing aids, and frequency modulation systems. Personal sound amplification products shall not qualify as hearing aids. If You purchased Your plan outside the Health Insurance Marketplace, this Contract shall provide benefits for Hearing Aids for children 18 years of age or under in accordance with the provisions of Georgia OCGA 33-24-59.21. This Contract provides for one Hearing Aid per hearing impaired ear not to exceed $3,000.00 per Hearing Aid every 48 months, and Medically Necessary services and supplies on a continuous basis, as needed, during each 48-month coverage period, not to exceed $3,000.00 per hearing impaired ear. This Contract shall provide these benefits in accordance with the conditions, limitations, exclusions, cost-sharing arrangements and Copayment requirements as outlined in the Summary of Benefits and Coverage. The Hearing Aid benefit ONLY applies to plans purchased outside the Health Insurance Marketplace. HOME HEALTH CARE SERVICES Home Health Care provides a program for a Member’s care and treatment in the home. Your coverage is outlined in the Summary of Benefits and Coverage. A visit consists of up to four hours of care. The program consists of required intermittent skilled care, which may include observation, evaluation, teaching and nursing services consistent with the diagnosis, established and approved in writing by the Member’s attending Physician. These services have calendar year visit limits. Plan limits are outlined in the Summary of Benefits and Coverage. Some special conditions apply: • The Physician’s certification statement and plan of care. • Claims will be reviewed to verify that services consist of skilled care that is medically consistent with the diagnosis. • A Member must be essentially confined at home. Covered Services: • Visits by an RN or LPN-Benefits cannot be provided for services if the nurse is related to the Member. • Visits by a qualified physiotherapist or speech therapist and by an inhalation therapist certified by the National Board of Respiratory Therapy. • Visits by a Home Health Care Nursing Aide when rendered under the direct supervision of an RN. • Administration of prescribed drugs. • Oxygen and its administration. Covered Services for Home Health Care do not include: • Food, housing, homemaker services, sitters, home-delivered meals; Home Health Care services which are not Medically Necessary or of a non-skilled level of care. Services and/or supplies which are not included in the Home Health Care plan as described. • Services of a person who ordinarily resides in the patient’s home or is a member of the family of either the patient or patient’s spouse. • Any services for any period during which the Member is not under the continuing care of a Physician. • Convalescent or Custodial Care where the Member has spent a period of time for recovery of an illness or surgery and where skilled care is not required or the services being rendered are only for aid in daily living, i.e., for the convenience of the patient. • Any services or supplies not specifically listed as Covered Services. • Routine care of a newborn child. • Dietitian services. • Maintenance therapy. • Private duty nursing care. HOSPICE CARE SERVICES Hospice benefits cover inpatient and outpatient services for patients certified by a Physician as terminally ill. Your Contract provides Covered Services for inpatient and outpatient Hospice care under certain conditions as stated in the Summary of Benefits and Coverage. The Hospice treatment program must: • Be recognized as an approved Hospice program by Alliant; • Include support services to help covered family members deal with the patient’s death; and • Be directed by a Physician and coordinated by an RN with a treatment plan that: ° Provides an organized system of homecare; ° Uses a Hospice team; and ° Has around-the-clock care available. The following conditions apply: • To qualify for Hospice care, the attending Physician must certify that the patient is not expected to live more than six months; • The Physician must design and recommend a Hospice Care Program; and • The Physician’s certification statement and plan of care. HOSPITAL SERVICES For In-Network Care, Your Physician must arrange Your hospital admission. Inpatient Inpatient Hospital Services: • Inpatient room charges are Covered Services to include semiprivate room and board, general nursing care and intensive or cardiac care. If You stay in a private room, Covered Services are based on the Hospital’s prevailing semiprivate room rate. If You are admitted to a Hospital that has only private rooms, Covered Services are based on the Hospital’s prevailing room rate. Services and Supplies: • Services and supplies provided and billed by the Hospital while You receive Inpatient care, including the use of operating, recovery and delivery rooms. Laboratory and diagnostic examinations, intravenous solutions, basal metabolism studies, electrocardiograms, electroencephalograms, x-ray examinations, and radiation and speech therapy are also covered. • Convenience or comfort items (such as radios, TV’s, telephones, visitors’ meals, etc.) are not covered. Length of Stay: • Determined by Medical Necessity. OUTPATIENT Outpatient Services: • Your Contract provides Covered Services when the following outpatient services are Medically Necessary: ° Pre-admission tests, surgery, diagnostic x-rays and laboratory services. • In an effort to manage quality and cost for Our members, Alliant reserves the right to establish Preferred or In-Network Providers for certain services. To determine if a preferred Provider exists, it is the responsibility of the member to verify the in-network status of a Provider. Members may verify network status by visiting Our Find-A-Provider tool on XxxxxxxXxxxx.xxx or calling Client Services at (000) 000-0000. • Refer to Emergency Room Services/Emergency Medical Services definition.

GENERAL ANESTHESIA SERVICES. Covered Services must be When Medically Necessary and ordered by the attending Physician and administered by another Physician who customarily bills for such services. The Covered Services must be connected to a procedure that is also a Covered Service. Anesthesia services administered by a Certified Registered Nurse Anesthetist (CRNA) are also covered. Such anesthesia service includes the following procedures which are given to cause muscle relaxation, loss of feeling, or loss of consciousness: • Spinal or regional anesthesia; • Injection or inhalation of a drug or other agent (local infiltration is excluded). HABILITATIVE SERVICES SERVICES‌ We cover Medically Necessary habilitative services. Habilitative services are defined as health care services and devices that are designed to assist individuals acquiring, retaining or improving self-help, socialization, and adaptive skills and functioning necessary for performing routine activities of daily life successfully in their home and community-community based settings. These services include physical therapy, occupational therapy, speech therapy, and Durable Medical Equipment. These services require Prior Authorization and have calendar year visit limits. Plan limits are outlined in the Summary of Benefits and Coverage. HEARING AIDS AIDS‌ Hearing Aid means any nonexperimental and wearable instrument or device offered to aid or compensate for impaired human hearing that is worn in or on the body. The term Hearing Aid includes any parts, ear molds, repair parts, and replacement parts of such instrument or device, including, but not limited to, nonimplanted bone anchored hearing aids, nonimplanted bone conduction hearing aids, and frequency modulation systems. Personal sound amplification products shall not qualify as hearing aids. If You you purchased Your your plan outside the Health Insurance Marketplace, this Contract shall provide benefits for Hearing Aids for children 18 years of age or under in accordance with the provisions of Georgia OCGA 33-24-59.21HB 206. This As required by HB 206, this Contract provides for one Hearing Aid per hearing impaired ear not to exceed $3,000.00 per Hearing Aid every 48 months, and Medically Necessary medically necessary services and supplies on a continuous basis, as needed, during each 48-month coverage period, not to exceed $3,000.00 per hearing impaired ear. This Contract shall provide these benefits in accordance with the conditions, schedule of benefits, limitations, exclusions, cost-sharing arrangements and Copayment requirements as outlined in the Summary of Benefits and Coverage. The Hearing Aid benefit ONLY applies to plans purchased outside the Health Insurance Marketplace. HOME HEALTH CARE SERVICES SERVICES‌ Home Health Care provides a program for a Member’s care and treatment in the home. Your coverage is outlined in the Summary of Benefits and Coverage. A visit consists of up to four hours of care. The program consists of required intermittent skilled care, which may include observation, evaluation, teaching and nursing services consistent with the diagnosis, established and approved in writing by the Member’s attending Physician. These services require Prior Authorization and have calendar year visit limits. Plan limits are outlined in the Summary of Benefits and Coverage. Note: Covered Services available under Home Health Care do NOT reduce outpatient benefits available under the Physical Therapy section shown in this Contract. Some special conditions apply: • The Physician’s certification statement and plan of carerecommended program must obtain a Prior Authorization. • Claims will be reviewed to verify that services consist of skilled care that is medically consistent with the diagnosis. • A Member must be essentially confined at home. Covered Services: • Visits by an RN or LPN-Benefits cannot be provided for services if the nurse is related to the Member. • Visits by a qualified physiotherapist or speech therapist and by an inhalation therapist certified by the National Board of Respiratory Therapy. • Visits by a Home Health Care Nursing Aide when rendered under the direct supervision of an RN. • Administration of prescribed drugs. • Oxygen and its administration. Covered Services for Home Health Care do not include: include:‌ • Food, housing, homemaker services, sitters, home-delivered meals; Home Health Care services which are not Medically Necessary or of a non-skilled level of care. Services and/or supplies which are not included in the Home Health Care plan as described. • Services of a person who ordinarily resides in the patient’s home or is a member of the family of either the patient or patient’s spouse. • Any services for any period during which the Member is not under the continuing care of a Physician. • Convalescent or Custodial Care where the Member has spent a period of time for recovery of an illness or surgery and where skilled care is not required or the services being rendered are only for aid in daily living, i.e., for the convenience of the patient. • Any services or supplies not specifically listed as Covered Services. • Routine care of a newborn child. • Dietitian services. • Maintenance therapy. • Private duty nursing care. HOSPICE CARE SERVICES SERVICES‌ Hospice benefits cover inpatient and outpatient services for patients certified by a Physician as terminally ill. Your Contract provides Covered Services for inpatient and outpatient Hospice care under certain conditions as stated in the Summary of Benefits and Coverage. The Hospice treatment program must: • Be recognized as an approved Hospice program by Alliant; • Include support services to help covered family members deal with the patient’s death; and • Be directed by a Physician and coordinated by an RN with a treatment plan that: ° Provides an organized system of homecare; ° Uses a Hospice team; and ° Has around-the-clock care available. The following conditions apply: • To qualify for Hospice care, the attending Physician must certify that the patient is not expected to live more than six months; • The Physician must design and recommend a Hospice Care Program; and • The Physician’s certification statement and plan of care. HOSPITAL SERVICES For In-Network Care, Your Physician must arrange Your hospital admission. Inpatient Inpatient Hospital Services: • Inpatient room charges are Covered Services to include semiprivate room and board, general nursing care and intensive or cardiac care. If You stay in a private room, Covered Services are based on the Hospital’s prevailing semiprivate room rate. If You are admitted to a Hospital that has only private rooms, Covered Services are based on the Hospital’s prevailing room rate. Services and Supplies: • Services and supplies provided and billed by the Hospital while You receive Inpatient care, including the use of operating, recovery and delivery rooms. Laboratory and diagnostic examinations, intravenous solutions, basal metabolism studies, electrocardiograms, electroencephalograms, x-ray examinations, and radiation and speech therapy are also covered. • Convenience or comfort items (such as radios, TV’s, telephones, visitors’ meals, etc.) are not covered. Length of Stay: • Determined by Medical Necessity. OUTPATIENT Outpatient Services: • Your Contract provides Covered Services when the following outpatient services are Medically Necessary: ° Pre-admission tests, surgery, diagnostic x-rays and laboratory services. • In an effort to manage quality and cost for Our members, Alliant reserves the right to establish Preferred or In-Network Providers for certain services. To determine if a preferred Provider exists, it is the responsibility of the member to verify the in-network status of a Provider. Members may verify network status by visiting Our Find-A-Provider tool on XxxxxxxXxxxx.xxx or calling Client Services at (000) 000-0000. • Refer to Emergency Room Services/Emergency Medical Services definition.

GENERAL ANESTHESIA SERVICES. Covered Services must be Medically Necessary and ordered by the attending Physician and administered by another Physician who customarily bills for such services. The Covered Services must be connected to a procedure that is also a Covered Service. Anesthesia services administered by a Certified Registered Nurse Anesthetist (CRNA) are also covered. Such anesthesia service includes the following procedures which are given to cause muscle relaxation, loss of feeling, or loss of consciousness: • Spinal or regional anesthesia; • Injection or inhalation of a drug or other agent (local infiltration is excluded). HABILITATIVE SERVICES We cover Medically Necessary habilitative services. Habilitative services are defined as health care services and devices that are designed to assist individuals acquiring, retaining or improving self-help, socialization, and adaptive skills and functioning necessary for performing routine activities of daily life successfully in their home and community-based settings. These services include physical therapy, occupational therapy, speech therapy, and Durable Medical Equipment. These services have calendar year visit limits. Plan limits are outlined in the Summary of Benefits and Coverage. HEARING AIDS Hearing Aid means any nonexperimental and wearable instrument or device offered to aid or compensate for impaired human hearing that is worn in or on the body. The term Hearing Aid includes any parts, ear molds, repair parts, and replacement parts of such instrument or device, including, but not limited to, nonimplanted bone anchored hearing aids, nonimplanted bone conduction hearing aids, and frequency modulation systems. Personal sound amplification products shall not qualify as hearing aids. If You purchased Your plan outside the Health Insurance Marketplace, this Contract shall provide benefits for Hearing Aids for children 18 years of age or under in accordance with the provisions of Georgia OCGA 33-24-59.21. This Contract provides for one Hearing Aid per hearing impaired ear not to exceed $3,000.00 per Hearing Aid every 48 months, and Medically Necessary services and supplies on a continuous basis, as needed, during each 48-month coverage period, not to exceed $3,000.00 per hearing impaired ear. This Contract shall provide these benefits in accordance with the conditions, limitations, exclusions, cost-sharing arrangements and Copayment requirements as outlined in the Summary of Benefits and Coverage. The Hearing Aid benefit ONLY applies to plans purchased outside the Health Insurance Marketplace. HOME HEALTH CARE SERVICES Home Health Care provides a program for a Member’s care and treatment in the home. Your coverage is outlined in the Summary of Benefits and Coverage. A visit consists of up to four hours of care. The program consists of required intermittent skilled care, which may include observation, evaluation, teaching and nursing services consistent with the diagnosis, established and approved in writing by the Member’s attending Physician. These services have calendar year visit limits. Plan limits are outlined in the Summary of Benefits and Coverage. Some special conditions apply: • The Physician’s certification statement and plan of care. • Claims will be reviewed to verify that services consist of skilled care that is medically consistent with the diagnosis. • A Member must be essentially confined at home. Covered Services: • Visits by an RN or LPN-Benefits cannot be provided for services if the nurse is related to the Member. • Visits by a qualified physiotherapist or speech therapist and by an inhalation therapist certified by the National Board of Respiratory Therapy. • Visits by a Home Health Care Nursing Aide when rendered under the direct supervision of an RN. • Administration of prescribed drugs. • Oxygen and its administration. Covered Services for Home Health Care do not include: • Food, housing, homemaker services, sitters, home-delivered meals; Home Health Care services which are not Medically Necessary or of a non-skilled level of care. Services and/or supplies which are not included in the Home Health Care plan as described. • Services of a person who ordinarily resides in the patient’s home or is a member of the family of either the patient or patient’s spouse. • Any services for any period during which the Member is not under the continuing care of a Physician. • Convalescent or Custodial Care where the Member has spent a period of time for recovery of an illness or surgery and where skilled care is not required or the services being rendered are only for aid in daily living, i.e., for the convenience of the patient. • Any services or supplies not specifically listed as Covered Services. • Routine care of a newborn child. • Dietitian services. • Maintenance therapy. • Private duty nursing care. HOSPICE CARE SERVICES Hospice benefits cover inpatient and outpatient services for patients certified by a Physician as terminally ill. Your Contract provides Covered Services for inpatient and outpatient Hospice care under certain conditions as stated in the Summary of Benefits and Coverage. The Hospice treatment program must: • Be recognized as an approved Hospice program by Alliant; • Include support services to help covered family members deal with the patient’s death; and • Be directed by a Physician and coordinated by an RN with a treatment plan that: ° Provides an organized system of homecare; ° Uses a Hospice team; and ° Has around-the-clock care available. The following conditions apply: • To qualify for Hospice care, the attending Physician must certify that the patient is not expected to live more than six months; • The Physician must design and recommend a Hospice Care Program; and • The Physician’s certification statement and plan of care. HOSPITAL SERVICES For In-Network Care, Your Physician must arrange Your hospital admission. Inpatient Inpatient Hospital Services: • Inpatient room charges are Covered Services to include semiprivate room and board, general nursing care and intensive or cardiac care. If You stay in a private room, Covered Services are based on the Hospital’s prevailing semiprivate room rate. If You are admitted to a Hospital that has only private rooms, Covered Services are based on the Hospital’s prevailing room rate. Services and Supplies: • Services and supplies provided and billed by the Hospital while You receive Inpatient care, including the use of operating, recovery and delivery rooms. Laboratory and diagnostic examinations, intravenous solutions, basal metabolism studies, electrocardiograms, electroencephalograms, x-ray examinations, and radiation and speech therapy are also covered. • Convenience or comfort items (such as radios, TV’s, telephones, visitors’ meals, etc.) are not covered. Length of Stay: • Determined by Medical Necessity. OUTPATIENT Outpatient Services: • Your Contract provides Covered Services when the following outpatient services are Medically Necessary: ° Pre-admission tests, surgery, diagnostic x-rays and laboratory services. • In an effort to manage quality and cost for Our members, Alliant reserves the right to establish Preferred or In-In- Network Providers for certain services. To determine if a preferred Provider exists, it is the responsibility of the member to verify the inIn-network Network status of a Provider. Members may verify network status by visiting Our Find-A-Provider tool on XxxxxxxXxxxx.xxx or calling Client Services at (000) 000-0000. • Refer to Emergency Room Services/Emergency Medical Services definition.

GENERAL ANESTHESIA SERVICES. Covered Services must be Medically Necessary and ordered by the attending Physician and administered by another Physician who customarily bills for such services. The Covered Services must be connected to a procedure that is also a Covered Service. Anesthesia services administered by a Certified Registered Nurse Anesthetist (CRNA) are also covered. Such anesthesia service includes the following procedures which are given to cause muscle relaxation, loss of feeling, or loss of consciousness: • Spinal or regional anesthesia; • Injection or inhalation of a drug or other agent (local infiltration is excluded). HABILITATIVE SERVICES We cover Medically Necessary habilitative services. Habilitative services are defined as health care services and devices that are designed to assist individuals acquiring, retaining or improving self-help, socialization, and adaptive skills and functioning necessary for performing routine activities of daily life successfully in their home and community-based settings. These services include physical therapy, occupational therapy, speech therapy, and Durable Medical Equipment. These services have calendar year visit limits. Plan limits are outlined in the Summary of Benefits and Coverage. HEARING AIDS Hearing Aid means any nonexperimental and wearable instrument or device offered to aid or compensate for impaired human hearing that is worn in or on the body. The term Hearing Aid includes any parts, ear molds, repair parts, and replacement parts of such instrument or device, including, but not limited to, nonimplanted bone anchored hearing aids, nonimplanted bone conduction hearing aids, and frequency modulation systems. Personal sound amplification products shall not qualify as hearing aids. If You purchased Your plan outside the Health Insurance Marketplace, this Contract shall provide benefits for Hearing Aids for children 18 years of age or under in accordance with the provisions of Georgia OCGA 33-24-59.21. This Contract provides for one Hearing Aid per hearing impaired ear not to exceed $3,000.00 per Hearing Aid every 48 months, and Medically Necessary services and supplies on a continuous basis, as needed, during each 48-month coverage period, not to exceed $3,000.00 per hearing impaired ear. This Contract shall provide these benefits in accordance with the conditions, limitations, exclusions, cost-sharing arrangements and Copayment requirements as outlined in the Summary of Benefits and Coverage. The Hearing Aid benefit ONLY applies to plans purchased outside the Health Insurance Marketplace. HOME HEALTH CARE SERVICES Home Health Care provides a program for a Member’s care and treatment in the home. Your coverage is outlined in the Summary of Benefits and Coverage. A visit consists of up to four hours of care. The program consists of required intermittent skilled care, which may include observation, evaluation, teaching and nursing services consistent with the diagnosis, established and approved in writing by the Member’s attending Physician. These services have calendar year visit limits. Plan limits are outlined in the Summary of Benefits and Coverage. Some special conditions apply: • The Physician’s certification statement and plan of care. • Claims will be reviewed to verify that services consist of skilled care that is medically consistent with the diagnosis. • A Member must be essentially confined at home. Covered Services: • Visits by an RN or LPN-Benefits cannot be provided for services if the nurse is related to the Member. • Visits by a qualified physiotherapist or speech therapist and by an inhalation therapist certified by the National Board of Respiratory Therapy. • Visits by a Home Health Care Nursing Aide when rendered under the direct supervision of an RN. • Administration of prescribed drugs. • Oxygen and its administration. Covered Services for Home Health Care do not include: • Food, housing, homemaker services, sitters, home-delivered meals; Home Health Care services which are not Medically Necessary or of a non-skilled level of care. Services and/or supplies which are not included in the Home Health Care plan as described. • Services of a person who ordinarily resides in the patient’s home or is a member of the family of either the patient or patient’s spouse. • Any services for any period during which the Member is not under the continuing care of a Physician. • Convalescent or Custodial Care where the Member has spent a period of time for recovery of an illness or surgery and where skilled care is not required or the services being rendered are only for aid in daily living, i.e., for the convenience of the patient. • Any services or supplies not specifically listed as Covered Services. • Routine care of a newborn child. • Dietitian services. • Maintenance therapy. • Private duty nursing care. HOSPICE CARE SERVICES Hospice benefits cover inpatient and outpatient services for patients certified by a Physician as terminally ill. Your Contract provides Covered Services for inpatient and outpatient Hospice care under certain conditions as stated in the Summary of Benefits and Coverage. The Hospice treatment program must: • Be recognized as an approved Hospice program by Alliant; • Include support services to help covered family members deal with the patient’s death; and • Be directed by a Physician and coordinated by an RN with a treatment plan that: ° Provides an organized system of homecare; ° Uses a Hospice team; and ° Has around-the-clock care available. The following conditions apply: • To qualify for Hospice care, the attending Physician must certify that the patient is not expected to live more than six months; • The Physician must design and recommend a Hospice Care Program; and • The Physician’s certification statement and plan of care. HOSPITAL SERVICES For In-Network Care, Your Physician must arrange Your hospital admission. Inpatient Inpatient Hospital Services: • Inpatient room charges are Covered Services to include semiprivate room and board, general nursing care and intensive or cardiac care. If You stay in a private room, Covered Services are based on the Hospital’s prevailing semiprivate room rate. If You are admitted to a Hospital that has only private rooms, Covered Services are based on the Hospital’s prevailing room rate. Services and Supplies: • Services and supplies provided and billed by the Hospital while You receive Inpatient care, including the use of operating, recovery and delivery rooms. Laboratory and diagnostic examinations, intravenous solutions, basal metabolism studies, electrocardiograms, electroencephalograms, x-ray examinations, and radiation and speech therapy are also covered. • Convenience or comfort items (such as radios, TV’s, telephones, visitors’ meals, etc.) are not covered. Length of Stay: • Determined by Medical Necessity. OUTPATIENT Outpatient Services: • Your Contract provides Covered Services when the following outpatient services are Medically Necessary: ° Pre-admission tests, surgery, diagnostic x-rays and laboratory services. • In an effort to manage quality and cost for Our members, Alliant reserves the right to establish Preferred or In-In- Network Providers for certain services. To determine if a preferred Provider exists, it is the responsibility of the member to verify the in-network status of a Provider. Members may verify network status by visiting Our Find-A-Provider tool on XxxxxxxXxxxx.xxx or calling Client Services at (000) 000-0000. • Refer to Emergency Room Services/Emergency Medical Services definition.