Common use of Maternity Care Clause in Contracts

Maternity Care. Obstetrical care received both before and after the delivery of a child or children. It includes regular nursery care for a newborn infant as long as the mother’s Hospital stay is a covered benefit and the newborn infant is an eligible Member under the Contract. Maximum Allowed Cost or Maximum Allowable Charge (MAC) Maximum Allowed Cost and/or Maximum Allowable Charge shall mean the maximum amount payable for a Covered Service under the Contract and meeting Medical Necessity and Prior Authorization requirements. The MAC will not include any identifiable billing mistakes including, but not limited to, up-coding, unbundled services/charges, duplicate charges, and charges for services not performed. Medical Child Support Order (MCSO) An MCSO is any court judgment, decree or order (including a court’s approval of a domestic relations settlement agreement) that: • Provides for child support payment related to health benefits with respect to the child of a health plan participant or requires health benefit coverage of such child in such plan, and is ordered under state domestic relations law; or • Enforces a state law relating to medical child support payment with respect to a health plan. Medical Facility Any Hospital, ambulatory care facility, Chemical Dependency Treatment Facility, Skilled Nursing facility, Home Health Care Agency or mental health facility, as defined in this Certificate. The facility must be licensed, registered or approved by the Joint Commission on Accreditation of Hospitals or meet specific requirements established by Us. Medical Necessity or Medically Necessary We reserve the right to determine whether a health care service or supply is Medically Necessary. The fact that a Physician has prescribed, ordered, recommended or approved a service or supply does not, in itself, make it Medically Necessary. We consider a health care service Medically Necessary if it is: • Appropriate and consistent with the diagnosis and the omission of which could adversely affect or fail to improve the patient’s condition; • Compatible with the standards of acceptable medical practice in the United States; • Not provided solely for Your convenience or the convenience of the doctor, health care Provider or Hospital; • Not primarily Custodial Care; and • Provided in a safe and appropriate setting given the nature of the diagnosis and the severity of the symptoms. For example, a Hospital stay is necessary when treatment cannot be safely provided on an outpatient basis. Member The Subscriber and each Dependent, as defined in this Certificate, while such person is covered by this Contract.

Maternity Care. Obstetrical care received both before and after the delivery of a child or children. It includes regular nursery care for a newborn infant as long as the mother’s Hospital stay is a covered benefit and the newborn infant is an eligible Member under the Contract. Maximum Allowed Cost or Maximum Allowable Charge (MAC) Maximum Allowed Cost and/or Maximum Allowable Charge shall mean the maximum amount payable for a Covered Service under the Contract and meeting Medical Necessity and Prior Authorization requirements. MAC will be the amount equal to the greatest of the following: • The amount negotiated with in-network providers for the service furnished; • The amount for the service calculated using the same method the plan generally uses to determine payments for out-of-network services; or • The amount that would be paid under Medicare for the same service. The MAC will not include any identifiable billing mistakes including, but not limited to, up-coding, unbundled services/charges, duplicate charges, and charges for services not performed. Medical Child Support Order (MCSO) An MCSO is any court judgment, decree or order (including a court’s approval of a domestic relations settlement agreement) that: • Provides for child support payment related to health benefits with respect to the child of a health plan participant or requires health benefit coverage of such child in such plan, and is ordered under state domestic relations law; or • Enforces a state law relating to medical child support payment with respect to a health plan. Medical Facility Any Hospital, ambulatory care facility, Chemical Dependency Treatment Facility, Skilled Nursing facility, Home Health Care Agency or mental health facility, as defined in this Certificate. The facility must be licensed, registered or approved by the Joint Commission on Accreditation of Hospitals or meet specific requirements established by Usus. Medical Necessity or Medically Necessary We reserve the right to determine whether a health care service or supply is Medically Necessary. The fact that a Physician has prescribed, ordered, recommended or approved a service or supply does not, in itself, make it Medically Necessary. We consider a health care service Medically Necessary if it is: • Appropriate and consistent with the diagnosis and the omission of which could adversely affect or fail to improve the patient’s condition; • Compatible with the standards of acceptable medical practice in the United States; • Not provided solely for Your your convenience or the convenience of the doctor, health care Provider or Hospital; • Not primarily Custodial Care; and • Provided in a safe and appropriate setting given the nature of the diagnosis and the severity of the symptoms. For example, a Hospital stay is necessary when treatment cannot be safely provided on an outpatient basis. Member The Subscriber and each Dependent, as defined in this Certificate, while such person is covered by this Contract.

Maternity Care. Obstetrical care received both before and after the delivery of a child or children. It includes regular nursery care for a newborn infant as long as the mother’s Hospital stay is a covered benefit and the newborn infant is an eligible Member under the Contract. Maximum Allowed Cost or Maximum Allowable Charge (MAC) Maximum Allowed Cost and/or Maximum Allowable Charge shall mean the maximum amount payable for a Covered Service under the Contract and meeting Medical Necessity and Prior Authorization requirements. MAC will be the amount equal to the greatest of the following: • The amount negotiated with in-network providers for the service furnished; • The amount for the service calculated using the same method the plan generally uses todetermine payments for out-of-network services; or • The amount that would be paid under Medicare for the same service. The MAC will not include any identifiable billing mistakes including, but not limited to, up-coding, unbundled services/charges, duplicate charges, and charges for services not performed. Medical Child Support Order (MCSO) An MCSO is any court judgment, decree or order (including a court’s approval of a domestic relations settlement agreement) that: • Provides for child support payment related to health benefits with respect to the child of a Group health plan participant or requires health benefit coverage of such child in such plan, and is ordered under state domestic relations law; or • Enforces a state law relating to medical child support payment with respect to a Group health plan. Medical Facility Any Hospital, ambulatory care facility, Chemical Dependency Treatment Facility, Skilled Nursing facility, Home Health Care Agency or mental health facility, as defined in this Certificate. The facility must be licensed, registered or approved by the Joint Commission on Accreditation of Hospitals or meet specific requirements established by Usus. Medical Necessity or Medically Necessary We reserve the right to determine whether a health care service or supply is Medically Necessary. The fact that a Physician has prescribed, ordered, recommended or approved a service or supply does not, in itself, make it Medically Necessary. We consider a health care service Medically Necessary if it is: • Appropriate and consistent with the diagnosis and the omission of which could adversely affect or fail to improve the patient’s conditionpatient’scondition; • Compatible with the standards of acceptable medical practice in the United States; • Not provided solely for Your your convenience or the convenience of the doctor, health care Provider or Hospital; • Not primarily Custodial Care; and • Provided in a safe and appropriate setting given the nature of the diagnosis and the severity of the symptoms. For example, a Hospital stay is necessary when treatment cannot be safely provided on an outpatient basis. Member The Subscriber and each Dependent, as defined in this Certificate, while such person is covered by this Contract.

Maternity Care. ‌ Obstetrical care received both before and after the delivery of a child or children. It includes regular nursery care for a newborn infant as long as the mother’s Hospital stay is a covered benefit and the newborn infant is an eligible Member under the Contract. Maximum Allowed Cost or (MAC)‌ The Maximum Allowable Charge Allowed Cost (MAC) Maximum Allowed Cost and/or Maximum Allowable Charge shall mean is the maximum amount payable for a Covered Service under the Contract and meeting Medical Necessity and Prior Authorization requirements. The MAC of reimbursement Alliant will not include any identifiable billing mistakes including, but not limited to, up-coding, unbundled services/charges, duplicate charges, and charges pay for services and supplies: • That meet our definition of Covered Services, to the extent such services and supplies are covered under your Plan and are not performedexcluded; • That are Medically Necessary; and • That is provided in accordance with all applicable Pre-Authorization, utilization management (i.e., coverage certification) or other requirements set forth in your Plan. MCSO-Medical Child Support Order (MCSO) Order‌ An MCSO is any court judgment, decree or order (including a court’s approval of a domestic relations settlement agreement) that: • Provides for child support payment related to health benefits with respect to the child of a Group health plan participant or requires health benefit coverage of such child in such plan, and is ordered under state domestic relations law; or • Enforces a state law relating to medical child support payment with respect to a Group health plan. Medical Facility Facility‌ Any Hospital, ambulatory care facility, Chemical Dependency Treatment Facility, Skilled Nursing chemical dependency facility, Home Health Care Agency skilled nursing care facility, home health agency or mental health facility, as defined in this CertificateCertificate Booklet. The facility must be licensed, registered or approved by the Joint Commission on Accreditation of Hospitals or meet specific requirements established by Usus. Medical Necessity or Medically Necessary Necessary‌ We reserve the right to determine whether a health care service or supply is Medically Necessary. The fact that a Physician has prescribed, ordered, recommended or approved a service or supply does not, in itself, make it Medically Necessary. We consider a health care service Medically Necessary if it is: • Appropriate and consistent with the diagnosis and the omission of which could adversely affect or fail to improve the patient’s condition; • Compatible with the standards of acceptable medical practice in the United States; • Not provided solely for Your your convenience or the convenience of the doctor, health care Provider or Hospital; • Not primarily Custodial Care; and • Provided in a safe and appropriate setting given the nature of the diagnosis and the severity of the symptoms. For example, a Hospital stay is necessary when treatment cannot be safely provided on an outpatient basis. Member Member‌ The Subscriber and each Dependent, as defined in this Certificatebooklet, while such person is covered by this Contract.

Maternity Care. Obstetrical care received both before and after the delivery of a child or children. It includes regular nursery care for a newborn infant as long as the mother’s Hospital stay is a covered benefit and the newborn infant is an eligible Member under the Contract. Maximum Allowed Cost or Maximum Allowable Charge (MAC) Maximum Allowed Cost and/or Maximum Allowable Charge shall mean the maximum amount payable for a Covered Service under the Contract and meeting Medical Necessity and Prior Authorization requirements. MAC will be the amount equal to the greatest of the following: • The amount negotiated with in-network providers for the service furnished; • The amount for the service calculated using the same method the plan generally uses todetermine payments for out-of-network services; or • The amount that would be paid under Medicare for the same service. The MAC will not include any identifiable billing mistakes including, but not limited to, up-coding, unbundled services/charges, duplicate charges, and charges for services not performed. Medical Child Support Order (MCSO) An MCSO is any court judgment, decree or order (including a court’s approval of a domestic relations settlement agreement) that: • Provides for child support payment related to health benefits with respect to the child of a health plan participant or requires health benefit coverage of such child in such plan, and is ordered under state domestic relations law; or • Enforces a state law relating to medical child support payment with respect to a health plan. Medical Facility Any Hospital, ambulatory care facility, Chemical Dependency Treatment Facility, Skilled Nursing facility, Home Health Care Agency or mental health facility, as defined in this Certificate. The facility must be licensed, registered or approved by the Joint Commission on Accreditation of Hospitals or meet specific requirements established by Usus. Medical Necessity or Medically Necessary We reserve the right to determine whether a health care service or supply is Medically Necessary. The fact that a Physician has prescribed, ordered, recommended or approved a service or supply does not, in itself, make it Medically Necessary. We consider a health care service Medically Necessary if it is: • Appropriate and consistent with the diagnosis and the omission of which could adversely affect or fail to improve the patient’s conditionpatient’scondition; • Compatible with the standards of acceptable medical practice in the United States; • Not provided solely for Your your convenience or the convenience of the doctor, health care Provider or Hospital; • Not primarily Custodial Care; and • Provided in a safe and appropriate setting given the nature of the diagnosis and the severity of the symptoms. For example, a Hospital stay is necessary when treatment cannot be safely provided on an outpatient basis. Member The Subscriber and each Dependent, as defined in this Certificate, while such person is covered by this Contract.

Maternity Care. Obstetrical care received both before and after the delivery of deliveryof a child or children. It includes regular nursery care for a newborn infant as long as the mother’s Hospital stay is a covered benefit and the newborn infant is an eligible Member under the Contract. Maximum Allowed Cost or Maximum Allowable MaximumAllowable Charge (MAC) Maximum Allowed Cost and/or Maximum Allowable Charge shall Chargeshall mean the maximum amount payable for a Covered Service under the Contract and meeting Medical Necessity and Prior Authorization requirements. The MAC will not include any identifiable billing mistakes including, but not limited to, up-coding, unbundled services/charges, duplicate charges, and charges for services not performed. Medical Child Support Order (MCSO) An MCSO is any court judgment, decree or order (including a court’s approval of a domestic relations settlement agreement) that: • Provides for child support payment related to health benefits with respect to the child of a health plan participant or requires health benefit coverage of such child in such plan, and is ordered under orderedunder state domestic relations law; or • Enforces a state law relating to medical child support payment with respect to a health plan. Medical Facility Any Hospital, ambulatory care facility, Chemical Dependency Treatment Facility, Skilled Nursing facility, Home Health Care Agency or mental health facility, as defined in this Certificate. The facility must be licensed, registered or approved by the Joint Commission on Accreditation of Hospitals or meet specific requirements established requirementsestablished by Us. Medical Necessity or Medically Necessary We reserve the right to determine whether a health care service careservice or supply is Medically Necessary. The fact that a Physician has prescribed, ordered, recommended or approved a service or supply does not, in itself, make it Medically Necessary. We consider a health care service Medically Necessary if it is: • Appropriate and consistent with the diagnosis and the andthe omission of which could adversely affect or fail to failto improve the patient’s condition; • Compatible with the standards of acceptable medical acceptablemedical practice in the United States; • Not provided solely for Your convenience or the orthe convenience of the doctor, health care Provider or Hospital; • Not primarily Custodial Care; and • Provided in a safe and appropriate setting given the nature of the diagnosis and the severity of the symptomsthesymptoms. For example, a Hospital stay is necessary when treatment cannot be safely provided on an outpatient basisoutpatientbasis. Member The Subscriber and each Dependent, as defined in this Certificate, while such person is covered by this Contract.