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 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. 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. 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. 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. 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 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. 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. 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. 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. The Subscriber and each Dependent, as defined in this Certificate, while such person is covered by this Contract.