Common use of Medical Community Clause in Contracts

Medical Community. A majority of Physicians who are Board Certified in the appropriate specialty. • Medical Emergency. The existence of a medical condition 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 (i) placing the health of the individual (or, with respect to a pregnant woman, the health of the woman and her unborn child) in serious jeopardy; (ii) serious impairment to bodily functions; or (iii) serious dysfunction of any bodily organ or part. • Medical Services. The professional services of Health Professionals, including medical, surgical, diagnostic, therapeutic, preventive care and birthing facility services. • Medically Necessary, Medically Necessary Services, or Medical Necessity. Services that are appropriate and consistent with the diagnosis in accordance with accepted medical standards as described in the Covered Benefits section of this Certificate. Medical Necessity, when used in relation to services, shall have the same meaning as Medically Necessary Services. This definition applies only to the determination by HMO of whether health care services are Covered Benefits under this Certificate. • Member(s). A Subscriber or Covered Dependent as defined in this Certificate. • Mental or Behavioral Condition. A condition which manifests signs and/or symptoms which are primarily mental or behavioral, for which the primary treatment is psychotherapy, psychotherapeutic methods or procedures, and/or the administration of psychotropic medication, regardless of any underlying physical or medical cause. Mental or behavioral disorders and conditions include, but are not limited to, psychosis, affective disorders, anxiety disorders, personality disorders, obsessive-compulsive disorders, attention disorders with or without hyperactivity, and other psychological, emotional, nervous, behavioral, or stress-related abnormalities associated with transient or permanent dysfunction of the brain or related neurohormonal systems, whether or not caused by or in any way resulting from chemical imbalance, physical trauma, or a physical or medical condition. • Non-Hospital Facility. A facility, licensed by the appropriate regulatory authority, for the care or treatment of alcohol or drug dependent persons, except for transitional living facilities. • Open Enrollment Period. A period each calendar year, when eligible enrollees of the Contract Holder may enroll in HMO without a waiting period or exclusion or limitation based on health status or, if already enrolled in HMO, may transfer to an alternative health plan offered by the Contract Holder. • Partial Hospitalization. The provision of medical, nursing, counseling or therapeutic services on a planned and regularly scheduled basis in a Hospital or Non-Hospital Facility which is licensed as an alcohol or drug abuse or mental illness treatment program by the appropriate regulatory authority, and which is designed for a patient or client who would benefit from more intensive services than are offered in outpatient treatment but who does not require inpatient care. • Participating. A description of a Provider that has entered into a contractual agreement with HMO for the provision of services to Members.