PARTICIPATING PROFESSIONAL PROVIDER a Professional Provider who has agreed to a rate of reimbursement determined by contract for the provision of Covered Services to Covered Persons. PENALTY – a type of cost-sharing in which the Covered Person is assessed a percentage reduction in benefits payable for failure to obtain Precertification of certain Covered Services. Penalties, if any, are identified in the Schedule of Benefits and explained in detail in the Managed Care section. PERSONAL CHOICE DISCOUNT – the percentage reduction from hospital billed charges for Covered Services that the Carrier passes on to its Personal Choice customers as a share of the savings the Carrier is expected to realize from its negotiated hospital contracts with Preferred Facility Providers. The amount of the Personal Choice Discount may be changed prospectively from time to time. The Personal Choice Discount is on file with the Pennsylvania Insurance Department. PERVASIVE DEVELOPMENTAL DISORDERS (PDD) – disorders characterized by severe and pervasive impairment in several areas of development: reciprocal social interaction skills, communication skills, or the presence of stereotyped behavior, interests and activities. Examples are Asperger's syndrome and childhood disintegrative disorder. PHYSICIAN - a person who is a doctor of medicine (M.D.) or a doctor of osteopathy (D.O.), licensed, and legally entitled to practice medicine in all its branches, perform Surgery and dispense drugs.
PARTICIPATING PROFESSIONAL PROVIDER. Services are covered at 80% of the Provider’s Reasonable Charge which is based on the Usual, Customary, and Reasonable Allowance as defined in this Subsection 5, and that the participating professional provider has agreed to accept as payment in full for covered services, less any subscriber deductible obligation.
PARTICIPATING PROFESSIONAL PROVIDER a Professional Provider who has agreed to a rate of reimbursement determined by contract for the provision of Covered Services to Covered Persons.
