Common use of PLAN OF TREATMENT Clause in Contracts

PLAN OF TREATMENT. a plan of care which is developed or approved by a Member’s Primary Care Physician for the treatment of an injury or illness. The Plan of Treatment should be limited in scope and extent to that care which is Medically Necessary for the Member's diagnosis and condition. PREAUTHORIZATION – An authorization (or approval) from Keystone Health Plan Central or its designee which results from a process utilized to determine member eligibility at the time of request, benefit coverage and medical necessity of proposed medical services prior to delivery of services. Preauthorization is required for the procedures identified in the Preauthorization Program attachment to this Agreement. PREMIUM – The payment due for coverage under this Agreement. PROFESSIONAL PROVIDER – a person or practitioner who is certified, registered or who is licensed and performing services within the scope of such licensure. The Professional Providers are:  Audiologist  Certified Registered Nurse Anesthetist  Certified Registered Nurse Midwife  Certified Nurse Practitioner  Chiropractor  Clinical or Physician Laboratory  Doctor of Medicine (M.D.)  Doctor of Osteopathy (D.O.)  Licensed Dietitian-Nutritionist  Licensed Social Worker  Occupational Therapist  Oral Surgeon  Physical Therapist  Physician Assistant  Podiatrist  Psychologist  Respiratory Therapist  Social worker/Other Masters Prepared Therapists  Speech Language Pathologist PROVIDER – A hospital, physician, person or practitioner licensed (where required) and performing services within the scope of such licensure and as identified in this Agreement. Providers include participating providers and non-participating providers. QUALIFIED HEALTH PLAN or QHP – Qualified Health Plan or QHP means a health plan that has in effect a certification from the United Stated Secretary of Health and Human Services that it is certified to be offered on the Exchange/Marketplace.

PLAN OF TREATMENT. a plan of care which is developed or approved by a Member’s Primary Care Physician for the treatment of an injury or illness. The Plan of Treatment should be limited in scope and extent to that care which is Medically Necessary for the Member's diagnosis and condition. PREAUTHORIZATION – An authorization (or approval) from Keystone Health Plan Central or its designee which results from a process utilized to determine member eligibility at the time of request, benefit coverage and medical necessity of proposed medical services prior to delivery of services. Preauthorization is required for the procedures identified in the Preauthorization Program attachment to this Agreement. PREMIUM – The payment due for coverage under this Agreement. PROFESSIONAL PROVIDER – a person or practitioner who is certified, registered or who is licensed and performing services within the scope of such licensure. The Professional Providers are:  • Audiologist  • Certified Registered Nurse Anesthetist  • Certified Registered Nurse Midwife  • Certified Nurse Practitioner  • Chiropractor  • Clinical or Physician Laboratory  • Doctor of Medicine (M.D.)  • Doctor of Osteopathy (D.O.)  • Licensed Dietitian-Nutritionist  • Licensed Social Worker  • Occupational Therapist  • Oral Surgeon  • Physical Therapist  • Physician Assistant  • Podiatrist  • Psychologist  • Respiratory Therapist  • Social worker/Other Masters Prepared Therapists  • Speech Language Pathologist PROVIDER – A hospital, physician, person or practitioner licensed (where required) and performing services within the scope of such licensure and as identified in this Agreement. Providers include participating providers and non-participating providers. QUALIFIED HEALTH PLAN or QHP – Qualified Health Plan or QHP means a health plan that has in effect a certification from the United Stated Secretary of Health and Human Services that it is certified to be offered on the Exchange/Marketplace. QUALIFIED INDIVIDUAL – a person who resides in Keystone’s Limited Eligibility & Service area and is determined by the Marketplace to be eligible to purchase a qualified health plan (QHP) and who has not been determined by the Marketplace to be ineligible to continue enrollment in a QHP. RECONSTRUCTIVE SURGERY – Shall mean a procedure performed to improve or correct a Functional Impairment, restore a bodily function or correct deformity resulting from an otherwise covered sickness, Birth Defect or accidental injury. The fact that a Member might suffer psychological consequences from a deformity does not, in the absence of bodily Functional Impairment, qualify Surgery as being Reconstructive Surgery. REFERRAL – The process by which a primary care physician coordinates a member’s care with another provider for benefits which the primary care physician does not provide. Referrals must be properly documented and are valid only for benefits as defined in this Agreement. REHABILITATION HOSPITAL – a Facility Provider, approved by the HMO, which is primarily engaged in providing rehabilitation care services on an Inpatient basis. Rehabilitation care services consist of the combined use of medical, social, educational, and vocational services to enable patients disabled by disease or injury to achieve the highest possible level of functional ability. Services are provided by or under the supervision of an organized staff of Physicians. Continuous nursing services are provided under the supervision of a Registered Nurse. ROUTINE COSTS ASSOCIATED WITH QUALIFYING CLINICAL TRIALS – Routine costs include all the following: A. Covered Services under this Subscriber Agreement that would typically be provided absent a Qualifying Clinical Trial.

PLAN OF TREATMENT. a plan of care which is developed or approved by a Member’s Primary Care Physician for the treatment of an injury or illness. The Plan of Treatment should be limited in scope and extent to that care which is Medically Necessary for the Member's diagnosis and condition. PREAUTHORIZATION – An authorization (or approval) from Keystone Health Plan Central or its designee which results from a process utilized to determine member eligibility at the time of request, benefit coverage and medical necessity of proposed medical services prior to delivery of services. Preauthorization is required for the procedures identified in the Preauthorization Program attachment to this Agreement. PREMIUM – The payment due for coverage under this Agreement. PROFESSIONAL PROVIDER – a person or practitioner who is certified, registered or who is licensed and performing services within the scope of such licensure. The Professional Providers are:  • Audiologist  • Certified Registered Nurse Anesthetist  • Certified Registered Nurse Midwife  • Certified Nurse Practitioner  • Chiropractor  • Clinical or Physician Laboratory  • Doctor of Medicine (M.D.)  • Doctor of Osteopathy (D.O.)  • Licensed Dietitian-Nutritionist  • Licensed Social Worker  • Occupational Therapist  • Oral Surgeon  • Physical Therapist  • Physician Assistant  • Podiatrist  • Psychologist  • Respiratory Therapist  • Social worker/Other Masters Prepared Therapists  • Speech Language Pathologist PROVIDER – A hospital, physician, person or practitioner licensed (where required) and performing services within the scope of such licensure and as identified in this Agreement. Providers include participating providers and non-participating providers. QUALIFIED HEALTH PLAN RECONSTRUCTIVE SURGERY – Shall mean a procedure performed to improve or QHP correct a Functional Impairment, restore a bodily function or correct deformity resulting from an otherwise covered sickness, Birth Defect or accidental injury. The fact that a Member might suffer psychological consequences from a deformity does not, in the absence of bodily Functional Impairment, qualify Surgery as being Reconstructive Surgery. REFERRAL – Qualified Health Plan The process by which a primary care physician coordinates a member’s care with another provider for benefits which the primary care physician does not provide. Referrals must be properly documented and are valid only for benefits as defined in this Agreement. REHABILITATION HOSPITAL – a Facility Provider, approved by the HMO, which is primarily engaged in providing rehabilitation care services on an Inpatient basis. Rehabilitation care services consist of the combined use of medical, social, educational, and vocational services to enable patients disabled by disease or QHP means injury to achieve the highest possible level of functional ability. Services are provided by or under the supervision of an organized staff of Physicians. Continuous nursing services are provided under the supervision of a health plan Registered Nurse. ROUTINE COSTS ASSOCIATED WITH QUALIFYING CLINICAL TRIALS – Routine costs include all the following: A. Covered Services under this Subscriber Agreement that has in effect would typically be provided absent a certification from the United Stated Secretary of Health and Human Services that it is certified to be offered on the Exchange/MarketplaceQualifying Clinical Trial.

PLAN OF TREATMENT. a plan of care which is developed or approved by a Member’s Primary Care Physician for the treatment of an injury or illness. The Plan of Treatment should be limited in scope and extent to that care which is Medically Necessary for the Member's diagnosis and condition. PREAUTHORIZATION – An authorization (or approval) from Keystone Health Plan Central or its designee which results from a process utilized to determine member eligibility at the time of request, benefit coverage and medical necessity of proposed medical services prior to delivery of services. Preauthorization is required for the procedures identified in the Preauthorization Program attachment to this Agreement. PREMIUM – The payment due for coverage under this Agreement. PROFESSIONAL PROVIDER – a person or practitioner who is certified, registered or who is licensed and performing services within the scope of such licensure. The Professional Providers are:  Audiologist  Certified Registered Nurse Anesthetist  Certified Registered Nurse Midwife  Certified Nurse Practitioner  Chiropractor  Clinical or Physician Laboratory  Doctor of Medicine (M.D.)  Doctor of Osteopathy (D.O.)  Licensed Dietitian-Nutritionist  Licensed Social Worker  Occupational Therapist  Oral Surgeon  Physical Therapist  Physician Assistant  Podiatrist  Psychologist  Respiratory Therapist  Social worker/Other Masters Prepared Therapists  Speech Language Pathologist PROVIDER – A hospital, physician, person or practitioner licensed (where required) and performing services within the scope of such licensure and as identified in this Agreement. Providers include participating providers and non-participating providers. QUALIFIED HEALTH PLAN RECONSTRUCTIVE SURGERY – Shall mean a procedure performed to improve or QHP correct a Functional Impairment, restore a bodily function or correct deformity resulting from an otherwise covered sickness, Birth Defect or accidental injury. The fact that a Member might suffer psychological consequences from a deformity does not, in the absence of bodily Functional Impairment, qualify Surgery as being Reconstructive Surgery. REFERRAL – Qualified Health Plan The process by which a primary care physician coordinates a member’s care with another provider for benefits which the primary care physician does not provide. Referrals must be properly documented and are valid only for benefits as defined in this Agreement. REHABILITATION HOSPITAL – a Facility Provider, approved by the HMO, which is primarily engaged in providing rehabilitation care services on an Inpatient basis. Rehabilitation care services consist of the combined use of medical, social, educational, and vocational services to enable patients disabled by disease or QHP means injury to achieve the highest possible level of functional ability. Services are provided by or under the supervision of an organized staff of Physicians. Continuous nursing services are provided under the supervision of a health plan Registered Nurse. ROUTINE COSTS ASSOCIATED WITH QUALIFYING CLINICAL TRIALS – Routine costs include all the following: A. Covered Services under this Subscriber Agreement that has in effect would typically be provided absent a certification from the United Stated Secretary of Health and Human Services that it is certified to be offered on the Exchange/MarketplaceQualifying Clinical Trial.

PLAN OF TREATMENT. a plan of care which is developed or approved by a Member’s Primary Care Physician for the treatment of an injury or illness. The Plan of Treatment should be limited in scope and extent to that care which is Medically Necessary for the Member's diagnosis and condition. PREAUTHORIZATION – An authorization (or approval) from Keystone Health Plan Central or its designee which results from a process utilized to determine member eligibility at the time of request, benefit coverage and medical necessity of proposed medical services prior to delivery of services. Preauthorization is required for the procedures identified in the Preauthorization Program attachment to this Agreement. PREMIUM – The payment due for coverage under this Agreement. PROFESSIONAL PROVIDER – a person or practitioner who is certified, registered or who is licensed and performing services within the scope of such licensure. The Professional Providers are:  • Audiologist  • Certified Registered Nurse Anesthetist  • Certified Registered Nurse Midwife  • Certified Nurse Practitioner  • Chiropractor  • Clinical or Physician Laboratory  • Doctor of Medicine (M.D.)  • Occupational Therapist • Oral Surgeon • Physical Therapist • Physician Assistant • Podiatrist • Psychologist • Respiratory Therapist • Doctor of Osteopathy (D.O.)  • Licensed Dietitian-Nutritionist  • Licensed Social Worker  Occupational Therapist  Oral Surgeon  Physical Therapist  Physician Assistant  Podiatrist  Psychologist  Respiratory Therapist  • Social worker/Other Masters Prepared Therapists  • Speech Language Pathologist PROVIDER – A hospital, physician, person or practitioner licensed (where required) and performing services within the scope of such licensure and as identified in this Agreement. Providers include participating providers and non-participating providers. QUALIFIED HEALTH PLAN or QHP – Qualified Health Plan or QHP means a health plan that has in effect a certification from the United Stated Secretary of Health and Human Services that it is certified to be offered on the Exchange/Marketplace. QUALIFIED INDIVIDUAL – a person who resides in Keystone’s 13-County Eligibility Service area and is determined by the Marketplace to be eligible to purchase a qualified health plan (QHP) and who has not been determined by the Marketplace to be ineligible to continue enrollment in a QHP. RECONSTRUCTIVE SURGERY – Shall mean a procedure performed to improve or correct a Functional Impairment, restore a bodily function or correct deformity resulting from an otherwise covered sickness, Birth Defect or accidental injury. The fact that a Member might suffer psychological consequences from a deformity does not, in the absence of bodily Functional Impairment, qualify Surgery as being Reconstructive Surgery. REFERRAL – The process by which a primary care physician coordinates a member’s care with another provider for benefits which the primary care physician does not provide. Referrals must be properly documented and are valid only for benefits as defined in this Agreement. REHABILITATION HOSPITAL – a Facility Provider, approved by the HMO, which is primarily engaged in providing rehabilitation care services on an Inpatient basis. Rehabilitation care services consist of the combined use of medical, social, educational, and vocational services to enable patients disabled by disease or injury to achieve the highest possible level of functional ability. Services are provided by or under the supervision of an organized staff of Physicians. Continuous nursing services are provided under the supervision of a Registered Nurse. ROUTINE COSTS ASSOCIATED WITH QUALIFYING CLINICAL TRIALS – Routine costs include all the following: A. Covered Services under this Subscriber Agreement that would typically be provided absent a Qualifying Clinical Trial.