Qualified Individual. a person who resides in Keystone’s Limited Network 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.
Appears in 5 contracts
Samples: Subscriber Agreement, Subscriber Agreement, Subscriber Agreement
