SECTION DE - DEFINITIONS. For the purposes of this Agreement, the terms below have the following meaning: ADVERSE BENEFIT DETERMINATION – any of the following: a denial, reduction, or termination of, or a failure to provide or make payment (in whole or in part) for a benefit, including any such denial, reduction, termination, or failure to provide or make payment that is based on a determination of a Member’s eligibility to participate in a plan, and including a denial, reduction, or termination of, or a failure to provide or make payment (in whole or in part) for a benefit resulting from the application of any utilization review, as well as a failure to cover an item or service for which benefits are otherwise provided because it is determined to be Investigational or not Medically Necessary. ALLOWABLE AMOUNT – the payment level that Keystone reimburses for benefits provided to a Member under the Member’s coverage. For Participating Providers, the allowable amount is the amount provided for in the contract between the Provider and Keystone, unless otherwise specified in this Agreement. has permanent facilities and equipment for the primary purpose of performing surgical procedures on an outpatient basis; provides treatment by or under the supervision of physicians whenever the patient is in the facility; does not provide inpatient accommodations; and is not, other than incidentally, a facility used as an office or clinic for the private practice of a physician.
Appears in 6 contracts
Samples: Individual Hmo Subscriber Agreement, Hmo Subscriber Agreement, Hmo Subscriber Agreement
