Page 28 - Aegion Value Plan SPDs
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Physician -
1. a legally licensed doctor of medicine, doctor of osteopathy or optometry, podiatry; or
chiropractic
2. any other legally licensed practitioner of the healing arts rendering services which are:
a. covered by the Plan;
b. required by law to be covered when rendered by such practitioner; and
c. within the scope of his or her license.
Physician does not include:
1. the Member; or
2. the Member’s spouse, parent, child, sister, brother, or in-law.
Residential Treatment Center / Facility -A Provider licensed and operated as required by law,
which includes:
Room, board and skilled nursing care (either an RN or LVN/LPN) available on-site at least eight
hours daily with 24 hour availability;
A staff with one or more Doctors available at all times.
Residential treatment takes place in a structured Facility-based setting.
The resources and programming to adequately diagnose, care and treat a psychiatric and/or
substance use disorder.
Facilities are designated residential, subacute, or intermediate care and may occur in care
systems that provide multiple levels of care.
Is fully accredited by The Joint Commission (TJC), the Commission on Accreditation of
Rehabilitation Facilities (CARF), the National Integrated Accreditation for Healthcare
Organizations (NIAHO), or the Council on Accreditation (COA).
The term Residential Treatment Center/Facility does not include a Provider, or that part of a Provider,
used mainly for:
Nursing care
Rest care
Convalescent care
Care of the aged
Custodial Care
Educational care
Skilled Nursing Facility - An institution operated alone or with a Hospital which gives care after a
Member leaves the Hospital for a condition requiring more care than can be rendered at home. It
must be licensed by the appropriate agency and accredited by The Joint Commission or the
Commission on Accreditation of Rehabilitation Facilities (CARF), as applicable, or meet specific
rules set by the by the Claims Administrator.
Specialist (Specialty Care Physician\Provider or SCP) - A Specialist is a doctor who focuses on
a specific area of medicine or group of patients to diagnose, manage, prevent, or treat certain types
of symptoms and conditions. A non-Physician Specialist is a Provider who has added training in a
specific area of health care.
Urgent Care Center - A health care facility that is organizationally separate from a Hospital and
whose primary purpose is the offering and provision of immediate, short-term medical care, without
appointment, for Urgent Care.
Recovery – A Recovery is money You receive from another, their insurer or from any "Uninsured Motorist,”
“Underinsured Motorist,” “Medical-Payments,” “No-Fault,” or “Personal Injury Protection,” or other insurance
28
1. a legally licensed doctor of medicine, doctor of osteopathy or optometry, podiatry; or
chiropractic
2. any other legally licensed practitioner of the healing arts rendering services which are:
a. covered by the Plan;
b. required by law to be covered when rendered by such practitioner; and
c. within the scope of his or her license.
Physician does not include:
1. the Member; or
2. the Member’s spouse, parent, child, sister, brother, or in-law.
Residential Treatment Center / Facility -A Provider licensed and operated as required by law,
which includes:
Room, board and skilled nursing care (either an RN or LVN/LPN) available on-site at least eight
hours daily with 24 hour availability;
A staff with one or more Doctors available at all times.
Residential treatment takes place in a structured Facility-based setting.
The resources and programming to adequately diagnose, care and treat a psychiatric and/or
substance use disorder.
Facilities are designated residential, subacute, or intermediate care and may occur in care
systems that provide multiple levels of care.
Is fully accredited by The Joint Commission (TJC), the Commission on Accreditation of
Rehabilitation Facilities (CARF), the National Integrated Accreditation for Healthcare
Organizations (NIAHO), or the Council on Accreditation (COA).
The term Residential Treatment Center/Facility does not include a Provider, or that part of a Provider,
used mainly for:
Nursing care
Rest care
Convalescent care
Care of the aged
Custodial Care
Educational care
Skilled Nursing Facility - An institution operated alone or with a Hospital which gives care after a
Member leaves the Hospital for a condition requiring more care than can be rendered at home. It
must be licensed by the appropriate agency and accredited by The Joint Commission or the
Commission on Accreditation of Rehabilitation Facilities (CARF), as applicable, or meet specific
rules set by the by the Claims Administrator.
Specialist (Specialty Care Physician\Provider or SCP) - A Specialist is a doctor who focuses on
a specific area of medicine or group of patients to diagnose, manage, prevent, or treat certain types
of symptoms and conditions. A non-Physician Specialist is a Provider who has added training in a
specific area of health care.
Urgent Care Center - A health care facility that is organizationally separate from a Hospital and
whose primary purpose is the offering and provision of immediate, short-term medical care, without
appointment, for Urgent Care.
Recovery – A Recovery is money You receive from another, their insurer or from any "Uninsured Motorist,”
“Underinsured Motorist,” “Medical-Payments,” “No-Fault,” or “Personal Injury Protection,” or other insurance
28
