Page 26 - Aegion PPO SPDs
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DEFINITIONS
This section defines terms which have special meanings. If a word or phrase has a special meaning or is
a title, it will be capitalized. The word or phrase is defined in this section or at the place in the text where it
is used.
Actively at Work - Present and capable of carrying out the normal assigned job duties of the Employer.
Subscribers who are absent from work due to a health-related disability, maternity leave or regularly
scheduled vacation will be considered Actively at Work.
Administrative Services Agreement - The agreement between the Claims Administrator and the
Employer regarding the administration of certain elements of the health care benefits of the Employer's
Group Health Plan. This Benefit Booklet in conjunction with the Administrative Services Agreement, the
application, if any, any amendment or rider, Your Identification Card and Your application for enrollment
constitutes the entire Plan. If there is any conflict between either this Benefit Booklet or the Administrative
Services Agreement and any amendment or rider, the amendment or rider shall control. If there is any
conflict between this Benefit Booklet and the Administrative Services Agreement, the Administrative
Services Agreement shall control.
Administrator - An organization or entity that the Employer contracts with to provide administrative and
claims payment services under the Plan. The Administrator is Anthem Blue Cross Blue Shield (“Anthem”).
The Administrator provides administrative claims payment services only, on behalf of the Employer and
does not assume any financial risk or obligation with respect to claims.
Alternate Care - Care or services that otherwise would not be covered. They may be approved by the
Health Care Management staff as more appropriate and cost effective than other covered services. This
can help members conserve their benefits.
Alternate Recipient - Any child of a Subscriber who is recognized under a Qualified Medical Child Support
Order (QMCSO) as having a right to enrollment under the Plan with regard to such Subscriber.
Ambulance Services - A state-licensed emergency vehicle which carries injured or sick persons to a
Hospital. Services which offer non-emergency, convalescent or invalid care do not meet this definition.
Authorized Service - A Covered Service rendered by any Provider other than a Network Provider, which
has been authorized in advance (except for Emergency Care which may be authorized after the service is
rendered) by the Claims Administrator to be paid at the Network level. The Member may be responsible for
the difference between the Out-of-Network Provider’s charge and the Maximum Allowed Amount, in
addition to any applicable Network Coinsurance, Copayment or Deductible. For more information, see the
Claims Payment section.
Behavioral Health Care - Includes services for Mental Health and Substance Abuse. Mental Health and
Substance Abuse is a condition that is listed in the current edition of the diagnostic and Statistical Manual
of Mental Disorders (DSM) as a mental health or substance abuse condition.
Benefit Booklet - This summary of the terms of Your health benefits.
Benefit Period - The period of time that benefits for Covered Services are payable under the Plan. The
Benefit Period is listed in the Schedule of Benefits. If Your coverage ends earlier, the Benefit Period ends
at the same time.
Claims Administrator - The company the Plan Sponsor chose to administer its health benefits. Healthy
Alliance Life Insurance Company was chosen to administer this Plan. The Claims Administrator provides
administrative claims payment services only and does not assume any financial risk or obligation with
respect to claims.
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This section defines terms which have special meanings. If a word or phrase has a special meaning or is
a title, it will be capitalized. The word or phrase is defined in this section or at the place in the text where it
is used.
Actively at Work - Present and capable of carrying out the normal assigned job duties of the Employer.
Subscribers who are absent from work due to a health-related disability, maternity leave or regularly
scheduled vacation will be considered Actively at Work.
Administrative Services Agreement - The agreement between the Claims Administrator and the
Employer regarding the administration of certain elements of the health care benefits of the Employer's
Group Health Plan. This Benefit Booklet in conjunction with the Administrative Services Agreement, the
application, if any, any amendment or rider, Your Identification Card and Your application for enrollment
constitutes the entire Plan. If there is any conflict between either this Benefit Booklet or the Administrative
Services Agreement and any amendment or rider, the amendment or rider shall control. If there is any
conflict between this Benefit Booklet and the Administrative Services Agreement, the Administrative
Services Agreement shall control.
Administrator - An organization or entity that the Employer contracts with to provide administrative and
claims payment services under the Plan. The Administrator is Anthem Blue Cross Blue Shield (“Anthem”).
The Administrator provides administrative claims payment services only, on behalf of the Employer and
does not assume any financial risk or obligation with respect to claims.
Alternate Care - Care or services that otherwise would not be covered. They may be approved by the
Health Care Management staff as more appropriate and cost effective than other covered services. This
can help members conserve their benefits.
Alternate Recipient - Any child of a Subscriber who is recognized under a Qualified Medical Child Support
Order (QMCSO) as having a right to enrollment under the Plan with regard to such Subscriber.
Ambulance Services - A state-licensed emergency vehicle which carries injured or sick persons to a
Hospital. Services which offer non-emergency, convalescent or invalid care do not meet this definition.
Authorized Service - A Covered Service rendered by any Provider other than a Network Provider, which
has been authorized in advance (except for Emergency Care which may be authorized after the service is
rendered) by the Claims Administrator to be paid at the Network level. The Member may be responsible for
the difference between the Out-of-Network Provider’s charge and the Maximum Allowed Amount, in
addition to any applicable Network Coinsurance, Copayment or Deductible. For more information, see the
Claims Payment section.
Behavioral Health Care - Includes services for Mental Health and Substance Abuse. Mental Health and
Substance Abuse is a condition that is listed in the current edition of the diagnostic and Statistical Manual
of Mental Disorders (DSM) as a mental health or substance abuse condition.
Benefit Booklet - This summary of the terms of Your health benefits.
Benefit Period - The period of time that benefits for Covered Services are payable under the Plan. The
Benefit Period is listed in the Schedule of Benefits. If Your coverage ends earlier, the Benefit Period ends
at the same time.
Claims Administrator - The company the Plan Sponsor chose to administer its health benefits. Healthy
Alliance Life Insurance Company was chosen to administer this Plan. The Claims Administrator provides
administrative claims payment services only and does not assume any financial risk or obligation with
respect to claims.
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