Page 30 - Aegion PPO SPDs
P. 30
Inpatient - A Member who receives care as a registered bed patient in a Hospital or other Provider where
a room and board charge is made. It does not mean a Member who is placed under observation for fewer
than 24 hours.
Intensive Outpatient Programs - Structured, multidisciplinary behavioral health treatment that provides a
combination of individual, group and family therapy in a program that operates no less than 3 hours per
day, 3 days per week. Out-of-Network Facility-based Programs must occur at Facilities that are both
licensed and accredited.
Late Enrollee - Late Enrollees mean Employees or Dependents who request enrollment in a health benefit
plan after the initial open enrollment period. An individual will not be considered a Late Enrollee if: (a) the
person enrolls during his/her initial enrollment period under the Plan: (b) the person enrolls during a special
enrollment period; or (c) a court orders that coverage be provided for a minor Covered Dependent under a
Member’s Plan, but only as long as the Member requests enrollment for such Dependent within thirty (30)
days after the court order is so issued. Late Enrollees are those who declined coverage during the initial
open enrollment period and did not submit a certification to the Plan that coverage was declined because
other coverage existed.
Late Enrollment - Enrollment other than on:
The earliest date on which benefits can become effective under the Plan; or
The date of an event that qualifies for Special Enrollment.
Lifetime Maximum - The maximum dollar amount for Covered Services paid by the Plan during Your
lifetime.
Maternity Care - Obstetrical care received both before and after the delivery of a child or children. It also
includes care for miscarriage or abortion. It includes regular nursery care for a newborn infant as long as
the mother’s Hospital stay is a covered benefit and the newborn infant is an eligible Member under the
Plan.
Maximum Allowed Amount - The maximum amount that the Plan will allow for Covered Services You
receive. For more information, see the Claims Payment section.
Medically Necessary or Medical Necessity - Procedures, supplies, equipment, or services that we
conclude are:
1. Appropriate for the symptoms, diagnosis, or treatment of a medical condition; and
2. Given for the diagnosis or direct care and treatment of the medical condition; and
3. Within the standards of good medical practice within the organized medical community; and
4. Not mainly for the convenience of the Doctor or another Provider, and the most appropriate procedure,
supply, equipment, or service which can be safely given.
The most appropriate procedure, supply, equipment, or service must meet the following
requirements:
5. There must be valid scientific evidence to show that the expected health benefits from the procedure,
supply, equipment, or service are clinically significant and will have a greater chance of benefit, without
a disproportionately greater risk of harm or complications, than other possible treatments; and
6. Generally approved forms of treatment that are less invasive have been tried and did not work or are
otherwise unsuitable; and
7. For Hospital stays, acute care as an Inpatient is needed due to the kind of services the patient needs
or the severity of the medical condition, and that safe and adequate care cannot be given as an
outpatient or in a less intensive medical setting.
30
a room and board charge is made. It does not mean a Member who is placed under observation for fewer
than 24 hours.
Intensive Outpatient Programs - Structured, multidisciplinary behavioral health treatment that provides a
combination of individual, group and family therapy in a program that operates no less than 3 hours per
day, 3 days per week. Out-of-Network Facility-based Programs must occur at Facilities that are both
licensed and accredited.
Late Enrollee - Late Enrollees mean Employees or Dependents who request enrollment in a health benefit
plan after the initial open enrollment period. An individual will not be considered a Late Enrollee if: (a) the
person enrolls during his/her initial enrollment period under the Plan: (b) the person enrolls during a special
enrollment period; or (c) a court orders that coverage be provided for a minor Covered Dependent under a
Member’s Plan, but only as long as the Member requests enrollment for such Dependent within thirty (30)
days after the court order is so issued. Late Enrollees are those who declined coverage during the initial
open enrollment period and did not submit a certification to the Plan that coverage was declined because
other coverage existed.
Late Enrollment - Enrollment other than on:
The earliest date on which benefits can become effective under the Plan; or
The date of an event that qualifies for Special Enrollment.
Lifetime Maximum - The maximum dollar amount for Covered Services paid by the Plan during Your
lifetime.
Maternity Care - Obstetrical care received both before and after the delivery of a child or children. It also
includes care for miscarriage or abortion. It includes regular nursery care for a newborn infant as long as
the mother’s Hospital stay is a covered benefit and the newborn infant is an eligible Member under the
Plan.
Maximum Allowed Amount - The maximum amount that the Plan will allow for Covered Services You
receive. For more information, see the Claims Payment section.
Medically Necessary or Medical Necessity - Procedures, supplies, equipment, or services that we
conclude are:
1. Appropriate for the symptoms, diagnosis, or treatment of a medical condition; and
2. Given for the diagnosis or direct care and treatment of the medical condition; and
3. Within the standards of good medical practice within the organized medical community; and
4. Not mainly for the convenience of the Doctor or another Provider, and the most appropriate procedure,
supply, equipment, or service which can be safely given.
The most appropriate procedure, supply, equipment, or service must meet the following
requirements:
5. There must be valid scientific evidence to show that the expected health benefits from the procedure,
supply, equipment, or service are clinically significant and will have a greater chance of benefit, without
a disproportionately greater risk of harm or complications, than other possible treatments; and
6. Generally approved forms of treatment that are less invasive have been tried and did not work or are
otherwise unsuitable; and
7. For Hospital stays, acute care as an Inpatient is needed due to the kind of services the patient needs
or the severity of the medical condition, and that safe and adequate care cannot be given as an
outpatient or in a less intensive medical setting.
30
