Page 32 - Aegion PPO SPDs
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Benefit payments and other provisions of this Plan are limited when a Member uses the services of Out-of-
Network Providers. For Missouri residents, only POS Providers are Network Providers.
Non-Network Transplant Facility - Any Hospital which has not contracted with the transplant network
engaged by Claims Administrator to provide Covered Transplant Procedures. A Hospital may be a Non-
Network Transplant Facility with respect to:
Certain Covered Transplant Procedures; or
All Covered Transplant Procedures.
Out-of-Pocket Maximum - The maximum amount of a Member’s payments during a given calendar year.
When the Out-of-Pocket Maximum is reached, the level of benefits is increased to 100% of the Maximum
Allowed Amount for Covered Services and no additional Deductible, Copayments or Coinsurance are
required unless otherwise specified in this Benefit Booklet.
Outpatient - A Member who receives services or supplies while not an Inpatient.
Partial Hospitalization Program - Structured, multidisciplinary behavioral health treatment that offers
nursing care and active individual, group and family treatment in a program that operates no less than 6
hours per day, 5 days per week. Out-of-Network Facility-based Programs must occur at Facilities that are
both licensed and accredited.
Physician - Any licensed Doctor of Medicine (M.D.) legally entitled to practice medicine and perform
surgery, any licensed Doctor of Osteopathy (D.O.) legally licensed to perform the duties of a D.O., Doctor
of Chiropractic (D.C.), legally licensed to perform the duties of a chiropractor, any licensed Doctor of
Podiatric Medicine (D.P.M.) legally entitled to practice podiatry, and any licensed Doctor of Dental
Surgery (D.D.S.) legally entitled to perform oral surgery, Optometrists and Clinical Psychologists (PhD)
are also Providers when acting within the scope of their licenses, and when rendering services covered
under this Plan.
Plan – The arrangement chosen by the Plan Sponsor to fund and provide for delivery of the Employer’s
health benefits.
Plan Administrator - The person or entity named by the Plan Sponsor to manage the Plan and answer
questions about Plan details. The Plan Administrator is not the Claims Administrator.
Plan Sponsor - The legal entity that has adopted the Plan and has authority regarding its operation,
amendment and termination. The Plan Sponsor is not the Claims Administrator.
Precertification - Is a Health Care Management feature which requires that an approval be obtained from
the Claims Administrator before incurring expenses for certain Covered Services. The Plan’s procedures
and timeframes for making decisions for Precertification requests differ depending on when the request is
received and the type of service that is the subject of the Precertification request.
Provider - A duly licensed person or Facility that provides services within the scope of an applicable license
and is a person or Facility that the Plan approves. This includes any Provider rendering services which are
required by applicable state law to be covered when rendered by such Provider. Providers include, but are
not limited to, the following persons and Facilities:
Alternative Care Facility – A non-hospital health care Facility, or an attached Facility designated
as free standing by a Hospital, that the Plan approves, which provides Outpatient Services primarily
for but not limited to:
1. diagnostic Services such as Computerized Axial Tomography (CAT scan) or Magnetic
Resonance Imaging (MRI);
32
Network Providers. For Missouri residents, only POS Providers are Network Providers.
Non-Network Transplant Facility - Any Hospital which has not contracted with the transplant network
engaged by Claims Administrator to provide Covered Transplant Procedures. A Hospital may be a Non-
Network Transplant Facility with respect to:
Certain Covered Transplant Procedures; or
All Covered Transplant Procedures.
Out-of-Pocket Maximum - The maximum amount of a Member’s payments during a given calendar year.
When the Out-of-Pocket Maximum is reached, the level of benefits is increased to 100% of the Maximum
Allowed Amount for Covered Services and no additional Deductible, Copayments or Coinsurance are
required unless otherwise specified in this Benefit Booklet.
Outpatient - A Member who receives services or supplies while not an Inpatient.
Partial Hospitalization Program - Structured, multidisciplinary behavioral health treatment that offers
nursing care and active individual, group and family treatment in a program that operates no less than 6
hours per day, 5 days per week. Out-of-Network Facility-based Programs must occur at Facilities that are
both licensed and accredited.
Physician - Any licensed Doctor of Medicine (M.D.) legally entitled to practice medicine and perform
surgery, any licensed Doctor of Osteopathy (D.O.) legally licensed to perform the duties of a D.O., Doctor
of Chiropractic (D.C.), legally licensed to perform the duties of a chiropractor, any licensed Doctor of
Podiatric Medicine (D.P.M.) legally entitled to practice podiatry, and any licensed Doctor of Dental
Surgery (D.D.S.) legally entitled to perform oral surgery, Optometrists and Clinical Psychologists (PhD)
are also Providers when acting within the scope of their licenses, and when rendering services covered
under this Plan.
Plan – The arrangement chosen by the Plan Sponsor to fund and provide for delivery of the Employer’s
health benefits.
Plan Administrator - The person or entity named by the Plan Sponsor to manage the Plan and answer
questions about Plan details. The Plan Administrator is not the Claims Administrator.
Plan Sponsor - The legal entity that has adopted the Plan and has authority regarding its operation,
amendment and termination. The Plan Sponsor is not the Claims Administrator.
Precertification - Is a Health Care Management feature which requires that an approval be obtained from
the Claims Administrator before incurring expenses for certain Covered Services. The Plan’s procedures
and timeframes for making decisions for Precertification requests differ depending on when the request is
received and the type of service that is the subject of the Precertification request.
Provider - A duly licensed person or Facility that provides services within the scope of an applicable license
and is a person or Facility that the Plan approves. This includes any Provider rendering services which are
required by applicable state law to be covered when rendered by such Provider. Providers include, but are
not limited to, the following persons and Facilities:
Alternative Care Facility – A non-hospital health care Facility, or an attached Facility designated
as free standing by a Hospital, that the Plan approves, which provides Outpatient Services primarily
for but not limited to:
1. diagnostic Services such as Computerized Axial Tomography (CAT scan) or Magnetic
Resonance Imaging (MRI);
32
