Page 59 - Aegion PPO SPDs
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charges from a Hospital or other provider for room, board and general nursing services;
ancillary services; and
professional services from a Physician while an Inpatient.
Room, Board, and General Nursing Services
a room with two or more beds;
a private room. The private room allowance is the Hospital’s average semi-private room rate unless it
is Medically Necessary that You occupy a private room for isolation and no isolation Facilities are
available;
a room in a special care unit approved by the Claims Administrator. The unit must have Facilities,
equipment and supportive services for intensive care of critically ill patients.
Ancillary Services
operating, delivery and treatment rooms and equipment;
prescribed drugs;
anesthesia, anesthesia supplies and services given by an employee of the Hospital or other Provider;
medical and surgical dressings, supplies, casts and splints;
diagnostic services; and
therapy services.
Professional Services
Medical care visits limited to one visit per day by any one Physician.
Intensive medical care for constant attendance and treatment when Your condition requires it for a
prolonged time.
Concurrent care for a medical condition by a Physician who is not Your surgeon while You are in the
Hospital for Surgery. Care by two or more Physicians during one Hospital stay when the nature or
severity of Your condition requires the skills of separate Physicians.
Consultation which is a personal bedside examination by another Physician when requested by Your
Physician. Staff consultations required by Hospital rules are excluded.
Surgery and the administration of general anesthesia.
Newborn exam. A Physician other than the Physician who performed the obstetrical delivery must do
the examination.
Online Visits
When available in Your area, Your coverage will include online visits from a LiveHealth Online
Provider. Covered Services include a medical consultation using the internet via a webcam, chat or
voice. See Schedule of Benefits for any applicable Deductible, Coinsurance, Copayment and benefit
limitation information. For Behavioral Health and Substance Abuse Online Visits, see the “Behavioral
Health Care and Substance Abuse Treatment” section. Non-Covered Services include, but are not limited
to communications used for:
reporting normal lab or other test results;
office appointment requests;
billing, insurance coverage or payment questions;
requests for referrals to Physicians outside of the online care panel;
benefit precertification; and
Physician to Physician consultation.
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ancillary services; and
professional services from a Physician while an Inpatient.
Room, Board, and General Nursing Services
a room with two or more beds;
a private room. The private room allowance is the Hospital’s average semi-private room rate unless it
is Medically Necessary that You occupy a private room for isolation and no isolation Facilities are
available;
a room in a special care unit approved by the Claims Administrator. The unit must have Facilities,
equipment and supportive services for intensive care of critically ill patients.
Ancillary Services
operating, delivery and treatment rooms and equipment;
prescribed drugs;
anesthesia, anesthesia supplies and services given by an employee of the Hospital or other Provider;
medical and surgical dressings, supplies, casts and splints;
diagnostic services; and
therapy services.
Professional Services
Medical care visits limited to one visit per day by any one Physician.
Intensive medical care for constant attendance and treatment when Your condition requires it for a
prolonged time.
Concurrent care for a medical condition by a Physician who is not Your surgeon while You are in the
Hospital for Surgery. Care by two or more Physicians during one Hospital stay when the nature or
severity of Your condition requires the skills of separate Physicians.
Consultation which is a personal bedside examination by another Physician when requested by Your
Physician. Staff consultations required by Hospital rules are excluded.
Surgery and the administration of general anesthesia.
Newborn exam. A Physician other than the Physician who performed the obstetrical delivery must do
the examination.
Online Visits
When available in Your area, Your coverage will include online visits from a LiveHealth Online
Provider. Covered Services include a medical consultation using the internet via a webcam, chat or
voice. See Schedule of Benefits for any applicable Deductible, Coinsurance, Copayment and benefit
limitation information. For Behavioral Health and Substance Abuse Online Visits, see the “Behavioral
Health Care and Substance Abuse Treatment” section. Non-Covered Services include, but are not limited
to communications used for:
reporting normal lab or other test results;
office appointment requests;
billing, insurance coverage or payment questions;
requests for referrals to Physicians outside of the online care panel;
benefit precertification; and
Physician to Physician consultation.
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