Page 89 - QCS.19 SPD - HSA

Manipulative Treatment - the therapeutic application of chiropractic and/or osteopathic manipulative treatment
with or without ancillary physiologic treatment and/or rehabilitative methods rendered to restore/improve motion,
reduce pain and improve function in the management of an identifiable neuromusculoskeletal condition.

Maximum Allowable Cost (MAC) List - a list of Generic Prescription Drug Products that will be covered at a
price level that we establish. This list is subject to our periodic review and modification.
Medical Child Support Order - any judgment, decree, or order including approval of a settlement agreement
which is made:
· under a state domestic relations law and requires child support or requires health and/or dental coverage
for the child; or

· by a state agency under a state law for medical child support that is required under the federal Social
Security Act.

The Medical Child Support Order must be issued by a court of competent jurisdiction, or issued through a state
administrative process, and has the force and effect of law.
Medical Necessity or Medically Necessary – health care services that are all of the following as determined by
us or our designee:
· In accordance with Generally Accepted Standards of Medical Practice.

· Clinically appropriate, in terms of type, frequency, extent, site and duration, and considered effective for
your Sickness, Injury, Mental Illness, mental illness, substance use disorder substance related and
addictive disorders disease or its symptoms.

· Not mainly for your convenience or that of your doctor or other health care provider.
· Not more costly than an alternative drug, service(s) or supply that is at least as likely to produce
equivalent therapeutic or diagnostic results as to the diagnosis or treatment of your Sickness, Injury,
disease or symptoms.
Generally Accepted Standards of Medical Practice are standards that are based on credible scientific evidence
published in peer-reviewed medical literature generally recognized by the relevant medical community, relying
primarily on controlled clinical trials, or, if not available, observational studies from more than one institution that
suggest a causal relationship between the service or treatment and health outcomes.
If no credible scientific evidence is available, then standards that are based on Physician specialty society
recommendations or professional standards of care may be considered. The Claims Administrator reserves the
right to consult expert opinion in determining whether health care services are Medically Necessary. The decision
to apply Physician specialty society recommendations, the choice of expert and the determination of when to use
any such expert opinion, shall be within the Claims Administrator’s authority.

We develop and maintain clinical policies that describe the Generally Accepted Standards of Medical Practice
scientific evidence, prevailing medical standards and clinical guidelines supporting our determinations regarding
specific services. These clinical policies (as developed by us and revised from time to time), are available to
Covered Persons on www.myallsaversmember.com or by calling Customer Care at the telephone number on your
ID card, and to Physicians and other health care professionals on UnitedHealthcareOnline.
Medicare - Parts A, B, C and D of the insurance program established by Title XVIII, United States Social Security
Act, as amended by 42 U.S.C. Sections 1394, et seq. and as later amended.
Mental Health Care Services - Covered Health Care Services for the diagnosis and treatment of those mental
health or psychiatric categories that are listed in the current edition of the International Classification of Diseases
section on Mental and Behavioral Disorders or the Diagnostic and Statistical Manual of the American Psychiatric
Association does not mean that treatment for the condition is a Covered Health Care Service.
Network - when used to describe a provider of health care services, this means a provider that has a participation
agreement in effect (either directly or indirectly) with the Claims Administrator or with its affiliate to participate in
the Network. This does not include those providers who have agreed to discount their charges for Covered Health
Care Services by way of their participation in the Shared Savings Program. The Claims Administrator’s affiliates
are those entities affiliated with us through common ownership or control with us or with our ultimate corporate
parent, including direct and indirect subsidiaries.
A provider may enter into an agreement to provide only certain Covered Health Care Services, but not all
Covered Health Care Services, or to be a Network provider for only some of our products. In this case, the
provider will be a Network provider for the Covered Health Care Services and products included in the

Page 84 Section 15 - Glossary
HSA - 2017