Page 118 - 2021 Medical Plan SPD

Texas Mutual Insurance Company Medical Plan

Intensive Outpatient Treatment - a structured outpatient mental health or substance-related and
addictive disorders treatment program. The program may be freestanding or Hospital-based and provides
services for at least three hours per day, two or more days per week.
Intermittent Care - skilled nursing care that is provided either:

• Fewer than seven days each week.
• Fewer than eight hours each day for periods of 21 days or less.

Exceptions may be made in certain circumstances when the need for more care is finite and predictable.
Manipulative Treatment (adjustment) - a form of care provided by chiropractors and osteopaths for
diagnosed muscle, nerve and joint problems. Body parts are moved either by hands or by a small
instrument to:

• Restore or improve motion.
• Reduce pain.
• Increase function.

Medicaid - a federal program administered and operated individually by participating state and territorial
governments. The program provides medical benefits to eligible low-income people needing health care.
The federal and state governments share the program's costs.
Medically Necessary - health care services that are all of the following as determined by the Claims
Administrator or the Claims Administrator's designee.
• In accordance with Generally Accepted Standards of Medical Practice.

• Clinically appropriate, in terms of type, frequency, extent, service site and duration, and considered
effective for your Sickness, Injury, Mental Illness, 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), service site 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 has
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 determined by the Claims Administrator.
The Claims Administrator develops and maintain clinical policies that describe the Generally Accepted
Standards of Medical Practice scientific evidence, prevailing medical standards and clinical guidelines
supporting the Claims Administrator's determinations regarding specific services. These clinical policies
(as developed by the Claims Administrator and revised from time to time), are available to Covered
Persons through www.myuhc.com or the telephone number on your ID card. They are also available to
Physicians and other health care professionals on UHCprovider.com.

115 Section 9: Defined Terms