EOC - Erlanger Health System

variations in individual development and
aging including:
(1) comfort measures in the absence of
disease or injury.
(2) Cosmetic Surgery; and
g. not be for the sole convenience of the
Provider, Member or Member’s family.
45. Medically Necessary or Medical Necessity
– Services that have been determined by the
administrator to be of proven value for use in
the general population. To be Medically
Necessary, a service must:
a. have final approval from the appropriate
government regulatory bodies;
b. have scientific evidence permitting
conclusions concerning the effect of the
service on health outcomes;
c. improve the net health outcome;
d. be as beneficial as any established
alternative;
e. demonstrate the improvement outside the
investigational setting;
f. not be an experimental or Investigational
Service.
46. Medicare – Title XVIII of the Social
Security Act, as amended.
47. Member, You, Your – Any person enrolled
as a Subscriber or Covered Dependent under
the Plan.
48. Member Payment – The dollar amounts for
Covered Services that You are responsible
for as set forth in Attachment C, Schedule of
Benefits, including Copayments,
Deductibles, Coinsurance and Penalties. The
administrator may require proof that You
have made any required Member Payment.
49. Network Provider – A Provider who has
contracted with the administrator to provide
access to benefits to Members at specified
rates. Such Providers may be referred to as
BlueCard PPO Participating Providers,
Network hospitals, In-Transplant Network,
etc.
50. Non-Contracted Provider – A Provider that
renders Covered Services to a Member, in
the situation where We have not contracted
with that Provider type to provide those
Covered Services. These Providers can
change, as We contract with different
Providers. A Provider’s status as a Non-
Contracted Provider, Network Provider, or
Out-of-Network Provider can and does
change. We reserve the right to change a
Provider’s status.
51. Non-Routine Diagnostic Services
(Advanced Radiological Imaging)– Services
listed under Advanced Radiological Imaging
in Attachment A, Covered Services.
52. Open Enrollment Period – Those periods
of time established by the Plan during which
eligible Employees and their dependents
may enroll as Members.
53. Out-of-Network Provider – Any Provider
who is an eligible Provider type but who
does not hold a contract with the
administrator to provide Covered Services.
54. Out-of-Pocket Maximum – The total dollar
amount, as stated in Attachment C, Schedule
of Benefits, that a Member must incur and
pay for Covered Services during the
Calendar Year, including Deductible and
Coinsurance. There are 2 Out-of-Pocket
Maximums – one for services rendered by
Network Providers and one for services
rendered by Out-of-Network Providers.
Copayments, Penalties and any balance of
charges (the difference between Billed
Charges and the Maximum Allowable
Charge) are not considered when
determining if the Out-of-Pocket Maximum
has been satisfied.
When the Out-of-Pocket Maximum, Network
Providers is satisfied, 100% of available
benefits is payable for other Covered
Services from Network Providers incurred by
the Member during the remainder of that
Calendar Year, excluding applicable
Copayments and Penalties, and any balance
of charges (the difference between Billed
Charges and the Maximum Allowable
Amount).
When the Out-of-Pocket Maximum, Out-of-
Network Providers is reached, 100% of
available benefits is payable for expenses for
other Covered Services from Out-of-
Network Providers incurred by the Member
during the remainder of that Calendar Year,
excluding applicable Copayments and
Penalties, and any balance of charges (the
32 Erlanger Health System 2009