CIGNA High Deductible Health Plan (HDHP) - UCAR Finance ...

• fulfills any licensing requirements of the state or locality in
which it operates.
Injury
The term Injury means an accidental bodily injury.
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Hospital
The term Hospital means:
• an institution licensed as a hospital, which: maintains, on
the premises, all facilities necessary for medical and
surgical treatment; provides such treatment on an inpatient
basis, for compensation, under the supervision of
Physicians; and provides 24-hour service by Registered
Graduate Nurses;
• an institution which qualifies as a hospital, a psychiatric
hospital or a tuberculosis hospital, and a provider of
services under Medicare, if such institution is accredited as
a hospital by the Joint Commission on the Accreditation of
Healthcare Organizations; or
• an institution which: specializes in treatment of Mental
Health and Substance Abuse or other related illness;
provides residential treatment programs; and is licensed in
accordance with the laws of the appropriate legally
authorized agency.
The term Hospital will not include an institution which is
primarily a place for rest, a place for the aged, or a nursing
home.
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Hospital Confinement or Confined in a Hospital
A person will be considered Confined in a Hospital if he is:
• a registered bed patient in a Hospital upon the
recommendation of a Physician;
• receiving treatment for Mental Health and Substance Abuse
Services in a Partial Hospitalization program;
• receiving treatment for Mental Health and Substance Abuse
Services in a Mental Health or Substance Abuse Residential
Treatment Center.
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Maximum Reimbursable Charge - Medical
The Maximum Reimbursable Charge for covered services is
determined based on the lesser of:
• the provider’s normal charge for a similar service or supply;
or
• a policyholder-selected percentile of charges made by
providers of such service or supply in the geographic area
where it is received as compiled in a database selected by
CIGNA.
The percentile used to determine the Maximum Reimbursable
Charge is listed in The Schedule.
The Maximum Reimbursable Charge is subject to all other
benefit limitations and applicable coding and payment
methodologies determined by CIGNA. Additional information
about how CIGNA determines the Maximum Reimbursable
Charge is available upon request.
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Medicaid
The term Medicaid means a state program of medical aid for
needy persons established under Title XIX of the Social
Security Act of 1965 as amended.
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Medically Necessary/Medical Necessity
Medically Necessary Covered Services and Supplies are those
determined by the Medical Director to be:
• required to diagnose or treat an illness, injury, disease or its
symptoms;
• in accordance with generally accepted standards of medical
practice;
• clinically appropriate in terms of type, frequency, extent,
site and duration;
• not primarily for the convenience of the patient, Physician
or other health care provider; and
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