AETNA PPO PLAN - My Benefits Portfolio - Trinity Health

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RESIDENTIAL TREATMENT FACILITY – MENTAL DISORDERS This is an institution that meets all of the following requirements: • On-site licensed Behavioral Health Provider 24 hours per day/seven days a week • Provides a comprehensive patient assessment (preferably before admission, but at least upon admission) • Is admitted by a Physician • Has access to necessary medical services 24 hours per day/seven days a week • Provides living arrangements that foster community living and peer interaction that are consistent with developmental needs • Offers group therapy session with at least an RN or Masters-Level Health Professional • Has the ability to involve family/support systems in therapy (required for children and adolescents; encouraged for adults) • Provides access to at least weekly sessions with a Psychiatrist or psychologist for individual psychotherapy • Has peer oriented activities • Services are managed by a licensed Behavior Health Provider who, while not needing to be individually contracted, needs to (1) meet the Aetna credentialing criteria as an individual practitioner, and (2) function under the direction/supervision of a licensed psychiatrist (medial Director) • Has individualized active treatment plan directed toward the alleviation of the impairment that caused the admission • Provides a level of skilled intervention consistent with patient risk • Meets any and all applicable licensing standards established by the jurisdiction in which it is located • Is not a Wilderness Treatment Program or any such related or similar program, school and/or education service SURGERY A cutting operation, suturing of a wound, treatment of a fracture, relocation of dislocation, radiotherapy (if used in lieu of a cutting operation) diagnostic and therapeutic endoscopic procedures, laser surgery, and injections classified a Surgery under the CPT. URGENT CARE PROVIDER This is a freestanding medical facility which provides unscheduled medical services to treat an Urgent Condition if the person’s Physician is not reasonable available, routinely provides ongoing unscheduled medical services for more than eight consecutive hours and makes charges. They are licensed and certified as required by any state or federal law or regulation. They keep a medical record on each patient. Urgent Care Provider provides an ongoing quality assurance program, which includes reviews by Physicians other than those who own or direct the facility. Its run by a staff of Physicians, at least on Physician must be on call at all times and has a full-time administrator who is licensed Physician. Similar to a Physician’s office, but only one that has contracted with Aetna to provide urgent care; and is with Aetna’s consent, included in the directory as Preferred Urgent Care Provider. It is not the emergency room or Outpatient department of a hospital. 10
URGENT CONDITION This means a sudden Illness; Injury; or condition; that is severe enough to require prompt medical attention to avoid serious deterioration of the covered person’s health; includes a condition which would subject the covered person to severe pain that could not be adequately managed without urgent care or treatment; does not require the level of care provided in the emergency room of a hospital; and requires immediate Outpatient medical care that cannot be postponed until the covered person’s Physician becomes reasonably available. 11
Page 1 and 2: AETNA PPO PLAN SUMMARY PLAN DESCRIP
Page 3 and 4: Women’s Health and Cancer Rights
Page 5 and 6: PURPOSE This document, along with o
Page 7 and 8: COBRA Continuation coverage as requ
Page 9 and 10: • Scientific data such as control
Page 11 and 12: A service or supply is not Medicall
Page 13: charge Aetna determines to be the p
Page 17 and 18: CONTINUATION OF COVERAGE FOR ILL ST
Page 19 and 20: During Annual Open Enrollment, you
Page 21 and 22: • Change in marital status, inclu
Page 23 and 24: • The last day of the pay period
Page 25 and 26: • CHIP participant; or • Depend
Page 27 and 28: SPECIFIC INFORMATION ABOUT YOUR COB
Page 29 and 30: notified of the Social Security Adm
Page 31 and 32: USERRA CONTINUATION COVERAGE If you
Page 33 and 34: Privacy of Health Information HIPAA
Page 35 and 36: Coverage will be provided in a mann
Page 37 and 38: not submitted sufficient informatio
Page 39 and 40: The notice of Adverse Benefit Deter
Page 41 and 42: Determination concerns an admission
Page 43 and 44: 4) Assisting in Plan’s Reimbursem
Page 45 and 46: EMPLOYEE RETIREMENT INCOME SECURITY
Page 47 and 48: IMPORTANT INFORMATION ABOUT THE PLA
Page 49 and 50: COVERED MEDICAL EXPENSES The Plan p
Page 51 and 52: necessary for the diagnosis or trea
Page 53 and 54: URGENT CARE COPAY A separate Urgent
Page 55 and 56: OUTPATIENT SURGICAL EXPENSES Covere
Page 57 and 58: LIMITATIONS TO HOME CARE EXPENSES C
Page 59 and 60: Not included are charges for: • A
Page 61 and 62: Short-term rehabilitation is therap
Page 63 and 64: • Platelet Proliferation Stimulan
Page 65 and 66:
Effective July 1, 2011 (or such lat
Page 67 and 68:
• Services for weight loss render
Page 69 and 70:
COMPLEX IMAGING SERVICES Covered Ex
Page 71 and 72:
Surgery, during which the Covered I
Page 73 and 74:
• For root canal therapy; • For
Page 75 and 76:
GENERAL EXCLUSIONS GENERAL EXCLUSIO
Page 77 and 78:
• Those for or in connection with
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AETNA PPO PLAN - My Benefits Portfolio - Trinity Health

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