CALIFORNIA - Pacificare Health Systems

PART A
Section 11. Definitions
126
Definitions
PacifiCare is dedicated to making its services easily
accessible and understandable. To help you understand
the precise meanings of many terms used to explain
your benefits, we have provided the following
definitions. These definitions apply to the capitalized
terms used in your Combined Evidence of Coverage
and Disclosure Form, as well as the Schedule of
Benefits.
Annual Copayment Maximum – The maximum
amount of Copayments a Member is required to pay
for certain Covered Services in a calendar year. (Please
refer to your Schedule of Benefits.)
Binding Arbitration – The submission of a dispute to
one or more impartial persons for a final and binding
decision, except for fraud or collusion on the part
of the arbitrator. This means that once the arbitrator
has issued a decision, neither party may appeal
the decision. Any such dispute will not be resolved
by a lawsuit or resort to court process, except as
California law provides for judicial review of arbitration
proceedings.
Biofeedback – Biofeedback therapy provides visual,
auditory or other evidence of the status of certain body
functions so that a person can exert voluntary control
over the functions, and thereby alleviate an abnormal
bodily condition. Biofeedback therapy often uses
electrical devices to transform bodily signals indicative
of such functions as heart rate, blood pressure,
skin temperature, salivation, peripheral vasomotor
activity, and gross muscle tone into a tone or light, the
loudness or brightness of which shows the extent of
activity in the function being measured.
Case Management – A collaborative process that
assesses, plans, implements, coordinates, monitors and
evaluates options to meet an individual’s health care
needs based on the health care benefits and available
resources in order to promote a quality outcome for
the individual Member.
Chronic Condition – A medical condition that is
continuous or persistent over an extended period
of time and requires ongoing treatment for its
management.
Claim Determination Period – A calendar year.
Cognitive Behavioral Therapy – Psychotherapy where
the emphasis is on the role of thought patterns in
moods and behaviors.
Cognitive Rehabilitation Therapy – Cognitive
Rehabilitation Therapy is therapy for the treatment of
functional deficits as a result of traumatic brain injury
and cerebral vascular insult. It is intended to help in
achieving the return of higher-level cognitive ability.
This therapy is direct (one-on-one) patient contact.
Complementary and Alternative Medicine – Defined
by the National Center for Complementary and
Alternative Medicine as the broad range of healing
philosophies (schools of thought), approaches and
therapies that Conventional Medicine does not
commonly use, accept, study or make available.
Generally defined, these treatments and health care
practices are not taught widely in medical schools
and not generally used in hospitals. These types
of therapies used alone are often referred to as
“alternative.” When used in combination with other
alternative therapies or in addition to conventional
therapies, these therapies are often referred to as
“complementary.”
Conventional Medicine – Defined by the National
Center for Complementary and Alternative Medicine
as medicine as practiced by holders of M.D. (medical
doctor) or D.O. (doctor of osteopathy) degrees.
Other terms for conventional medicine are allopathic,
Western, regular and mainstream medicine.
Completion of Covered Services – Covered Services
for the Continuity of Care Condition under treatment
by the Terminated Provider or Non-Participating
Provider will be considered complete when (i)
the Member’s Continuity of Care Condition under
treatment is medically/clinically stable, and (ii) there
are no clinical contraindications that would prevent
a medically/clinically safe transfer to a Participating
Provider as determined by a PacifiCare Medical
Director in consultation with the Member, the
Terminated Provider or Non-Participating Provider,
and as applicable, the Member’s assigned Participating
Provider.
Continuity of Care Condition(s) – The Completion
of Covered Services will be provided by: (i) a
Terminated Provider to a Member who, at the time
of the Participating Provider’s contract Termination,
was receiving Covered Services from that Participating