Benefit Contract - This term shall mean the individual and group health benefit contracts of Payor, including the terms and conditions of a Member's coverage. Benefit Contracts include, but are not limited to, insurance policies, health benefit third party administrators (TPAs), administrative services only agreements, benefits services only agreements, third party administrator agreements, multiple employer trusts, pre-paid TPAs, competitive medical TPAs, governmental programs, and self-insured TPAs and trusts.

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Claim - A request by a covered person for payment of a benefit under the plan, including hospital, medical/surgical, and mental health/substance abuse services, prescription drugs, and other services and supplies.

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Copayment - A specified amount the covered person must pay at the time services are rendered for certain covered services, which may not be used as part of the deductible. All services received during a provider office visit (on the same site) are covered by the payment of a single copayment.

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Covered Service - A service or supply that is available under the plan, when medically necessary and obtained in full compliance with all plan rules-including the plan delivery system rules. A charge for a covered service shall be considered to have been incurred on the date the service or supply was provided.

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Customary Charge - The fee for health care services charged by Physician that does not exceed the fee Physician would charge any other person regardless of whether the person is a Member.

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Deductible - A specified dollar amount of covered services that must be incurred by the covered person before the plan shall provide benefits for all or part of the remaining covered services during the plan year.

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Dependent - An individual who relies on an employee for support or obtains health coverage through a spouse, parent or grandparent who is the covered person.

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Drug Formulary - A listing of prescription medications which are approved for use and/or coverage by the plan and which will be dispensed through participating pharmacies to a covered person. The list is subject to periodic review and modification by the health plan.

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Eligibility Date - The defined date a covered person becomes eligible for benefits under an existing contract.

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Emergency Medical Condition - A medical condition manifesting itself by acute symptoms of sufficient severity including, severe pain, from a chronic medical condition, that would lead a prudent lay person, to reasonably expect the absence of immediate medical attention to result in any of the following: (a) placing the health of an individual, or with respect to a pregnant woman, the health of the woman or her unborn child, in serious jeopardy; (b) serious impairment to bodily functions; (c) serious dysfunction of any bodily organ or part: With respect to a pregnant woman who is having contractions, (1) a situation in which there is inadequate time to effect a safe transfer to another hospital before delivery, or (2) may pose a threat to the health and safety of the woman or the unborn child.

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Generic Drug - A chemically equivalent copy designed from a brand-name drug that has an expired patent. A generic is typically less expensive and sold under a common or "generic" name for that drug, not the name brand.

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Medically Necessary - A service or treatment which is appropriate and consistent with diagnosis, and which, in accordance with accepted standards of practice in the medical community of the area in which the health services are rendered, could not have been omitted without adversely affecting the member's condition or the quality of medical care rendered.

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Member - An individual who is covered under a Benefit Contract.

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Member Expenses - Any amounts that are the Member's responsibility to pay Physician in accordance with the Member's Benefit Contract, including copayments, coinsurance and deductibles.

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Non-Participating Provider - Term used to describe a provider that has not contracted with the carrier or health plan to be a participating provider of health care.

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Participating Provider - Any provider who has an agreement with the carrier or the carrier's associated medical groups to provide covered services.

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Payor - The entity or person authorized by Network to access one or more networks of Participating Providers developed by Network and that has the financial responsibility for payment of Covered Services provided under a Benefit Contract, including, but not limited to, insurance carriers, self-funded employers, third party administrators, trust funds, governmental programs, and administrative service groups.

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Referral - The recommendation by a physician and/or health plan for a member to receive care from a different physician or facility.

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Service Area - The geographic area serviced by the health plan as approved by the state regulatory agencies and/or detailed in the certification of authority.

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