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This section defines words and terms used
throughout the certificate to help members understand the content.
Members should refer to this section to find out exactly how, for the
purposes of this certificate, a word or term is used.
Accidental injuries: unintentional internal or
external injuries, e.g., strains, animal bites, burns, contusions and
abrasions which result in trauma to the body. Accidental injuries are
different from illness related conditions.
Acupuncture services: the treatment of a disease or
condition by inserting special needles along specific nerve pathways for
therapeutic purposes. The placement of the needles varies with the
disease or condition being treated.
Acute care: care that is provided in an office,
urgent care setting, emergency room or hospital for a medical illness,
accident or injury. Acute care may be emergency, urgent or non-urgent,
but is not primarily preventive in nature.
Alcoholism/substance treatment center: a
detoxification and/or rehabilitation facility licensed by the state to
treat alcoholism/drug abuse.
Alternative/complimentary care: therapeutic
practices that are not currently considered an integral part of
conventional medical practice. Therapies are termed Complimentary when
used in addition to conventional treatments and as Alternative when used
instead of conventional treatment. Alternative medicine includes, but is
not limited to, Chinese or Ayurvedic medicine, herbal treatments,
vitamin therapy, homeopathic medicine and other non-traditional remedies
for treating diseases or conditions.
Ambulance: a specially designed and equipped vehicle
used only for transporting the sick and injured. It must have customary
safety and lifesaving equipment such as first aid supplies and oxygen
equipment. The vehicle must be operated by trained personnel and
licensed as an ambulance.
Ancillary services: services and supplies (in
addition to room services) that hospitals, alcoholism treatment centers
and other facilities bill for and regularly make available for the
treatment of the member’s condition. Such services include, but are
not limited to:
- Use of operating room, recovery room, emergency room, treatment
rooms and related equipment.
- Drugs and medicines, biologics (medicines made from living
organisms and their products), and pharmaceuticals.
- Dressings and supplies, sterile trays, casts, and splints.
- Diagnostic and therapeutic services.
- Blood processing and transportation and blood handling costs and
administration.
Anesthesia: the loss of normal sensation or feeling.
There are two different types of anesthesia:
- General anesthesia, also known as total body anesthesia, causes
the patient to become unconscious or “put to sleep” for a period
of time.
- Local anesthesia causes loss of feeling or numbness in a specific
area usually injected with a local anesthetic drug such as Lidocaine.
Anniversary date: the annual date on which a group
renews its coverage.
Anthem Blue Cross and Blue Shield: Rocky Mountain
Hospital and Medical Service, Inc., a Colorado insurance company doing
business as Anthem Blue Cross and Blue Shield. Also referred to as
“Anthem.”
Appeal: a process for reconsideration of Anthem’s
decision regarding a member’s claim.
Authorization: approval of benefits for a covered
procedure or service.
Benefit period: the number of days or units of
service, such as two office visits per member’s benefit year, for
which Anthem will provide benefits during a specified length of time.
Billed charges: a provider’s regular charges for
services and supplies, as offered to the public generally and without
any adjustment for any applicable PPO, participating provider or other
discounts.
Birth abnormality: a condition that is recognizable
at birth, such as a fractured arm.
Birthday rule: the guideline that determines which
of two parents' health insurance coverages is primary for the coverage
of dependent child(ren). Generally, under the birthday rule, the parent
whose birthday comes first during the year is considered to have the
primary insurance coverage for the child(ren). Any balance may be
submitted to the other parent's insurance carrier for additional
consideration.
Care management: a plan of medically necessary and
appropriate health care, which is aimed at promoting more effective
interventions to meet member needs and optimize care. Care management is
also referred to as case management.
Care manager: a professional (e.g., nurse, doctor or
social worker) who works with members, providers and Anthem to
coordinate services deemed medically necessary for the member. A care
manager is also referred to as a case manager.
Certificate: this document, which explains the
benefits, limitations, exclusions, terms and conditions of the health
coverage.
Chemotherapy: drug therapy administered as treatment
for malignant conditions and diseases of certain body systems.
Chiropractic services: a system of therapy in which
disease is considered the result of abnormal function of the nervous
system. This method of treatment usually involves manipulation of the
spinal column and other body structures.
Chronic Pain: ongoing pain that lasts more than six
months that is due to non-life threatening causes, may continue for the
remainder of the person's life, and has not responded to current
available treatment methods.
COBRA: an acronym for the Consolidated Omnibus
Budget Reconciliation Act of 1985. This federal law allows individuals,
in certain cases, to continue their group health insurance coverage for
a specified period after termination of their employment for other
qualifying events.
Coinsurance: a provision
under which the subscriber and Anthem share costs incurred after the
deductible is met, according to a specific formula. The amount of
coinsurance the member pays to a provider is calculated after the
determination of the maximum benefit allowance, but before Anthem
subtracts any discount(s) Anthem may have negotiated with the provider.
Cold therapy: application of cold to decrease
swelling, pain or muscle spasm.
Complaint: an expression of dissatisfaction with
Anthem’s services or the practices of an in-network provider, whether
medical or non-medical in nature.
Congenital defect: a defect or anomaly existing
before birth, such as cleft lip or club foot. Disorders of growth and
development over time are not considered congenital.
Consultation/second opinion: a service provided by
another physician who gives an opinion about the treatment of the
member's condition. The consulting physician often has specialized
skills that are helpful in diagnosing or treating the illness or injury.
Coordination of benefits: also known as COB, a
stipulation in most health insurance policies that helps prevent
duplicate payments for services covered by more than one policy or
program of insurance. For example, a member may be covered by the
member’s own policy, as well as a spouse's policy. Eligible medical
expenses are covered first by a person's own policy. Any balance is
submitted to the spouse's health insurance carrier for additional
consideration.
Copayment: the portion of a claim or medical expense
that a member must pay out of the member’s own pocket to a provider or
a facility for each service. A copayment is usually a fixed amount that
is paid at the time the service is rendered.
Cosmetic services: beautification procedures,
services or surgery of a physical characteristic to improve an
individual’s appearance.
Cost sharing: the general term for out-of-pocket
expenses, e.g., copayments and deductibles, paid by a member.
Covered services: supplies or treatments which are:
- Medically necessary or otherwise specifically included as a
benefit under this certificate.
- Within the scope of the license of the provider performing the
service.
- Rendered while coverage under this certificate is in force.
- Not experimental/investigational or otherwise excluded or limited
by the certificate, or by any amendment or rider thereto.
- Authorized in advance by Anthem if such preauthorization is
required by the certificate.
Creditable coverage: a qualified prior health
coverage that an employee and/or dependent had within 90 days prior to
the effective date of Anthem’s coverage. Prior creditable health
coverage includes Medicare or Medicaid coverage, a group health
insurance coverage, an individual health benefit coverage, state high
risk pool coverage, any federal or state health benefit coverage or any
other health benefit coverage that provides basic medical and hospital
care, including, but not limited to, hospital services, physicians’
services, outpatient medical services, and laboratory and X-ray
services.
Cryocuff: water-circulating pad with pump. A machine
that circulates fluid through a specially designed pad to provide
continuous cold or heat therapy to a specific area.
Custodial care: care provided primarily to meet the
personal needs of the member. This includes help in walking, bathing or
dressing. It also includes, but is not limited to, preparing food or
special diets, feeding, administration of medicine that is usually
self-administered or any other care which does not require continuing
services of specialized medical personnel.
Deductible: an amount that
is required to be paid by a subscriber before Anthem will begin to
reimburse for services.
Dental services: services performed for treatment of
conditions related to the teeth or structures supporting the teeth.
Discharge planning: the evaluation of a member’s
medical needs and arrangement of appropriate care after discharge from a
facility.
Durable medical equipment: any equipment that can
withstand repeated use, is made to serve a medical condition, is useless
to a person who is not ill or injured, and is appropriate for use in the
home.
Effective date: the date coverage under this
certificate begins.
Elective surgery: a procedure that does not have to
be performed on an emergency basis and can be reasonably delayed. Such
surgery may still be considered medically necessary.
Emergency: the sudden, and
at the time, unexpected onset of a health condition that requires
immediate medical attention where failure to provide medical attention
would result in serious impairment to bodily functions or serious
dysfunction of a bodily organ or part, or would place the person’s
health in serious jeopardy.
Experimental/investigational —
- Any drug, biologic, device, diagnostic, product, equipment,
procedure, treatment, service or supply used in or directly related
to the diagnosis, evaluation or treatment of a disease, injury,
illness or other health condition which Anthem determines in its
sole discretion to be experimental or investigational.
Anthem will deem any drug, biologic, device, diagnostic, product,
equipment, procedure, treatment, service or supply to be
experimental or investigational if it determines that one or more of
the following criteria apply when the service is rendered with
respect to the use for which benefits are sought.
The drug, biologic, device, diagnostic, product, equipment,
procedure, treatment, service or supply:
- Cannot be legally marketed in the United States without the
final approval of the Food and Drug Administration (FDA) or any
other state or federal regulatory agency, and such final
approval has not been granted.
- Has been determined by the FDA to be contraindicated for the
specific use.
- Is provided as part of a clinical research protocol or
clinical trial, or is provided in any other manner that is
intended to evaluate the safety, toxicity or efficacy of the
drug, biologic, device, diagnostic, product, equipment,
procedure, treatment, service or supply; or is subject to review
and approval of an Institutional Review Board (IRB) or other
body serving a similar function.
- Is provided pursuant to informed consent documents that
describe the drug, biologic, device, diagnostic, product,
equipment, procedure, treatment, service or supply as
experimental/investigational, or otherwise indicate that the
safety, toxicity or efficacy of the drug, biologic, device,
diagnostic, product, equipment, procedure, treatment, service or
supply is under evaluation.
- Any service not deemed experimental or investigational based on
the criteria in subsection (a) may still be deemed to be
experimental or investigational by Anthem. In determining whether a
service is experimental or investigational, Anthem will consider the
information described in subsection (c) and assess all of the
following:
- Whether the scientific evidence is conclusory concerning the
effect of the service on health outcomes.
- Whether the evidence demonstrates that the service improves
the net health outcomes of the total population for whom the
service might be proposed as any established alternatives.
- Whether the evidence demonstrates the service has been shown
to improve the net health outcomes of the total population for
whom the service might be proposed under the usual conditions of
medical practice outside clinical investigatory settings.
- The information Anthem considers or evaluates to determine whether
a drug, biologic, device, diagnostic, product, equipment, procedure,
treatment, service or supply is experimental or investigational
under subsections (a) and (b) may include one or more items from the
following list, which is not all-inclusive:
- Randomized, controlled, clinical trials published in
authoritative, peer-reviewed United States medical or scientific
journal.
- Evaluations of national medical associations, consensus panels
and other technology evaluation bodies
- Documents issued by and/or filed with the FDA or other
federal, state or local agency with the authority to approve,
regulate or investigate the use of the drug, biologic, device,
diagnostic, product, equipment, procedure, treatment, service or
supply.
- Documents of an IRB or other similar body performing
substantially the same function
- Consent documentation(s) used by the treating physicians,
other medical professionals or facilities or by other treating
physicians, other medical professionals or facilities studying
substantially the same drug, biologic, device, diagnostic,
product, equipment, procedure, treatment, service or supply
- The written protocol(s) used by the treating physicians, other
medical professionals or facilities or by other treating
physicians, other medical professionals or facilities studying
substantially the same drug, biologic, device, diagnostic,
product, equipment, procedure, treatment, service or supply
- Medical records
- The opinions of consulting providers and other experts in the
field
- Anthem has the sole authority and discretion to identify and weigh
all information and determine all questions pertaining to whether a
drug, biologic, device, diagnostic, product, equipment, procedure,
treatment, service or supply is experimental or investigational.
Explanation of benefits: also known as an EOB, a
printed form sent by an insurance company to a member after a claim has
been filed and adjudicated. The EOB includes such information as the
date of service, name of provider, amount covered and patient balance.
An explanation of Medicare benefits, or EOMB, is similar, except it is
sent following submission of a Medicare claim.
Family membership: a membership that covers two or
more persons (the subscriber and one or more dependents).
Grievance: a written complaint about the quality of
care, denial of a benefit or service received from a provider.
Health Plan Description Form: the state regulated
document, found in the front of the certificate, which identifies the
type of coverage, copayment, deductible and coinsurance information.
Health benefit ID card: the card Anthem gives
members with information such as the subscriber’s name, number and
date issued.
Hemodialysis: the treatment of an acute or chronic
kidney ailment during which impurities are removed from the blood with
dialysis equipment.
Holistic medicine: various preventive and healing
techniques, that are theoretically based on the influence of the
external environment and the various ways different body tissues affect
each other along with the body’s natural healing powers.
Home health agency: An agency certified by the
Colorado Department of Public Health and Environment as meeting the
provisions of Title XVIII of the Federal “Social Security Act,” as
amended, for home health agencies. A home health agency is primarily
engaged in arranging and providing nursing services, home health aide
services, and other therapeutic and related services.
Home health care: the special term for skilled
nursing, occupational therapy and other health-related services provided
at home by a certified home health agency.
Home health services: the following services
provided by a certified home health agency under a plan of care to
eligible members in their place of residence: professional nursing
services; certified nurse aide services; medical supplies, equipment,
and appliances suitable for use in the home; and physical therapy,
occupational therapy, speech pathology and audiology services.
Hospice agency: an agency licensed by the Colorado
Department of Public Health and Environment to provide hospice care in
this state. A hospice is a centrally administered program of palliative,
supportive and interdisciplinary team services providing physical,
psychological, spiritual and sociological care for terminally ill
individuals and their families within a continuum of inpatient care,
home health care and follow up bereavement services available 24 hours a
day, seven days a week.
Hospice care: an alternative way of caring for
terminally ill individuals that stresses palliative care rather than
curative or restorative care. Hospice care focuses on the patient/family
as the unit of care. Supportive services are offered to the family
before and after the death of the member. Hospice care addresses
physical, social, psychological and spiritual needs of the member and
the member’s family.
Hospital: a health institution offering facilities,
beds and continuous services 24 hours a day and meets all licensing and
certification requirements of local and state regulatory agencies.
Individual membership: a membership covering one
person (the subscriber).
In-network: a term for providers or facilities that
enter into a network agreement with Anthem.
Inpatient medical rehabilitation: care that includes
a minimum of three hours of therapy, e.g., speech therapy, respiratory
therapy, occupational therapy and/or physical therapy, and often some
weekend therapy. Inpatient medical rehabilitation is generally provided
in a rehabilitation section of a hospital or a freestanding facility.
Some skilled nursing facilities have “rehabilitation” beds.
Intractable pain: a pain state in which the cause of
the pain cannot be removed and which in the generally accepted course of
medical practice no relief or cure of the cause of the pain is possible
or none has been found after reasonable efforts, including, but not
limited to, evaluation by the attending physician and one or more
physicians specializing in the treatment of the area, system or organ of
the body perceived as the source of the pain.
Laboratory and pathology services: testing
procedures required for the diagnosis or treatment of a condition.
Generally, these services involve the analysis of a specimen of tissue
or other material that has been removed from the body.
Long-term acute care facility: an institution that
provides an array of long-term critical care services to members with
serious illnesses or injuries. Long-term acute care is provided for
patients with complex medical needs. These include high-risk pulmonary
patients with ventilator or tracheotomy needs, medically unstable
members, extensive wound care or post operative surgery wound members,
and low level closed head injury members. LTAC facilities do not provide
care for low intensity patient needs.
Managed care: a system of health care delivery the
goal of which is to give members access to quality, cost effective
health care while optimizing utilization and cost of services, and
measuring provider and coverage performance.
Maximum benefit allowance:
the maximum dollar amount determined and approved by Anthem which Anthem
allows for covered services and procedures. Anthem’s determination of
a maximum benefit allowance is the maximum amount Anthem approves for
any particular service. Cost sharing amounts are based on this allowance
and on the allowance and are the amounts the member pays to a provider.
Maximum medical improvement: a determination at
Anthem’s sole discretion that no further medical care can reasonably
be expected to measurably improve a member’s condition. Maximum
medical improvement shall be determined without regard to whether
continued care is necessary to prevent deterioration of the condition or
is otherwise life sustaining.
Medically necessary: an intervention that is or will
be provided for the diagnosis, evaluation and treatment of a condition,
illness, disease or injury and that Anthem solely determines to be:
- Medically appropriate for and consistent with the symptoms and
proper diagnosis or treatment of the condition, illness, disease or
injury.
- Obtained from a physician and/or licensed, certified or registered
provider.
- Provided in accordance with applicable medical and/or professional
standards.
- Known to be effective, as proven by scientific evidence, in
materially improving health outcomes.
- The most appropriate supply, setting or level of service that can
safely be provided to the member and which cannot be omitted
consistent with recognized professional standards of care (which, in
the case of hospitalization, also means that safe and adequate care
could not be obtained as an outpatient).
- Cost-effective compared to alternative interventions, including no
intervention (“cost effective” does not mean lowest cost).
- Not experimental/investigational.
- Not primarily for the convenience of the member, the member’s
family or the provider.
- Not otherwise subject to an exclusion under this certificate.
The fact that a physician and/or provider may prescribe, order,
recommend or approve care, treatment, services or supplies does not, of
itself, make such care, treatment, services or supplies medically
necessary.
Medical supplies: items (except prescription drugs)
required for the treatment of an illness or injury.
Medicare: a federally funded health insurance
program that provides benefits for people age 65 and older. Some
individuals under age 65 who are disabled or who have end stage kidney
disease also are eligible for Medicare benefits.
Member: the subscriber or any dependent who is
enrolled for coverage under this certificate.
Member’s benefit year: The member’s benefit year
begins on the subscriber’s effective date, and expires on the
following December 31; a new member’s benefit year commences on each
subsequent January 1.
Mental health condition: non-biologically based
mental conditions with a psychiatric diagnosis or that require specific
psychotherapeutic treatment, regardless of the underlying condition
(e.g., depression secondary to diabetes or primary depression).
Myotherapy: the physical diagnosis, treatment and
pain management of conditions which cause pain in muscles and bones.
Nephritis: infection or inflammation of the kidney.
Nephrosis: condition in which there are degenerative
changes in the kidneys without the occurrence of inflammation.
Non-participating provider: a provider defined as
one of the following:
- A facility provider, such as a hospital, that has not entered into
an agreement with Anthem
- A professional provider, such as a physician, who has not entered
in to an agreement with Anthem Providers who have not contracted or
affiliated with Anthem’s designated subcontractor(s) for the
services they perform under this certificate
Occupational therapy: the use of educational and
rehabilitative techniques to improve a member’s functional ability to
live independently. Occupational therapy requires that a properly
accredited occupational therapist (OT) or certified occupational therapy
assistant (COTA) perform such therapy.
OMT: an acronym for Osteopathic Manipulative
Therapy, a hands-on modality of evaluation, diagnosis, and treatment
using palpation of the body's tissues and musculoskeletal system with a
variety of therapuetic techniques involving fascia, muscles, and joints
to help resolve both acute and chronic musculoskeletal injuries.
Organ transplants: a surgical process that involves
the removal of an organ from one person and placement of the organ into
another person. Transplant can also mean removal of body substances,
such as stem cells or bone marrow, for the purpose of treatment and
reimplanting the removed organ or tissue into the same person.
Orthopedic appliance: a rigid or semi-rigid support
used to eliminate, restrict or support motion in a part of the body that
is diseased, injured, weak or malformed.
Orthotic: a support or brace for weak or ineffective
joints or muscles.
Out-of-network: a term for providers or facilities
that do not enter into a network agreement with Anthem, usually at a
higher out-of-pocket expense to members than services rendered by an
in-network provider.
Out-of-pocket annual maximum:
the cost sharing total a member may be liable for under this certificate
for medical expenses during a specified period. The out-of-pocket annual
maximum is designed to protect members from catastrophic health care
expenses. For each member’s benefit year, after the out-of-pocket
annual maximum is reached, for most services payment will be made at 100
percent of the allowable charge for the remainder of the member’s
benefit year.
Outpatient medical care: non-surgical
services provided in a provider’s office, the outpatient department of
a hospital or other facility, or the member’s home.
Paraprofessional: a trained colleague who assists a
professional person, such as a radiology technician.
Participating provider: a facility provider (such as
a hospital) or a professional provider (such as a physician) that has
entered into an agreement with Anthem or another Blue Cross and Blue
Shield Plan to bill Anthem directly for covered services, and to accept
Anthem’s maximum benefit allowance as the maximum amount of payment
for covered services the participating provider must bill the member for
or use to calculate cost sharing amounts for covered services.
Physical therapy: the use of physical agents to
treat disability resulting from disease or injury. Physical agents used
include heat, cold, electrical currents, ultrasound, ultraviolet
radiation, massage and therapeutic exercise. Physical therapy must be
performed by a physician or registered physical therapist.
Physician: A doctor of
medicine or osteopathy who is licensed to practice medicine under the
laws of the state or jurisdiction where the services are provided.
PPO provider: a participating facility provider or a
participating professional provider that has entered into an additional
agreement with Anthem, to limit charges for services performed under
this certificate.
Preauthorization: a process in which requests for
services are reviewed prior to service for approval of benefits, length
of stay and appropriate location.
Premium: monthly charges that the member and/or
group must pay to establish and maintain coverage.
Prescription drugs:
prescription drugs include:
- Brand name prescription drug: the initial version
of a medication developed by a pharmaceutical manufacturer or a
version marketed under a pharmaceutical manufacturer's own
registered trade name or trademark. The original manufacturer is
granted an exclusive patent to manufacture and market a new drug for
a certain number of years. After the patent expires and FDA
requirements are met, any manufacturer can produce the drug and sell
the drug under its own brand name or under the drug's chemical
(generic) name. Anthem will designate brand name prescription drugs
as follows:
- As a formulary brand name prescription drug identified on the
formulary by Anthem as a prescription drug with a tier-2
copayment as listed on the Health Plan Description Form.
- As a non-formulary brand name prescription drug not identified
on the formulary by Anthem as a prescription drug with a Tier-3
copayment as listed on the Health Plan Description Form.
- Legend drug: a medicinal substance, dispensed for
outpatient use, which under the Federal Food, Drug & Cosmetic
Act is required to bear on its original packing label, “Caution:
Federal law prohibits dispensing without a prescription.”
Compounded medications that contain at least one such medicinal
substance are considered to be prescription legend drugs. Insulin is
considered a prescription legend drug under this certificate.
- Formulary: a list of pharmaceutical products
developed in consultation with physicians and pharmacists and
approved for their quality and cost effectiveness.
- Generic prescription drug: drugs determined by
the FDA to be bio-equivalent to brand name drugs and that are not
manufactured or marketed under a registered trade name or trademark.
A generic drug’s active ingredients duplicate those of a brand
name drug. Generic drugs must meet the same FDA specifications as
brand name drugs for safety, purity and potency and must be
dispensed in the same dosage form (tablet, capsule, and cream) as
the counterpart brand name drug. On average, generic drugs cost
about half as much as the counterpart brand name drug. Generic
prescription drugs are identified on the formulary by Anthem as
prescription drugs with a tier-1 copayment as listed on the Health
Plan Description Form.
Pharmacy: an establishment licensed to dispense
prescription drugs and other medications through a licensed pharmacist
upon a authorized health care professional’s order. A pharmacy may be
an in-network provider or an out-of-network provider. An in-network
pharmacy is contracted as an in-network pharmacy with Anthem to provide
covered drugs to members under the terms and conditions of this
certificate. An out-of-network pharmacy is not contracted with Anthem.
Preauthorization: the process applied to certain
drugs and/or therapeutic categories to define the conditions under which
these drugs will be covered. The drugs and criteria for coverage are
defined by the pharmacy and therapeutics committee.
Preventive care:
comprehensive care that emphasizes prevention, early detection and early
treatment of conditions through routine physical exams, immunizations
and health education.
Private duty nursing services: services that require
the training, judgment and technical skills of an actively practicing
registered nurse (R.N.) or licensed practical nurse (L.P.N.). Such
services must be prescribed by the attending physician for the
continuous medical treatment of the condition.
Prostate screening: testing to identify an increased
risk of prostate cancer in the absence of any abnormal symptoms.
Prosthesis: a device that replaces all or part of a
missing body part.
Provider: a person or facility recognized by Anthem
as a health care provider and that fits one or more of the following
descriptions:
- Professional provider: a physician or other
professional provider who is licensed or otherwise authorized by the
state or jurisdiction where services are provided to perform
designated health care services. For benefits to be payable,
services of a provider must be within the scope of the authority
granted by the license and covered by this certificate. Such
services are subject to review by a medical authority appointed by
Anthem. Other professional providers include, among others,
certified nurse midwives, dentists, optometrists and certified
registered nurse anesthetists. Services of such a provider must be
among those covered by this certificate and are subject to review by
a medical authority appointed by Anthem.
- Facility provider: there are two types of
facility providers, inpatient and outpatient.
- Inpatient facility provider: a hospital,
alcoholism treatment center, residential treatment center,
hospice facility, skilled nursing facility or other facility
which Anthem recognizes as a health care provider. These
facility providers may be referred to collectively as a facility
provider or separately as an alcoholism treatment center
provider.
- Outpatient facility provider: a dialysis
center, Veteran’s Administration or Department of Defense
hospital, home health agency or other facility provider (except
a hospital, alcoholism treatment center or hospice facility,
skilled nursing facility or residential treatment center)
recognized by Anthem and licensed or certified to perform
designated health care services by the state or jurisdiction
where services are provided. Services of such a provider must be
among those covered by this certificate and are subject to
review by a medical authority appointed by us. Example:
ambulatory surgery center.
Radiation therapy: X-ray, radon, cobalt, betatron,
telocobalt, radioactive isotope treatment and similar treatments for
malignant diseases and other medical conditions.
Reconstructive breast surgery: a surgical procedure
performed following a mastectomy on one or both breasts to re-establish
symmetry between the two breasts. The term includes, but is not limited
to, augmentation mammoplasty, reduction mammoplasty and mastoplasty.
Reconstructive surgery: surgery that restores or
improves bodily function to the level experienced before the event which
necessitated the surgery or, in the case of a congenital defect, to a
level considered normal. Such surgery may have a coincidental cosmetic
effect.
Referral: authorization given to a member to visit
another provider.
Resident: an individual who maintains legal domicile
within the state of Colorado and is presumed, for purposes of this
agreement, to be a primary resident of the state, as evidenced by any
three of the following:
- Payment of Colorado income tax
- Employment in Colorado, other than that normally provided on a
temporary basis to students
- Ownership of residential real estate property in Colorado
- State identification card or drivers license
- Acceptance of future employment in the state of Colorado
- Vehicle registered in Colorado
- Voter registration in Colorado
- Phone bill or utility bill from Colorado
Room expenses: expenses that include the cost of the
room, general nursing services and meal services for the member.
Second Opinion: a visit to another professional
provider (following a first visit with a different provider) for review
of the first provider’s opinion of proposed surgery or treatment.
Second surgical opinion: a mechanism used by managed
care organizations to reduce unnecessary surgery by encouraging
individuals to seek a second opinion prior to specific elective
surgeries. In some cases, the health coverage may require a second
opinion prior to a specific elective surgery.
Skilled nursing care facility: an institution that
provides skilled nursing care (e.g. therapies and protective
supervision) for uncontrolled, unstable or chronic condition members.
Skilled nursing care is provided under medical supervision to carry out
nonsurgical treatment of chronic diseases or convalescent stages of
acute diseases or injuries. Skilled nursing facilities do not provide
care for high intensity member medical needs, or members that are
medically unstable.
Special care units: special areas of a hospital with
highly skilled personnel and special equipment to provide acute care,
with constant treatment and observation.
Speech therapy (also called speech pathology):
services used for diagnosis and treatment of speech and language
disorders. A licensed and accredited speech/language pathologist must
perform speech therapy.
Spouse: a subscriber’s legal spouse.
Sub-acute medical care: medical care that requires
less care than a hospital but often more care than a skilled nursing
facility. Sub-acute medical care can be in the form of “transitional
care” when a member’s condition is improving, but the member is not
ready for a skilled nursing facility or home health care.
Sub-acute rehabilitation: care that includes a
minimum of one hour of therapy when a member cannot tolerate or does not
require three hours of therapy a day. Sub-acute rehabilitation is
generally provided in a skilled nursing facility.
Subscriber: the member in whose name the membership
with Anthem is established.
Surgery: any variety of technical procedures for
treatment or diagnosis of anatomical disease or injury, including, but
not limited to cutting, microsurgery (use of scopes), laser procedures,
grafting, suturing, castings, treatment of fractures and dislocations,
electrical, chemical or medical destruction of tissue, endoscopic
examinations, anesthetic epidural procedures, and other invasive
procedures. Covered surgical services also include usual and related
anesthesia and pre- and post-operative care, including recasting.
Surgical assistant: an assistant to the primary
surgeon for required surgical services provided during a covered
surgical procedure. Anthem, at its sole discretion, determines which
surgeries do or do not require a surgical assistant.
Ultrasound: a radiology imaging technique that uses
high frequency sound waves to see organs or the fetus in a pregnant
woman.
Urgent care: care provided for individuals who
require immediate medical attention but whose condition is not
life-threatening (non-emergency).
Utilization management: a process of integrating
review of medical services and care management in a cooperative effort
with other parties, including patients, physicians, and other health
care providers and payers.
Utilization review: a set of formal techniques
designed to monitor the use of, or evaluate the clinical necessity,
appropriateness, efficacy or efficiency of, health care services,
procedures or settings. Techniques include ambulatory review,
prospective review, second opinion, certification, concurrent review,
care management, discharge planning and/or retrospective review.
Utilization review also includes reviews to determine coverage. This is
based on whether or not a procedure or treatment is considered
experimental/investigational in a given circumstance (except if it is a
specific certificate exclusion), and review of a member’s medical
circumstances when necessary to determine if an exclusion applies in a
given situation.
Well-child visit: a
physician visit that includes the following components: an
age-appropriate physical exam, history, anticipatory guidance and
education (e.g., examining family functioning and dynamics, injury
prevention counseling, discussing dietary issues, reviewing
age-appropriate behaviors, etc.), and assessment of growth and
development. For older children, a well-child visit also includes safety
and health education counseling.
X-ray and radiology services: services including the
use of radiology, nuclear medicine and ultrasound equipment to obtain a
visual image of internal body organs and structures, and the
interpretation of these images.
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