What does it mean?
ACCIDENTAL INJURY means a bodily injury caused solely by external, traumatic, and unforeseen means. Accidental Injury does not include disease or infection, hernia, or cerebral vascular accident. Dental injury caused by chewing, biting, or malocclusion is not considered an Accidental Injury.
ACUPUNCTURE means the use of needles inserted into and removed from the body and the use of other devices, modalities and procedures at specific locations on the body for the prevention, cure or correction of any disease, illness, injury, pain or other condition by controlling and regulating the flow and balance of energy and functioning of the person to restore and maintain health.
ADMISSION means the period of time between the date a patient enters a hospital or other facility as an inpatient and the date he/she is discharged as an inpatient. The date of admission is the date of service for the hospitalization and all related services.
ALCOHOLISM means alcohol dependence or alcohol abuse meeting the criteria as stated in the Diagnostic and Statistical Manual IV for these disorders.
AMBULANCE SERVICE means a duly licensed transportation service, capable of providing Medically Necessary life support care in the event of a life-threatening situation.
AMBULATORY SURGICAL FACILITY means an appropriately licensed provider, with an organized staff of physicians that meets all of the following criteria:
- Has permanent facilities and equipment for the primary purpose of performing surgical procedures on an outpatient basis;
- Provides treatment by or under the supervision of physicians and nursing services whenever the patient is in the facility;
- Does not provide inpatient accommodations; and
- Is not a facility used primarily as an office or clinic for the private practice of a physician or other professional provider.
ANNUAL OUT-OF-POCKET MAXIMUM means a specified dollar amount of covered services received during a benefit period that is the Member's responsibility.
APPLICATION means the form that an employee is required to complete when enrolling for PHP coverage.
ATTENDING PHYSICIAN means the doctor who is responsible for the patient's hospital treatment or who is charged with the patient's overall care and who is responsible for directing the treatment program. A consulting physician is not the Attending Physician. A physician employed by the hospital is not ordinarily the Attending Physician.
BENEFIT CERTIFICATION means the process whereby PHP or PHP's delegated provider contractor reviews and approves, in advance, the provision of certain Covered Services to Members before those services are rendered. If a required Benefit Certification is not obtained for services rendered by an Out-of-Network provider, the Member may be responsible for the resulting charges. Benefit Certification is used in conjunction with the Referral in the management of health care needs; Benefit Certification does not replace, nor is it replaced by, a Referral. Services rendered beyond the scope of the Referral or the Benefit Certification may not be covered.
BIRTHING CENTER means an alternative birthing facility licensed under state law, with care primarily provided by a certified nurse midwife.
CALENDAR YEAR means the period beginning January 1 and ending December 31 of the following year.
CERTIFIED NURSE-MIDWIFE means a licensed registered nurse, certified by the American College of Nurse Midwives to administer maternity care within the scope of the license.
CHIROPRACTOR means a person who is a Doctor of Chiropractic licensed by the appropriate governmental agency to practice chiropractic medicine.
CO-DEPENDENCY means behaviors learned by family Members or significant others in order to survive in an environment of great emotional pain and stress when a family member is dependent upon the use of alcohol or drugs.
COINSURANCE means the amount, expressed as a percentage, of a covered health care expense that is partially paid by the Plan and partially the Member's responsibility to pay. The cost-sharing responsibility ends for most covered services in a particular calendar year when the out-of-pocket maximum has been reached.
CONGENITAL ANOMALY means any condition from birth significantly different from the common form, for example, a cleft palate or certain heart defects.
COPAYMENT means the amount, expressed as a fixed-dollar figure required to be paid by a Member in connection with health care services. Benefits payable by the Plan are reduced by the amount of the required copayment for the covered service.
COSMETIC SURGERY means surgery that is performed to reshape normal structures of the body in order to improve appearance and self-esteem.
COVERED SERVICES means services or supplies specified in this SPD, including any supplements, endorsements, addenda, or riders, for which benefits are provided, subject to the terms, conditions, limitations, and exclusions of this SPD.
CUSTODIAL CARE means care provided primarily for maintenance of the patient and designed essentially to assist in meeting the patient's daily activities. It is not provided for its therapeutic value in the treatment of an disease, illness, Accidental Injury or condition. Custodial care includes, but is not limited to, help in walking, bathing, dressing, eating, preparation of special diets, and supervision over self-administration of medication not requiring the constant attention of trained medical personnel.
DENTIST means a Doctor of Dental Surgery (DDS) or Doctor of Medical Dentistry (DMA) who is licensed to practice prevention, diagnosis, and treatment of diseases, accidental injuries, and malformation of the teeth, mouth, and jaws.
DEPENDENT means any member of a covered employee's family who meets the requirements of Section 3 of this SPD and is actually enrolled in the Plan.
DIAGNOSTIC SERVICES means procedures ordered by a physician or other professional provider to determine a definite condition or disease.
DURABLE MEDICAL EQUIPMENT means equipment prescribed by a physician that is Medically Necessary for the treatment of an illness or Accidental Injury, or to prevent the patient's further deterioration. This equipment is designed for repeated use, generally not useful in the absence of illness or Accidental Injury, and include items such as oxygen equipment, wheelchairs, hospital beds, crutches, and other medical equipment.
EXPERIMENTAL/INVESTIGATIONAL means any treatment, procedure, facility, equipment, drug, device, or supply not accepted as standard medical practice in the state services are provided. In addition, if a federal or other governmental agency approval is required for use of any items and such approval was not granted at the time services were administered, the service is Experimental. To be considered standard medical practice and not Experimental or Investigational, treatment must meet all five of the following criteria:
- A technology must have final approval from the appropriate regulatory government bodies;
- The scientific evidence as published in peer-reviewed literature must permit conclusions concerning the effect of the technology on health outcomes;
- The technology must improve the net health outcome;
- The technology must be as beneficial as any established alternatives; and
- The improvement must be attainable outside the investigational settings.
FAMILY COVERAGE means coverage for the employee, the employee's spouse, and/or the employee's Dependent children.
FREESTANDING DIALYSIS FACILITY means a provider primarily engaged in providing dialysis treatment, maintenance, or training to patients on an outpatient or home basis.
GRIEVANCE means an oral or written complaint submitted by or on behalf of a covered person regarding the:
- availability, delivery or quality of health care services;
- administrative practices of the health care insurer that affect the availability, delivery or quality of health care services;
- claims payment, handling or reimbursement for health care services; or
- matters pertaining to any aspect of the health benefits plan.
HEALTH CARE PROFESSIONAL means a physician or other health care practitioner, including a pharmacist, who is licensed, certified or otherwise authorized by the state to provide health care services consistent with state law.
HEALTH CARE SERVICES means services, supplies and procedures for the diagnosis, prevention, treatment, cure or relief of a health condition, illness, injury or disease, and includes, to the extent offered by the health benefits plan, physical and behavioral health, including community-based behavioral health.
HOME HEALTH AGENCY means an appropriately licensed provider that both:
- Brings skilled nursing and other services on an intermittent, visiting basis into the member's home in accordance with the licensing regulations for home health agencies in New Mexico or in the locality where the services are administered, and
- Is responsible for supervising the delivery of these services under a plan prescribed and approved in writing by the Attending Physician.
HOSPICE means a duly licensed program or facility providing care and support to terminally ill patients and their families.
HOSPITAL means a duly licensed provider that is a short-term, acute, general hospital that meets all of the following criteria:
- Is a duly licensed institution;
- For compensation from its patients, is primarily engaged in providing inpatient diagnostic and therapeutic services for the diagnosis, treatment, and care of injured and sick persons by or under the supervision of physicians;
- Has organized departments of medicine and major surgery;
- Provides 24-hour nursing service by or under the supervision of registered nurses;
- Is not, other than incidentally, a skilled nursing facility, nursing home, custodial care home, health resort, spa, or sanitarium; and
- Is not a place for rest, for the aged, for the treatment of mental illness, alcoholism, drug abuse, or pulmonary tuberculosis, and ordinarily does not provide hospice or rehabilitation care, and is not a residential treatment facility.
IDENTIFICATION CARD or ID CARD means the card issued to the covered employee enrolled under this Plan.
IMMUNOSUPPRESSIVE DRUGS means drugs used to inhibit the human immune system. Some of the reasons for using immunosuppressive drugs include but are not limited to:
- preventing transplant rejection;
- supplementing chemotherapy;
- treating certain diseases of the immune system (i.e. "auto-immune" diseases);
- reducing inflammation;
- relieving certain symptoms; and
- other times when it may be helpful to suppress the human immune response.
INDEPENDENT CLINICAL LABORATORY means a laboratory that performs clinical procedures under the supervision of a physician and that is not affiliated or associated with a hospital, physician, or other provider.
IN-NETWORK PROVIDER means physicians, hospitals, and other health care professionals, facilities, and suppliers that have contracted with PHP as In-Network Providers.
INPATIENT means a patient in residence in a hospital/treatment facility for at least one full night.
LICENSED ACUPUNCTURIST means an acupuncture practitioner who is licensed by the appropriate state authority. Certification alone does not meet the licensure requirement.
LICENSED PRACTICAL NURSE (LPN) means a nurse who has graduated from a formal practical nursing education program and is licensed by the appropriate state authority.
MAINTENANCE THERAPY means treatment that does not significantly enhance or increase the patient's function or productivity.
MATERNITY means any condition that is pregnancy related. Maternity care includes prenatal and postnatal care, and care for the complications of pregnancy, such as ectopic pregnancy, spontaneous abortion (miscarriage), elective abortion, or cesarean section.
MEDICAID means Title XIX of the Social Security Act and all amendments thereto.
MEDICAL CARE means professional services administered by a physician or another professional provider for the treatment of an illness or Accidental Injury.
MEDICAL EMERGENCY means an Accidental Injury or a condition that occurs suddenly and unexpectedly and is life threatening or could result in permanent damage if not treated immediately. To be eligible for possible emergency benefits, the Member must seek treatment within 48 hours of the Accidental Injury or onset of the condition.
MEDICAL NECESSITY OR MEDICALLY NECESSARY means health care services determined by a provider, in consultation with the health care insurer, to be appropriate or necessary, according to any applicable generally accepted principles of good medical practice and practice guidelines developed by the federal government, national or professional medical societies, boards and associations, and any applicable clinical protocols or practice guidelines developed by the health care insurer consistent with such federal, national, and professional practice guidelines, for the diagnosis or direct care and treatment of a physical or mental health condition, illness, injury, or disease.
MEDICARE means the program of health care for the aged, end-stage renal disease (ESRD) beneficiaries, and disabilities established by Title XVIII of the Social Security Act of 1965, as amended.
MEMBER means the eligible employee or dependent who is enrolled under this Plan.
NEGOTIATED FEE-FOR-SERVICE means the contracted amount that PHP agrees to pay to PCPs and In-Network Providers for hospital, professional services, and other charges, and for which PCPs and In-Network Providers agree to accept as payment for services rendered to Members.
OCCUPATIONAL THERAPIST means a person registered to practice occupational therapy. An occupational therapist treats neuromuscular and psychological dysfunction, caused by disease, trauma, congenital anomaly, or prior therapeutic process, through the use of specific tasks or goals directed activities designed to improve functional performance of the patient.
ORTHOPEDIC APPLIANCES means an individualized device constructed and fitted by a licensed orthopedic technician (prosthesist) to support a deficient bodily function or correct an existing deformity. Examples of orthopedic appliances are functional hand or leg brace, Milwaukee Brace, or fracture brace.
ORTHOTIC DEVICE means an external device intended to correct any defect of form or function of the human body.
OTHER PROVIDER means a person or facility other than a hospital that is licensed in the state where services are rendered, to administer covered services. Other providers include:
An institution or entity only listed as:
- Ambulance Provider
- Ambulatory Surgical Facility
- Birthing Center
- Durable Medical Equipment Supplier
- Freestanding Dialysis Facility
- Home Health Agency
- Hospice Agency
- Independent Clinical Laboratory
- Rehabilitation Hospital
- Urgent Care Facility
- A person or practitioner only listed as:
- Certified Nurse Midwife
- Certified Registered Nurse Anesthetist
- Licensed Acupuncturist
- Licensed Practical Nurse
- Occupational Therapist
- Physical Therapist
- Licensed Lay Midwife
- Registered Nurse
- Respiratory Therapist
- Speech Therapist
OUT-OF-NETWORK PROVIDER means a duly licensed health care provider, including medical facilities, that has no agreement with PHP for reimbursement of services to Members.
OUT-OF-POCKET MAXIMUM means a specified dollar amount of covered services received in a calendar year that is the Member's responsibility. For PCP-Coordinated Care, this amount includes only the copayments and coinsurance for PCP-Coordinated services.
OUTPATIENT means care received in a hospital department, ambulatory surgical facility, urgent care facility, or physician's office where the patient leaves the same day.
PHYSICAL THERAPIST means a licensed physical therapist. Where there is no licensure law, the physical therapist must be certified by the appropriate professional body. A physical therapist treats disease or Accidental Injury by physical and mechanical means.
PHYSICIAN means a duly licensed practitioner of the healing arts acting within the scope of his/her license.
PODIATRIST means a licensed Doctor of Podiatric Medicine (DPM). A podiatrist treats conditions of the feet.
PRESBYTERIAN HEALTH PLAN, INC. (PHP) means Presbyterian Health Plan, a corporation organized under the laws of the State of New Mexico.
PRESCRIPTION DRUGS means those drugs that, by federal law, require a physician's prescription for purchase.
PRIMARY CARE PHYSICIAN (PCP) means a duly licensed Doctor of Medicine or Osteopathy, formally selected by the Member to assume primary responsibility for his/her care.
PROSTHESIS, PROSTHETIC DEVICE means an externally attached or surgically implanted artificial substitute for an absent body part, for example, an artificial eye or limb.
PROVIDER means a duly licensed hospital, physician, or other provider performing within the scope of the appropriate licensure.
REASONABLE CHARGE OR REASONABLE AND CUSTOMARY (R&C) CHARGE means the amount determined to be payable by PHP for services rendered to members by Out-of-Network Providers, based upon the following criteria:
- Fees that a professional provider usually charges for a given service;
- Fees which fall within the range of usual charges for a given service filed by most professional providers in the same locality who have similar training and experience; and
- Fees which are usual and customary or which could not be considered excessive in particular case because of unusual circumstances.
REFERRAL means an order by a Member's PCP requesting and recommending that the Member receive services from another physician in accordance with the terms of this SPD.
REGISTERED NURSE (RN) means a nurse who has graduated from a formal program of nursing education diploma school, associated degree, or baccalaureate program and is licensed by appropriate state authority.
REHABILITATION HOSPITAL means an appropriately licensed facility that, for compensation from its patients, provides rehabilitation care services on an inpatient basis. Rehabilitation care services consist of the combined use of medical, social, educational, and vocational services to enable patients disabled by illness or Accidental Injury to achieve the highest possible functional ability. Services are provided by or under the supervision of an organized staff of physicians. Continuous nursing services are provided under the supervision of a registered nurse.
RESPIRATORY THERAPIST means a person qualified for employment in the field of respiratory therapy. A respiratory therapist assists patients with breathing problems.
SEMI-PRIVATE means a two or more bed hospital room, skilled nursing facility or other health care facility or program.
SKILLED NURSING CARE means services that can be provided only by someone with at least the qualifications of a licensed practical nurse or registered nurse.
SKILLED NURSING FACILITY means an institution which is licensed under state law to provide skilled nursing care services.
SPECIAL CARE UNIT means a designated unit that has concentrated all facilities, equipment, and supportive devices for the provision of an intensive level of care for critically ill patients.
SPECIALIST means a Doctor of Medicine (MD) or Doctor of Osteopathy (DO). A specialist is not a family practitioner, general practitioner, pediatrician, or internist.
SPEECH THERAPIST means a speech pathologist certified by the American Speech and Hearing Association. A speech therapist assists patients in overcoming speech disorders.
SUMMARY PLAN DESCRIPTION (SPD) means this booklet.
SURGERY means the performance of generally accepted operative and cutting procedures, including:
- Specialized instrumentations, endoscopic examinations, and other invasive procedures;
- Correction of fractures and dislocations; and
- Usual and related preoperative and postoperative care.
TEFRA means federal law regarding the working aged.
TERMINALLY ILL PATIENT means a Member with a life expectancy of six months or less as certified in writing by the Attending Physician.
TWO-PARTY COVERAGE means coverage for the employee and his/her spouse, or coverage for the employee and one or more dependent child(ren).
URGENT CARE means health care services provided by an Urgent Care Facility in emergencies or after a physician's office hours.
WELL CHILD CARE means routine pediatric care, and includes a history, physical examination, developmental assessment, anticipatory guidance, and appropriate immunizations and laboratory tests in accordance with prevailing medical standards as published by the American Academy of Pediatrics.
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