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More Relevant Definitions Discussing Georgia Health Insurance

Identification Card
The latest card given to you showing your Identification number and Group number, the type of coverage you have and the date the coverage became effective.

Ineligible Charges
Charges for health care services that are not Eligible Charges because the services are not Medically Necessary or pre-admission certification was not obtained. Such charges are not eligible for payment.

Ineligible Hospital
A facility which does not meet the minimum requirements to become a Participating Hospital. Services rendered to a Participant by such a Hospital are not eligible for payment.

Ineligible Provider
A provider which does not meet the minimum requirements to become a Participating Provider or with whom BCBSHP does not directly contract. Services rendered to a Participant by such a provider are not eligible for payment.

Infertile or Infertility
The condition of a presumably healthy Participant who is unable to conceive or produce conception after a period of one year of frequent, unprotected heterosexual vaginal intercourse. This does not include conditions for men when the cause is a vasectomy or orchiectomy or for women when the cause is tubal ligation or hysterectomy.

Initial Enrollee
A person actively employed by the Group (or one of that person's eligible Dependents) on the original Effective Date of the Health Plan Document between BCBSHP and the Employer or currently enrolled through the Employer under a BCBSHP Plan.

Injury
Bodily harm from a non-occupational accident.

In-Network Care
Covered Services provided to Participants and appropriately coordinated by the Primary Care Physician through Network Hospital and Network Providers or selected by the Participant from Network Providers for which a Primary Care Physician referral is not required. Such providers include a gynecologist for obstetrical or gynecological - related conditions, a dermatologist, an optometrist/ophthalmologist for medical conditions only.

Inpatient
A Participant who is treated as a registered bed patient in a Hospital and for whom a room and board charge is made.

Intensive Care Unit
A special unit of a Hospital that: 1. treats patients with serious illnesses or Injuries; 2. can provide special life-saving methods and equipment; 3. admits patients without regard to prognosis; and 4. provides constant observation of patients by a specially trained nursing staff.

Late Enrollees
Late Enrollees mean Employees or Dependents who request enrollment in a health benefit plan after the initial open enrollment period. An individual will not be considered a Late Enrollee if: (a) the person enrolls during his/hers initial enrollment period under the Plan: (b) the person enrolls during a special enrollment period; or (c) a court orders that coverage be provided for a minor covered Dependent under a Participant's Plan, but only as long as the Participant requests enrollment for such Dependent within thirty-one (31) days after the court order is so issued. Late Enrollees are those who declined coverage during the initial open enrollment period and did not submit a certification to the Claims Administrator that coverage was declined because other coverage existed.

Maternity Care
Obstetrical care received both before and after the delivery of a child or children. It also includes care for miscarriage or abortion. It includes regular nursery care for a newborn infant as long as the mother's Hospital stay is a covered benefit and the newborn infant is an eligible Participant under the Plan.

MCSO-Medical Child Support Order
An MCSO is any court judgment, decree or order (including a court's approval of a domestic relations settlement agreement) that:

• provides for child support payment related to health benefits with respect to the child of a group health plan participant or requires health benefit coverage of such child in such plan, and is ordered under state domestic relations law; or
• enforces a state law relating to medical child support payment with respect to a group health plan.

Medical Emergency
"Emergency services," "emergency care," or "Medical Emergency" means those health care services that are provided for a condition of recent onset and sufficient severity, including but not limited to, severe pain, that would lead to prudent layperson, possessing an average knowledge of medicine and health, to believe that his or her condition, sickness, or Injury is of such a nature that failure to obtain immediate medical care could result in: (a) placing the patient's health in serious jeopardy; (b) serious impairment to bodily functions; or (c) serious dysfunctions of any bodily organ or part. Such conditions include but are NOT limited to, chest pain, stroke, poisoning, serious breathing difficulty, unconsciousness, severe burns or cuts, uncontrolled bleeding, or convulsions and such other acute conditions as may be determined to be Medical Emergencies by the Plan.

Medical Facility
Any Hospital, ambulatory care facility, chemical dependency facility, skilled nursing care facility, home health agency or mental health facility, as defined in this SPD Booklets. The facility must be licensed, registered or approved by the Joint Commission on Accreditation of Hospitals or meet specific requirements established by the Claims Administrator.

Medical Necessity or Medically Necessary
The Plan Administrator reserve the right to determine whether a service or supply is Medically Necessary. The fact that a Physician has prescribed, ordered, recommended or approved a service or supply does not, in itself, make it Medically Necessary.

The Plan Administrator consider a service Medically Necessary if it is:

• appropriate and consistent with the diagnosis and the omission of which could adversely affect or fail to improve the patient's condition;
• compatible with the standards of acceptable medical practice in the United States;
• not provided solely for your convenience or the convenience of the doctor, health care provider or Hospital;
• not primarily Custodial Care; and
• provided in a safe and appropriate setting given the nature of the diagnosis and the severity of the symptoms.

For example, a Hospital stay is necessary when treatment cannot be safely provided on an outpatient basis.

Mental Health Disorders
Includes (whether organic or non-organic, whether of biological, non-biological, genetic, chemical or non-chemical origin, and irrespective of cause, basis or inducement) mental disorders, mental illnesses, psychiatric illnesses, mental conditions, psychiatric conditions and drug, alcohol or chemical dependency. This includes, but is not limited to, psychoses, neurotic disorders, schizophrenic disorders, affective disorders, chemical dependency disorders, personality disorders, and psychological or behavioral abnormalities associated with transient or permanent dysfunction of the brain or related neurohormonal systems. This is intended to include disorders, conditions, and illnesses listed in the Diagnostic and Statistical Manual of Mental Disorders.

Mental Health Care Provider
An institution such as a Hospital or ambulatory care facility established for the diagnosis and treatment of mental illness. The facility must have diagnostic and therapeutic facilities for care and treatment provided by or under the supervision of a licensed Physician. The facility must be operated in accordance with the laws of the State of Georgia, or accredited by the Joint Commission on Accreditation of Hospitals.