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A Final Page of Georgia Health Insurance-Related Definitions

Semiprivate Room
A Hospital room which contains two or more beds.

Service Area
Includes counties listed in the appropriate Service Area Map. (Please refer to your Provider Directory.)

Skilled Convalescent Care
Care required, while recovering from an illness or Injury, which is received in a Skilled Nursing Facility. This care requires a level or care or services less than that in a Hospital, but more than could be given at the patient's home or in a nursing home not certified as a Skilled Nursing Facility.

Skilled Nursing Facility
An institution operated alone or with a Hospital which gives care after a Participant leaves the Hospital for a condition requiring more care than can be rendered at home. It must be licensed by the appropriate state agency and accredited by the Joint Commission on Accreditation of Health Care Organizations or the Bureau of Hospitals of the American Osteopathic Association, or otherwise determined by the Claims Administrator to meet the reasonable standards applied by any of the aforesaid authorities.

Spinal Manipulation
Correction of subluxations in the body to remove nerve interference or its effects. Interference must be the result of or related to distortion, misalignment or subluxation of or in the vertebral column.

Spouse
For the purpose of this Plan, a Spouse is defined as a person who is married to a person of the opposite sex from that of the enrolling Employee.

Substance Abuse
Any use of alcohol and/or drugs which produces a pattern of pathological use causing impairment in social or occupational functioning or which produces physiological dependency evidenced by physical tolerance or withdrawal.

Substance Abuse Rehabilitation
Services, procedures and interventions to eliminate dependence on or abuse of legal and/or illegal chemical substances, according to individual treatment plans.

Technology Assessment Criteria
Five criteria all procedures must meet in order to be Covered Services under this Plan.

1. The technology must have final approval from the appropriate government regulatory bodies.
2. The scientific evidence must permit conclusions concerning the effect of the technology on health outcomes.
3. The technology must improve the net health outcome.
4. The technology must be as beneficial as any established alternative.
5. The technology must be beneficial in practice.

Urgent Care Center
A facility, appropriately licensed and meeting BCBSHP standards for an Urgent Care Center, with a staff of Physicians, at which urgently-needed medical procedures are performed on an outpatient basis--no patients stay overnight. The facility offers continuous service by both Physicians and registered nurses (R.N.s). A Physician's office does not qualify as an Urgent Care Center.

Usual-Customary-Reasonable (UCR) Fees (as determined by the Claims Administrator and approved by the Plan):
Usual Fee: The fee a Physician most frequently receives as reimbursement for the procedure performed.
Customary Fee: Based on a competitive profile of the usual fees received as reimbursement by similar Physicians in a given geographic area for the procedure performed, according to BCBSHP's records.

Reasonable Fee: The fee different from usual or customary fees because of unusual circumstances involving complications requiring additional time, skill and experience.

If it does not pay at contracted rates, the Claims Administrator may pay up to the usual fee not to exceed the customary fee, unless special circumstances or complications occur, in which case the Plan may consider the reasonable fee.

All payments are based on the UCR applicable to the Participant's actual residence (i.e., local UCR).

Utilization Review
A function performed by the Plan Administrator or by an organization or entity selected by the Plan Administrator to review and approve whether the services provided are Medically Necessary, including, but not limited to, whether acute hospitalization, length of stay, outpatient care or diagnostic services are appropriate.

You and your
Refer to the Employee, Participant and each Covered Dependent.