More Definitions Used by Georgia's Lumenos Health Insurance Company

Home Health Care Agency and/or Services

A hospital or a nonprofit or public agency which:

• Primarily provides skilled nursing services and other therapeutic services under the supervision of a physician or a registered graduate nurse
• Is run according to rules established by a group of medical professionals
• Maintains clinical records on all patients
• Does not primarily provide custodial care or care and treatment of the mentally il
• Is licensed and runs according to the laws

Hospice

Hospice is a health care program providing a coordinated set of services rendered at home, in outpatient settings, or in institutional settings for covered persons suffering from a condition that has a terminal prognosis.

To be covered, the hospice program must be licensed and the attending physician must certify that the terminally ill covered person has a life expectancy of six months or less. Charges incurred during periods of remission are not eligible under the provision of the Lumenos plan.

Hospital

A legally-constituted hospital that offers 24-hour resident service for patients. Hospitals have professional staff, nursing services and physical equipment that satisfy the legal requirements of the state, province, county, city or community in which they are established.

Inpatient Rehabilitation Facility

Coverage is provided for inpatient rehabilitation facilities. Most people who are admitted to an inpatient rehabilitation facility are recovering from injuries or illnesses that severely impair their physical functioning or understanding. These include strokes, spinal cord injuries, traumatic brain injuries, chronic pulmonary problems, neurological disorders and other debilitating conditions.

Administered by treatment teams, individual patient programs can include these services:

• Behavioral medicine
• Case management
• Dialysis
• Nutrition services
• Neuropsychology
• Occupational therapy (OT)
• On-site orthotic and prosthetic services
• Physical therapy (PT)
• Psychology
• Recreation therapy
• Rehabilitation engineering and technology
• Rehabilitation nursing
• Social work
• Speech and language therapy
• Vocational and community re-entry services

Medically Necessary

Medically necessary care is defined as:

• commonly recognized by the appropriate medical specialist, within standards of good practice
• appropriate, effective and consistent with the diagnosis or treatment of an illness or injury
• the appropriate supply or level of service that can be safely administered
• provided by a practitioner, hospital or covered provider
• a drug or supply approved by the U.S. Food & Drug Administration (FDA)

Medically necessary care is not:

• experimental or investigational in nature
• primarily for the convenience of the patient or covered provider
• provided primarily for the purpose of medical or other research
• care that does not require the technical skills of a medical, mental health or dental professional
• care that is more costly than care that could safely and adequately be furnished in an alternative setting
• scholastic, educational or developmental in nature, or intended for vocational training

Non-occupational

For non-occupational illness or accidents, any sickness or accident not related to work, you (or your covered dependents) are not entitled to Workers' Compensation benefits.

Qualified Medical Child Support Order (QMCSO)

A QMSCO is a court order, which requires the Company to provide health care coverage to the dependent child named in the order. It is not the equivalent of a divorce settlement requiring a named parent to provide health care insurance.

Reasonable and Customary (R&C) Charge

A Reasonable and Customary (R&C) charge is the charge for a particular service or procedure that is customarily charged by doctors in the community in which the service or procedure is performed. In determining the Reasonable and Customary charge, the Plan Administrator:

• reviews charges published by Ingenix (as updated semi-annually)
• takes into account the physician's or surgeon's degree of specialized knowledge and skill
• considers the nature and severity of the patient's condition, and that unusual circumstances or medical complications may require additional time, skill and experience in connection with a particular service or procedure

NOTE: The charge for the same service or procedure may vary from one community to another, and even within a community.

IMPORTANT! Reasonable and customary charges are determined by the Plan Administrator in accordance with generally accepted principles and applied by the Plan Administrator on a uniform and consistent basis where there is not a Reasonable and Customary rate published by Ingenix for such charges.

Semi-Private Room Rate

Means the room and board rate of any institution for Semi-Private rooms. "Semi-private rooms" are accommodations with two or more beds that are classified by the institution as Semi-Private. If the institution does not have Semi-Private rooms, then that institution's "Semi-Private room rate" will be deemed to be the most common daily room and board rate for Semi-Private rooms in similar institutions in the area. The term "area" means a city, county or any greater area necessary to obtain a representative cross-section of similar institutions.

Transplant Services

The medical, surgical, and hospital services, and immuno suppressive medications required to perform any of the following human-to-human organ or tissue transplants: kidney, cornea, bone marrow, lung, liver, or pancreas.

Urgent Care

Conditions that need immediate attention from a doctor or nurse, but are not critical or life threatening.