05/11/2021 - Laserfiche WebLink

Home Browse Search

billed as part of an "Episode of Care" commonly include, but are not necessarily limited to: (a) equipment used by a hospital or facility; (b) in-hospital or in -facility medications or biologics and supplies; (c) implants; (d) laboratory testing and services; (e) in-hospital meals; (f) hospital confinement days; (g) pre and post in-hospital or in -facility nursing care; (h) pre and post in=hospital physical therapy; (i) follow-up consultations; and (j} any other Medically Necessary Service related to the Diagnosis Case Code. An "Episode of Care" shall not include: (w) any diagnostic testing provided in advance of a medical procedure to determine whether or not such procedure is a. Medically Necessary Service; (x):any Convenience Items; (y) :any medical procedure or medical care that is not a Medically Necessary. Service and (z) any Serious Reportable Events ("SREs"), as defined by the National Quality Forum. 1.6 "HIPAA" means the Health Insurance Portability and Accountability Act of. 1996, including the Administrative Simplification provisions of HIPAA Title II, Subtitle F, the implementing regulations at 45 C.F.R. Parts 160-164, and the Health Information Technology. for Economic and Clinical Health Act, enacted as part of the American Recovery_ and Reinvestment Act of 2009 ("HITECH"), all as amended from time to time. 1.7 "Medically Necessary Service" means a medical service or supply which is determined by a licensed medical professional to be appropriate and necessary for the symptoms, diagnosis or treatment of the medical condition of a Participant and within standards of medical practice within the community for that level of care. 1.8 "Network" means EDH's contracted network .of physicians, hospitals, and other healthcare providers and facilities which provide non -emergent, planned surgical and medical procedures according to rates and terms negotiated by EDH. The "Network" comprises a part of EDH's branded offering commonly referred to as the SurgeryPlus'" benefit offering. 1.9 "Network Services" means the services offered by EDH to Participants electing to utilize the Network for an Episode of Care. "Network Services" include EDH's assistance with the administrative, settlement, case management, and/or travel and logistics aspects of an Episode of Care and EDH's facilitation of interaction among Sponsor, Providers, Participants, the Plan, and/or the Plan Administrator. The "Network Services" comprise a part of EDH's branded offering commonly referred to as the SurgeryPlusT" benefit offering. 1.10 "Participant" means any person who has enrolled for coverage in the Plan and is eligible to utilize the Network. "Participants" may include persons eligible for coverage as employees, dependents, retirees, through COBRA, or otherwise as persons in good standing under the terms of the Plana 1.11 "Plan" means the self-funded health benefit plan offered by Sponsor. 1.12 "Plan Administrator" means a third -party administrator engaged by Plan Sponsor to administer benefits offered pursuant to the Plan. 1.13 "Provider" means a licensed or otherwise legally authorized provider of medical, surgical, hospital, professional, and/or other health-related services that offers such services through the Network. A "Provider" may be a physician, physician group, nurse or nurse practitioner, diagnostic or therapeutic ancillary services provider, facility, lab, or provider of durable medical or other necessary equipment. 1.14 "Travel Services means the services coordinated by EDH pursuant to this Agreement relating to a Participant's and Accompanying Person's transportation and lodging during an Episode of Care. 1.15 "Treating Physician" means a Participant's local treating physician, primary care physician, and/or any other physician or medical care provider supplying medical records for review by a Provider ARTICLE 2. EDH'S ROLE AND RESPONSIBILITIES 2.1 Network Services. EDH will assist and support Sponsor in communicating the availability of the Network and Network Services to Participants. EDH will offer the Network to all Participants, and EDH will provide the applicable Network Services for any Participant seeking to utilize the Network for an Episode of Care. -2- 53