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I If) I I I ) 3.33.02 Performed, prescribed, or directed by Participating Providers; and 3.33.03 Medically Necessary (except for preventive services as stated herein) for the diagnosis and treatment of injury or illness. 3.34 Member means any Subscriber or Dependent, as described in Part Ill, Sections 3.46 and 3.15, of this Contract. 3.35 Non-participating Provider means any Health Professional or group of Health Professionals or Hospital, Medical Office, or Other Health Care Facility with whom AvMed has neither made arrangements nor contracted to render the professional health services set forth herein as a Participating Provider. Other Health Care Faeility(ies) means any licensed facility, other than acute care Hospitals and those facilities providing services to ventilator dependent patients, which provides inpatient services such as skilled nursing care and rehabilitative services for which AvMed has contracted or established arrangements for providing these services to Members. 3.36 10 3.37 Participating Provider means any Health Professional (or group of Health Professionals), Hospital, Medical Office, or Other Health Care Facility with whom AvMed has made arrangements or contracted to render the professional health services set forth herein. 3.38 Participating Physician means any Participating Provider licensed under Chapter 458 (physician), 459 (osteopath), 460 (chiropractor) or 461 (podiatrist), Florida Statutes. 3.39 Post-Service Claim means any Claim for benefits under the Plan that is not a Pre-Service Claim. 3.40 Pre-Service Claim means any Claim for benefits under the Plan with which (in whole or in part), a Member must obtain authorization from AvMed in advance of such services being provided to or ) received by the Member. 3.41 Primary Care Physician means a Participating Physician engaged in family practice, pediatrics, intemal medicine, obstetrics/gynecology, or any specialty physician from time to time designated by AvMed as a 'Primary Care Physician' in AvMed's current list of physicians and Hospitals. 3.42 Private Duty Nursing means services provided by registered nurses, licensed practical nurses, or any other trained attendant whose services ordinarily are rendered to, and restricted to, a particular Member by arrangements between the Member and the private-duty nurse or attendant. Such persons are engaged or paid by an individual Member or by someone acting on their behalf, including a hospital that initially incurs the costs and looks to the Mernber fOr reimbursement for such services. 3.43 Relevant Document means any documentation that: 3.43.01 Was relied upon in making a benefit determination; 3.43.02 Was submitted, considered or generated in the course of making a benefit determination, without regard to whether it was relied upon in making the determination; 3.43.03 Demonstrates compliance with the Plan's administrative process; and 3.43.04 Constitutes a statement of policy or guidance with respect to the Plan conceming the Adverse Benefit Determination for the Claimant's diagnosis, without regard to whether such advice or statement was relied upon in making the Adverse Benefit Determination. 3.44 Self-Administered Injectable Medication means a medication that has been approved by the FDA for self-injection and is administered by subcutaneous injection or a medication for which there are instructions to the patient for self-injection in the rnanufacturer's prescribing information (package insert). 6 A V -0100-2009 MP-5319 (10/09)