Reso 2010-1529 - Laserfiche WebLink

Home Browse Search

n ) III. DEFINITIONS 10 As used in this Contract, each of the following terms shall have the meaning indicated: 3.01 Adverse Benefit Determination means a denial, reduction, or termination of, or a failure to provide or make payment (in whole or in part) for, a benefit, including any such denial, reduction, termination, or failure to provide or make payment that is based on a determination of a Member's eligibility to participate in the Plan, and including a denial, reduction, or termination of, or a failure to provide or make payment (in whole or in part) for, a benefit resulting from the application of any Utilization Management Program, as well as a failure to cover an item or service for which benefits are otherwise provided hecause it is deteffilined to be experimental and/or investigational or not Medically Necessary. 3.02 Applied Behavior Aoalysis means the design, implementation, and evaluation of environmental modifications, using behavioral stimuli and consequences, to produce socially significant improvement in human behavior, including, but not limited to, the use of direct observation, measurement, and functional analysis of the relations between environment and behavior. Applied behavior analysis services shall be provided by an individual certified pursuant to Section 393.17, Florida Statutes, or an individual licensed under Chapter 490 or Chapter 491, Florida Statutes. 3.03 Attending Physician means tbe Participating Physician primarily responsible for the care ofa Member with respect to any particular injury or illness. 3.04 Autism Spectrum Disorder means any of the following disorders as defined in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association: ) 3.04.01 3.04.02 3.04.03 Autistic disorder; Asperger's syndrome; Pervasive developmental disorder not othenvise specified. 3.05 AvMed, Inc. othenvise known as 'AvMed', means a private not for profit Florida corporation, state licensed as a health maintenance organization under Chapter 641, Florida Statutes, for the purpose of arranging for prepaid health care services to its Members under the terms and conditions set forth in this Contract. 3.06 Claim means a request for benefits under this Contract made by a Mernber in accordance with AvMed's procedures for filing benefit claims, including Pre-Service Claims and Post-Service Claims. 3.07 Claimant means a Member or a Mernbcr's authorized representative acting on behalf of the Member. AvMed may establish procedures for determining whether an individual is authorized to act on behalf of the Member. If the Claim is an Urgent Care or Pre-Service Claim, a Health Professional, with knowledge of the Member's medical condition, shall be permitted to act as the Member's authorized representative and will he notified of all approvals on the Claimant's behalf. In the event of an Adverse Benefit Determination, AvMed will notify both the Member and the Heath Professional. 3.08 Concurrent Care rneans an ongoing course of treatment to be provided over a period of time or number of treatments that was previously approved by AvMed. 3.09 Con tract means this Group Medical and Hospital Service Contract which may at times be referred to as 'Group Contract' or 'Subscribing Group Contract' and all applications, rate letters, face sheets, riders, amendments, addenda, exhibits, supplemental agreements, and schedules which are or may be incorporated in this Contract from time to time. 3.10 Contract Year rneans the period of consecutive months agreed to by the Subscribing Group and AvMed on the Master Application, commencing on the effective date of this Contract. 2 A V -0100-2009 MP-5319 (10/09)