Reso 2010-1529 - Laserfiche WebLink

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') ) II. DEFINITIONS As used in this Contract, each of the following terms shall have the meaning indicated: 2.01 Accidental Dental Injury means an injury to sound natural teeth caused by a sudden, unintentional, and unexpected event or force. This term does not include injuries to the mouth, structures within the oral cavity, or injuries to natural teeth caused by biting or chewing, surgery, or treatment for a disease or illness. 2.02 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, tennination, 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 arc otherwise provided because it is determined to be experimental and/or investigational or not Medically Necessary. 2.03 Applied Behavior Analysis 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 rclations betwecn 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. n 2.04 Attending Physician means the physician primarily responsible for the care of a Member with respect to any particular injury or illness. 2.05 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: \ / 2.05.01 2.05.02 2.05.03 Autistic disorder; Asperger's syndrome; Pervasive developmental disorder not otherwise specified. 2.03 AvMed Choice Network means the providers and facilities that have contracted with AvMed to provide covered services to our Subscribers and Dependents. The Members' Co-payment, Deductible and Co-insurance responsibilities are outlined in the Schedule of Benefits. Generally, Members will have coverage at the highest level of benefits when they use the AvMed Choice Network. 2.06 AvMcd, Inc. otherwise 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 pnrpose of arranging for prepaid health care services to its Members under the tenns and conditions set forth in this Contract. 2.07 Benefit Level means: 2.07.01 Fur AvMed Choice providers and PHCS providers, the Co-payment or percentage of the contracted rate shown in the Schedule of Benefits after the applicable Deductible is met; or For Non-participating Providers, the Maximum Allowable Payment for covered services shown in the Schedule of Benefits after the applicable Deductible. The Deductible may not apply to all covered services. See Schedule of Benefits. 2.07.02 2.07.03 2.08 Claim means a request for benefits under this Contract made by a Member in accordance with AvMed's procedures for filing benefit claims, including Pre-Service Claims and Post-Service Claims. 2 A V-CHOtCE-2009 MP-5320 (10/09)