Reso 2010-1529 - Laserfiche WebLink

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) 2.09 Claimant means a Member or a Member'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 be 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. 2.10 Co-insurance means the amount a covered Member must pay, once the Deductible has been met if applicable, and is expressed as a percentage of the contracted rate for the covered benefit. 2.11 Concurrent Care means an ongoing course of treatment to be provided over a period of time or number of treatments that was previously approved by AvMed. ) Contract means this Group Medical and Hospital Service Contract with Point of Service Rider which may at times be referred to as 'Group Contract' or 'Point of Service Plan' 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. 2.13 Contract Year means the period of consecutive months agreed to by the Subscribing Group and AvMed on the Master Application, cOITunencing on the effective date of this Contract. 2.12 .j 2.14 Conversion Contract means an individual Member or Subscriber contract which shall be available to continue coverage (as provided for therein) of the Subscriber or the Dependent of the Subscriber upon termination of the Subscribing Group Contract as provided in Part VII of this Contract, and shall at times be referred to as the 'Individual Conversion Contract.' 2.15 Co-payment means the portion of the amount requested, in addition to the amount of the prepaid premiums, which the SubscriberlMember is required to pay at the time certain health services are provided nnder this Contract. The Co-payment may be a specific dollar amount or a percentage of the cost. The Member is responsible for the payment of any Co-payment amounts directly to the provider of the health services at the time of service. ) 2.16 Custodial Care means services and supplies that are furnished mainly to train or assist in the activities of daily living, such as bathing, feeding, dressing, walking, and taking oral medications. 'Custodial Care' also means services and supplies that can be safely and adequately provided by persons other than licensed health professionals, such as dressing changes and catheter care, or that ambulatory patients customarily provide for themselves, such as ostomy care, administering insulin, and measuring and recording urine and blood sugar levels. 2. I 7 Dental Care means dental x-rays, examinations and treatment of'the teeth or any services, supplies or charges directly related to: The care, filling, removal or replacement of teeth; or The treatment of injuries to or disease of the teeth, gums or structures directly supporting or attached to the teeth, that are customarily provided by dentists (including orthodontics reconstructive jaw surgery, casts, splints, and services for dental malocclusion). 2.18 Dependent means any member ofa Subscriber's family who meets all applicable requirements of Part III and is enrolled hereunder and for whom the prepayment required by Part VI has actually been received by Av Med 2.17.01 2.17.02 3 A V-CHOICE-2009 MP-5320 (10/09)