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I') ) 2.58 Urgent Care Claim means any Claim for medical care or treatment that could seriously jeopardize the Member's life or health or the Member's ability to regain maximum function or, in the opinion of a physician with knowledge of the Member's medical condition, would subject the Member to severe pain that cannot be adequately managed without the care or treatment requested. Generally, the detennination of whether a Claim is an Urgent Care Claim shall be made by an individual acting on behalf of AvMed applying the judgment of a prudent layperson who possesses an average knowledge of health and medicine. However, if a physician with knowledge of the Member's medical condition determines that the Claim is an Urgent Care Claim, it shall be deemed as such. 2.59 Urgent Carc/Immcdiate Care means medical screening, examination, and evaluation received in an Urgent Care Center or Immediate Care Center or rendered in your Primary Care Physician's office after- hours and the covered services for those conditions which, although not life-threatening, could result in serious injury or disability ifleft untreated. ,) 2.60 Utilization Management Program means those comprehensive initiatives that are designed to validate medical appropriateness and to coordinate covered services and supplies. These include, but are not limited to: ) Concurrent review of all patients hospitalized in acute care, psychiatric, rehabilitation, and skilled nursing facilities, including on-site review when appropriate; Case management and discharge planning for all inpatients and those requiring continued care in an alternative setting (such as home care or a skilled nursing facility) and for outpatients when deemed appropriate; and The Benefit Coordination Program which is designed to conduct prospective reviews for select medical services to ensure that services are covered and Medically Necessary. The Benefit Coordination Program may also advocate alternative cost-effective settings for the delivery of prescribed care and may identify other options for non-covered health care needs. 2.61 Ventilator Dependent Care Unit means care received in any facility which provides services to ventilator dependent patients other than acute Hospital care, including all types of facilities known as sub-acute care units, ventilator dependent units, alternative care units, sub-acute care centers, and all other like facilities whether maintained in a free standing facility or maintained in a Hospital or skilled nursing facility setting. 2.60.02 2.60.01 2.60.03 III. ELIGIBILITY 3.01 To be eligible to el110ll as a Subscriber, a person must be: 3.01.01 An employee of the Subscribing Group who works the required number of hours per week as set forth in the Master Application for this Contract; 3.01.02 Employed for the period of time required for eligibility as set forth in the Master Application; and 3.01.03 Entitled on his own behalf to participate in the mcdical and Hospital care benefits arranged by the Subscribing Group under this Contract. 3.02 To be eligible to enroll as a Dependent, a person must be, 3.02.01 The spouse of the Subscriber (a new sponse must be el110lled within 31 days after marriage in order to be covered); or 3.02.02 A child of the Subscriber, or a child of a covered Dependent of the Subscriber, provided that all of the following conditions apply: 8 A V-CllOICE-2009 MP-5320 (10/09)