Network Personal. Physician A provider who is employed by Xxxxxx Permanente or contracted with KFHPWA to provide primary care services to Members and is selected by each Member to provide or arrange for the provision of all non-emergent Covered Services, except for services set forth in the Agreement which a Member can access without Preauthorization. Network Personal Physicians must be capable of and licensed to provide the majority of primary health care services required by each Member. Network Provider The medical staff, clinic associate staff and allied health professionals employed by Xxxxxx Permanente, and any other health care professional or provider with whom KFHPWA has contracted to provide health care services to Members, including, but not limited to physicians, podiatrists, nurses, physician assistants, social workers, optometrists, psychologists, physical therapists and other professionals engaged in the delivery of healthcare services who are licensed or certified to practice in accordance with Title 18 Revised Code of Washington. Out-of-pocket Expenses Those Cost Shares paid by the Contract Holder or Member for Covered Services which are applied to the Out-of-pocket Limit. Out-of-pocket Limit The maximum amount of Out-of-pocket Expenses incurred and paid during the calendar year for Covered Services received by the Contract Holder and his/her Dependents within the same calendar year. The Out-of-pocket Expenses which apply toward the Out- of-pocket Limit are set forth in Section IV. Plan Coinsurance The percentage amount the Member is required to pay for Covered Services received. Preauthorization An approval by KFHPWA that entitles a Member to receive Covered Services from a specified health care provider. Services shall not exceed the limits of the Preauthorization and are subject to all terms and conditions of the Agreement. Members who have a complex or serious medical or psychiatric condition may receive a standing Preauthorization for specialty care provider services. Residential Treatment A term used to define facility-based treatment, which includes 24 hours per day, 7 days per week rehabilitation. Residential Treatment services are provided in a facility specifically licensed in the state where it practices as a residential treatment center. Residential treatment centers provide active treatment of patients in a controlled environment requiring at least weekly physician visits and offering treatment by a multi- disciplinary team of licensed professi...
