Common use of PPACA Clause in Contracts

PPACA. Patient Protection and Affordable Care Act. PPO Network A Preferred Provider Organization (PPO) is a limited panel of Providers as designated by Alliant known. PPO Network Provider A Preferred Provider Organization (PPO) is a Provider that is included in a limited panel of Providers as designated by Alliant and for which the greatest benefit will be payable when one of these Providers is used. Premium The amount required to pay for coverage. Prescription Drug A drug which cannot be purchased except with a prescription from a Physician and which must be dispensed by a pharmacist. Primary Care Physician (PCP) A licensed family practice, general practice, pediatrics, non- specialized obstetricians and gynecologists, or internal medicine Physician who has entered into an agreement to coordinate the care of Members. Prior Authorization A process used by Alliant to determine if a procedure or treatment is a medically necessary, covered service eligible under the plan for payment consideration. Prior Authorization approval is subject to all plan limits and exclusions. Provider Any Physician, health care practitioner, pharmacy, supplier or facility, including, but not limited to, a Hospital, clinical laboratory, Ambulatory Surgery Center, Retail Health Clinic, Skilled Nursing Facility, Long Term Acute Care facility, or Home Health Care Agency holding all licenses required by law to provide health care services. Psychiatric Services within a General Hospital Facility A general hospital facility that provides Inpatient psychiatric services for the diagnosis and treatment of mental illness on a 24-hour basis, by or under the supervision of a Physician. Reasonable and/or Reasonableness Shall mean in Alliant’s discretion, services or supplies, which are necessary for the care and treatment of illness or injury not caused by the treating Provider. Determination that a service(s) is reasonable will be made by Alliant, taking into consideration unusual circumstances or complications requiring additional time, skill and experience in connection with a particular service or supply; industry standards and practices as they relate to similar scenarios; and the cause of injury or illness necessitating the service(s). This determination will consider, but will not be limited to, the findings and assessments of the following entities: (a) The National Medical Associations, Societies, and organizations; and (b) The Food and Drug Administration. To be Reasonable, service(s) and/or fee(s) must follow generally accepted billing practices for unbundling or multiple procedures. Services, supplies, care and/or treatment that results from errors in medical care that are clearly identifiable, preventable, and serious in their consequence for patients, are not Reasonable. Alliant retains discretionary authority to determine whether service(s) and/or fee(s) are Reasonable based upon information presented to Alliant. A finding of Provider negligence and/or malpractice is not required for service(s) and/or fee(s) to be considered not Reasonable. Charge(s) and/or services are not considered to be Reasonable, and as such are not eligible for payment, when they result from Provider error(s) and/or facility-acquired conditions deemed “reasonably preventable” through the use of evidence-based guidelines, taking into consideration but not limited to CMS guidelines. Alliant reserves for itself and parties acting on its behalf the right to review charges processed and/or paid by Alliant, to identify charge(s) and/or service(s) that are not Reasonable and therefore not eligible for payment by Alliant under the Contract.” Referral Specific instructions from a Member’s Physician, in conformance with our policies and procedures, that direct a Member to an In-Network Provider for Medically Necessary care. Respite Care Care furnished during a period of time when the Member’s family or usual caretaker cannot, or will not, attend to the Member’s needs. Retail Health Clinic A facility that provides limited basic medical care services to Members on a “walk-in” basis. These clinics may operate in major pharmacies or retail stores. Medical services are typically provided by Physicians Assistants and Nurse Practitioners. Semiprivate Room A Hospital room which contains two or more beds. Service Area Specific geographic areas (such as counties) where coverage is offered. Skilled Convalescent Care Care required, while recovering from an illness or Injury, which is received in a Skilled Nursing Facility. This care requires a level of care or services less than that in a Hospital, but more than could be given at the patient’s home or in a nursing home not certified as a Skilled Nursing Facility.

PPACA. Patient Protection and Affordable Care Act. PPO Network A Preferred Provider Organization (PPO) is a limited panel of Providers as designated by Alliant known. PPO Network Provider A Preferred Provider Organization (PPO) is a Provider that is included in a limited panel of Providers as designated by Alliant and for which the greatest benefit will be payable when one of these Providers is used. Premium The amount required to pay for coverage. Prescription Drug A drug which cannot be purchased except with a prescription from a Physician and which must be dispensed by a pharmacist. Primary Care Physician (PCP) A licensed family practice, general practice, pediatrics, non- non-specialized obstetricians and gynecologists, or internal medicine Physician who has entered into an agreement to coordinate the care of Members. Prior Authorization A process used by Alliant to determine if a procedure or treatment is a medically necessary, covered service eligible under the plan for payment consideration. Prior Authorization approval is subject to all plan limits and exclusions. Provider Any Physician, health care practitioner, pharmacy, supplier or facility, including, but not limited to, a Hospital, clinical laboratory, Ambulatory Surgery Center, Retail Health Clinic, Skilled Nursing Facility, Long Term Acute Care facility, or Home Health Care Agency holding all licenses required by law to provide health care services. Psychiatric Services within a General Hospital Facility A general hospital facility that provides Inpatient psychiatric services for the diagnosis and treatment of mental illness on a 24-hour basis, by or under the supervision of a Physician. Reasonable and/or Reasonableness Shall mean in Alliant’s discretion, services or supplies, which are necessary for the care and treatment of illness or injury not caused by the treating Provider. Determination that a service(s) is reasonable will be made by Alliant, taking into consideration unusual circumstances or complications requiring additional time, skill and experience in connection with a particular service or supply; industry standards and practices as they relate to similar scenarios; and the cause of injury or illness necessitating the service(s). This determination will consider, but will not be limited to, the findings and assessments of the following entities: (a) The National Medical Associations, Societies, and organizations; and (b) The Food and Drug Administration. To be Reasonable, service(s) and/or fee(s) must follow generally accepted billing practices for unbundling or multiple procedures. Services, supplies, care and/or treatment that results from errors in medical care that are clearly identifiable, preventable, and serious in their consequence for patients, are not Reasonable. Alliant retains discretionary authority to determine whether service(s) and/or fee(s) are Reasonable based upon information presented to Alliant. A finding of Provider negligence and/or malpractice is not required for service(s) and/or service(s)and/or fee(s) to be considered not Reasonable. Charge(s) and/or services are not considered to be Reasonable, and as such are not eligible for payment, when they result from Provider error(s) and/or facility-acquired conditions deemed “reasonably preventable” through the use of evidence-based guidelines, taking into consideration but not limited to CMS guidelines. Alliant reserves for itself and parties acting on its behalf the right to review charges processed and/or and/ or paid by Alliant, to identify charge(s) and/or and/ or service(s) that are not Reasonable and therefore not eligible for payment by Alliant under the Contract.” Referral Specific instructions from a Member’s Physician, in conformance with our Our policies and procedures, that direct a Member to an In-Network Provider for Medically Necessary care. Respite Care Care furnished during a period of time when the Member’s family or usual caretaker cannot, or will not, attend to the Member’s needs. Retail Health Clinic A facility that provides limited basic medical care services to Members on a “walk-in” basis. These clinics may operate in major pharmacies or retail stores. Medical services are typically provided by Physicians Assistants and Nurse Practitioners. Semiprivate Room A Hospital room which contains two or more beds. Service Area Specific geographic areas (such as counties) where coverage is offered. Skilled Convalescent Care Care required, while recovering from an illness or Injury, which is received in a Skilled Nursing Facility. This care requires a level of care or services less than that in a Hospital, but more than could be given at the patient’s home or in a nursing home not certified as a Skilled Nursing Facility.

PPACA. Patient Protection and Affordable Care Act. PPO Network A Preferred Provider Organization (PPO) is a limited panel of Providers as designated by Alliant known. PPO Network Provider A Preferred Provider Organization (PPO) is a Provider that is included in a limited panel of Providers as designated by Alliant and for which the greatest benefit will be payable when one of these Providers is used. Premium The amount required to pay for coverage. Prescription Drug A drug which cannot be purchased except with a prescription from a Physician and which must be dispensed by a pharmacist. Primary Care Physician (PCP) A licensed family practice, general practice, pediatrics, non- specialized obstetricians and gynecologists, or internal medicine Physician who has entered into an agreement to coordinate the care of Members. Prior Authorization A process used by Alliant to determine if a procedure or treatment is a medically necessary, covered service eligible under the plan for payment consideration. Prior Authorization approval is subject to all plan limits and exclusions. Provider Any Physician, health care practitioner, pharmacy, supplier or facility, including, but not limited to, a Hospital, clinical laboratory, Ambulatory Surgery Center, Retail Health Clinic, Skilled Nursing Facility, Long Term Acute Care facility, or Home Health Care Agency holding all licenses required by law to provide health care services. Psychiatric Services within a General Hospital Facility A general hospital facility that provides Inpatient psychiatric services for the diagnosis and treatment of mental illness on a 24-hour basis, by or under the supervision of a Physician. Reasonable and/or Reasonableness Shall mean in Alliant’s discretion, services or supplies, which are necessary for the care and treatment of illness or injury not caused by the treating Provider. Determination that a service(s) is reasonable will be made by Alliant, taking into consideration unusual circumstances or complications requiring additional time, skill and experience in connection with a particular service or supply; industry standards and practices as they relate to similar scenarios; and the cause of injury or illness necessitating the service(s). This determination will consider, but will not be limited to, the findings and assessments of the following entities: (a) The National Medical Associations, Societies, and organizations; and (b) The Food and Drug Administration. To be Reasonable, service(s) and/or fee(s) must follow generally accepted billing practices for unbundling or multiple procedures. Services, supplies, care and/or treatment that results from errors in medical care that are clearly identifiable, preventable, and serious in their consequence for patients, are not Reasonable. Alliant retains discretionary authority to determine whether service(s) and/or fee(s) are Reasonable based upon information presented to Alliant. A finding of Provider negligence and/or malpractice is not required for service(s) and/or fee(s) to be considered not Reasonable. Charge(s) and/or services are not considered to be Reasonable, and as such are not eligible for payment, when they result from Provider error(s) and/or facility-acquired conditions deemed “reasonably preventable” through the use of evidence-based guidelines, taking into consideration but not limited to CMS guidelines. Alliant reserves for itself and parties acting on its behalf the right to review charges processed and/or paid by Alliant, to identify charge(s) and/or service(s) that are not Reasonable and therefore not eligible for payment by Alliant under the Contract.” Referral Specific instructions from a Member’s Physician, in conformance with our policies and procedures, that direct a Member to an In-Network Provider for Medically Necessary care. Respite Care Care furnished during a period of time when the Member’s family or usual caretaker cannot, or will not, attend to the Member’s needs. Retail Health Clinic A facility that provides limited basic medical care services to Members on a “walk-in” basis. These clinics may operate in major pharmacies or retail stores. Medical services are typically provided by Physicians Assistants and Nurse Practitioners. Semiprivate Room A Hospital room which contains two or more beds. Service Area Specific geographic areas (such as counties) where coverage is offered. Skilled Convalescent Care Care required, while recovering from an illness or Injury, which is received in a Skilled Nursing Facility. This care requires a level of care or services less than that in a Hospital, but more than could be given at the patient’s home or in a nursing home not certified as a Skilled Nursing Facility.