Common use of SECTION DE - DEFINITIONS Clause in Contracts

SECTION DE - DEFINITIONS. For the purposes of this Agreement, the terms below have the following meaning: ADVERSE BENEFIT DETERMINATION – any of the following: 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, termination, or failure to provide or make payment that is based on a determination of a Member’s eligibility to participate in a 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 review, as well as a failure to cover an item or service for which benefits are otherwise provided because it is determined to be Investigational or not Medically Necessary. AGREEMENT RENEWAL DATE – January 1st of each calendar year. AGREEMENT YEAR – the twelve (12) month period beginning on January 1st of each calendar year. ALLOWABLE AMOUNT – the payment level that Keystone reimburses for benefits provided to a Member under the Member’s coverage. For Participating Providers, the allowable amount is the amount provided for in the contract between the Provider and Keystone, unless otherwise specified in this Agreement. AMBULATORY SURGICAL FACILITY – A facility provider licensed and approved by the state in which it provides covered health care services or as otherwise approved by Keystone Health Plan Central and which:  has permanent facilities and equipment for the primary purpose of performing surgical procedures on an outpatient basis;  provides treatment by or under the supervision of physicians whenever the patient is in the facility;  does not provide inpatient accommodations; and  is not, other than incidentally, a facility used as an office or clinic for the private practice of a physician. ANESTHESIA – consists of the administration of regional anesthetic or the administration of a drug or other anesthetic agent by injection or inhalation, the purpose and effect of which is to obtain muscular relaxation, loss of sensation or loss of consciousness. ANNUAL ENROLLMENT PERIOD – Annual enrollment means the period each calendar year when an individual may enroll or change coverage in a QHP. APPLICATION – the written request of the Applicant for coverage, set forth in a format approved by the Marketplace. APPLICATION/CHANGE FORM – the properly completed written request for enrollment for HMO Membership submitted in a format provided by the Marketplace, together with any amendments or modifications thereof. APPROVED CLINICAL TRIAL – X xxxxx X, xxxxx XX, xxxxx XXX or phase IV clinical trial that is conducted in relation to prevention, detection, or treatment of cancer or other life threatening disease or condition and is described below:

SECTION DE - DEFINITIONS. For the purposes of this Agreement, the terms below have the following meaning: ADVERSE BENEFIT DETERMINATION – any of the following: 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, termination, or failure to provide or make payment that is based on a determination of a Member’s eligibility to participate in a 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 review, as well as a failure to cover an item or service for which benefits are otherwise provided because it is determined to be Investigational or not Medically Necessary. AGREEMENT RENEWAL DATE – January 1st of each calendar year. AGREEMENT YEAR – the twelve (12) month period beginning on January 1st of each calendar year. ALLOWABLE AMOUNT – the payment level that Keystone reimburses for benefits provided to a Member under the Member’s coverage. For Participating Providers, the allowable amount is the amount provided for in the contract between the Provider and Keystone, unless otherwise specified in this Agreement. AMBULATORY SURGICAL FACILITY – A facility provider licensed and approved by the state in which it provides covered health care services or as otherwise approved by Keystone Health Plan Central and which:  has permanent facilities and equipment for the primary purpose of performing surgical procedures on an outpatient basis;  provides treatment by or under the supervision of physicians whenever the patient is in the facility;  does not provide inpatient accommodations; and  is not, other than incidentally, a facility used as an office or clinic for the private practice of a physician. ANESTHESIA – consists of the administration of regional anesthetic or the administration of a drug or other anesthetic agent by injection or inhalation, the purpose and effect of which is to obtain muscular relaxation, loss of sensation or loss of consciousness. ANNUAL ENROLLMENT PERIOD – Annual enrollment means the period each calendar year when an individual may enroll or change coverage in a QHP. APPLICATION – the written request of the Applicant for coverage, set forth in a format approved by the MarketplaceHMO. APPLICATION/CHANGE FORM – the properly completed written request for enrollment for HMO Membership submitted in a format provided by the Marketplace, together with any amendments or modifications thereof. APPROVED CLINICAL TRIAL – X xxxxx XA phase I, xxxxx XXphase II, xxxxx XXX phase III or phase IV clinical trial that is conducted in relation to prevention, detection, or treatment of cancer or other life threatening disease or condition and is described below: