GLOSSARY OF TERMS

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Hospital is an institution that:

1. is primarily engaged in providing, by or under the supervision of physicians, inpatient diagnostic, surgical and therapeutic services for the diagnosis, treatment and rehabilitation of injured, disabled or sick persons;
2. Maintains clinical records on all patients;
3. has bylaws in effect with respect to its staff of physicians;
4. has a requirement that every patient be under the care of a physician;provides 24‑hour nursing service rendered or supervised by a registered nurse;
5. has in effect a hospital utilization review plan;
6. is licensed pursuant to any state or agency of the state responsible for licensing hospitals; and
7. has accreditation under one of the programs of the Joint Commission on Accreditation of Hospitals and Healthcare Organizations.

The term hospital does not include any institution, or part thereof, that is used principally as a rest facility, nursing facility, convalescent facility or facility for care of the aged. Nor does it include any facility when used for the treatment of alcohol or chemical dependency, except as may be authorized by the program administrator, ValueOptions.

Illness means a sickness, disorder or disease and includes pregnancy.

Injury means accidental bodily injury which is sustained directly and which is independent of all other causes.

Medical provider is a licensed or board certified practitioner of the healing arts, including but not limited to, a physician, nurse, physiotherapist, speech therapist, chiropractor, acupuncturist, mid-wife, podiatrist or optometrist, acting within the scope of such license or certification and performing services that are medically necessary.

Medically necessary describes any service, supply, treatment or hospital confinement, or part of a hospital confinement which is:

1. effective and essential to the treatment of the injury or illness for which it is prescribed or performed;
2. based on valid medical need according to accepted standards of medical practice and meets generally accepted standards of medical practice;
3. an appropriate level of care provided in the most appropriate setting, based on the diagnosis and condition, and that could not have been omitted without an adverse effect on the person’s condition or quality of medical care;
4. not primarily for the comfort, convenience or administrative ease of the licensed doctor or other health care provider, or for you and/or your covered dependents; and
5. ordered by a physician (except where the treatment is rendered by a medical provider and is generally recognized as not requiring a physician's order).

Mental health disorders are those conditions categorized as mental disorders in the most recent edition of the International Classification of Diseases, whether or not involving a biological, chemical or other type of disorder which might not otherwise be considered mental or nervous. Conditions for which the primary diagnosis and treatment is for alcohol or chemical dependency are not included in mental health disorders but are covered separately.

Network Hospital is a Hospital participating in a preferred provider network, in which the Covered Individual is enrolled by reason of his or her status under the Plan.

Network Provider is a medical provider, laboratory or radiology facility participating in a preferred provider network, in which the Covered Individual is enrolled by reason of his or her status under the Plan.

Non-Network Hospital is a Hospital that does not participate in a preferred provider network in which the Covered Individual is enrolled by reason of his or her status under the Plan.

Non-Network Provider is a medical provider, laboratory or radiology facility not participating in a preferred provider network, in which the Covered Individual is enrolled by reason of his or her status under the Plan.

Non-Participating Dentist is a dentist that is not within the DentaIGuard Preferred provider network offered by The Guardian Life Insurance Company.

Non-Participating Pharmacy is a pharmacy that is not participating in a preferred provider network of pharmacies maintained by Medco Health Solutions.