(For NAP and CAP Medical Plans)

The meanings of key terms used in the NAP and CAP Medical Plan descriptions are included in this Definitions section. In the Health Care Participation section and in the sections covering the NAPNAP and CAP plans, the first time a defined term appears in a major subsection the term is displayed in Large and Small Caps, to highlight that it is a defined term.

Physical harm or disability which is the result of a specific, unexpected incident caused by an outside force. The physical harm or disability must have occurred at an identifiable time and place. Accidental injury does not include illness or infection, except infection of a cut or wound.

A freestanding outpatient surgical facility. It must be licensed as an outpatient clinic according to state and local laws and must meet all requirements of an outpatient clinic providing surgical services. It must also meet accreditation standards of the Joint Commission on Accreditation of Health Care Organizations or the Accreditation Association of Ambulatory Health Care.

An authorized referral occurs when you, because of your medical needs, are referred to a non-network provider, but only when:

The date coverage begins under the Medical Plan.

Eligible expenses are: (1) expenses for Covered Health Services that are covered by the Plan; (2) those that Anthem Blue Cross considers "Medically Necessary" for the diagnosis or treatment of an illness or injury; and (3) those that do not exceed the "Customary and Reasonable" rate as determined by Anthem Blue Cross or, in the case of services rendered by network providers, the negotiated rate. Any costs not meeting this definition are the responsibility of the member. For additional information or questions, call Anthem Blue Cross Member Services.

Procedures that are mainly limited to laboratory and/or animal research.

Home health care providers that are licensed according to state and local laws to provide skilled nursing and other services on a visiting basis in your home, and recognized as home health providers under Medicare and/or accredited by a recognized accrediting agency such as the Joint Commission on the Accreditation of Health Care Organizations.

An agency or organization primarily engaged in providing palliative care (pain control and symptom relief) to the terminally ill and providing supportive care to those persons and their families to help them cope with the patient's terminal illness. This care may be provided in the home or on an inpatient basis. A hospice must be: (1) certified by Medicare as a hospice; (2) recognized by Medicare as a hospice demonstration site; or (3) accredited as a hospice by the Joint Commission on Accreditation of Hospitals. A list of hospices meeting these criteria is available upon request by contacting Anthem Blue Cross Member Services.

A facility which provides diagnosis, treatment and care of persons who need acute inpatient hospital care under the supervision of physicians. It must be licensed as a general acute care hospital according to state and local laws. It must also be registered as a general hospital by the American Hospital Association and meet accreditation standards of the Joint Commission on Accreditation of Health Care Organizations.

The presence of a condition recognized by a physician as a cause of infertility; or the inability to conceive a pregnancy or to carry a pregnancy to a live birth after a year or more of regular sexual relations without contraception.

Procedures or medications that have progressed to limited use on humans but are not widely accepted as proven and effective within the organized medical community.

The amount network providers agree to accept as payment in full for covered services. It is usually lower than their normal charge. Negotiated rates are determined by Prudent Buyer Plan Participating Provider Agreements and/or other Blue Card PPO Provider Agreements.

One of the following providers that has an agreement in effect with the Claims Administrator at the time services are rendered:

Network providers agree to accept the negotiated rate as payment for covered services. A directory of network providers is available upon request by contacting Anthem Blue Cross Member Services.

One of the following providers that, at the time services are rendered, does NOT have an agreement in effect with the Claims Administrator:

Remember that only a portion of the amount which a non-network provider charges for a service may be treated as a covered expense under the Medical Plans. See "How Benefits Are Determined" in each of these sections of this Handbook: The Network Access Plan (NAP) section and the Comprehensive Access Plan (CAP) section.

One of the following providers:

The provider must be licensed to provide covered medical services according to state and local laws.

An institution that provides continuous skilled nursing services. The facility must be licensed according to state and local laws and must be recognized as a skilled nursing facility under Medicare.

Special areas of a hospital that have highly skilled personnel and special equipment for acute conditions that require constant treatment and observation.

Inpatient confinement that begins when you are admitted to a facility and ends when you are discharged from that facility.

The services received for a sudden, serious, or unexpected illness, injury or condition, other than one that is life threatening, that requires immediate care for the relief of severe pain or diagnosis and treatment of the condition.