Glossary

1. is in compliance with the license or other legal requirements in the jurisdiction where it is located;
2. is primarily engaged in performing surgery on its premises;
3. has a licensed medical staff, including Physicians and Registered Nurses:
4. has permanent operating room(s), recovery room(s) and equipment for emergency care, and
5. has an agreement with a Hospital for immediate acceptance of patients who require Hospital care following treatment in the ambulatory surgical facility.

1. allowable by the ASPE health benefit plan,
2. administered or ordered by a Physician,
3. medically necessary to the diagnosis and treatment of an Injury or Sickness,
4. related to medical conditions that are not pre-existing per the ASPE health benefit plan definition, and
5. not in excess of the negotiated rate based on services provided or the usual, customary and reasonable fee schedule.

1. is prescribed by the Physician who documents the necessity for the item, including the expected duration of its use;
2. can withstand long term repeated use without replacement;is not useful in the absence of Injury or Sickness; and
3. can be used in the home without medical supervision.

1. is not accepted as standard medical treatment for the condition being treated; or
2. requires but has not received federal or other governmental agency approval at the time of service.

1. operates as a Hospital pursuant to law for the care and treatment of sick or injured persons as inpatients;
2. provides 24-hour nursing service by registered nurses on duty or on call;
3. has a staff of one or more Physicians available at all times;
4. provides organized facilities for diagnosis, treatment and surgery either on its premises, or in facilities available to it on a pre-arranged basis: and
5. is not primarily a nursing, rest, convalescent home or similar establishment, or any separate ward, wing or section of a Hospital used as such.

1. reserved for the critically ill requiring close observation; and
2. equipped to provide specialized care by trained and qualified personnel and special equipment and supplies on a standby basis.

1. Flying, except:
   • as a passenger on a regularly scheduled airline;
   • as a passenger on a chartered carrier for purposes of an approved grant program activity;
   • as a passenger in the Military Airlift Command of the U.S. or similar air transport services of other countries.
2. Playing, practicing, or participating in professional sports, or during travel for such purposes. Professional sports also include skateboarding, snowboarding, BMX racing, X-games (extreme sports), and boxing.
   If your participation in a professional sports event is part of your grant the perilous activity clause does not apply.
3. Operation of a vehicle while not properly licensed to do so or riding in a non-commercial vehicle operated by a person not licensed to do so in the jurisdiction in which the accident takes place.
4. Operation of a vehicle while under the influence of drugs or alcohol.
5. Dangerous activity not directly related to the fulfillment of grant objectives, e.g., boxing, bungee jumping, scuba diving, skydiving, rock climbing (indoor/outdoor), hang gliding, operation of an all-terrain vehicle (ATV) or motocross bike, downhill skiing, horseback riding, parachuting, zip lining, parasailing, bungee jumping, water skiing, wakeboard riding, jet skiing, windsurfing, snowmobiling, spelunking, and motorcycle/motor scooter riding.
   If your grant requires that you travel to areas requiring an ATV, motorcycle/motor scooter or snowmobile then item 5 does not apply.

1. as soon as non-Emergency hospitalization is recommended;
2. within forty-eight (48) hours of the first working day following an Emergency hospitalization;
3. when your Physician recommends any surgery, including Outpatient; or
4. for medical evacuation, repatriation and assistance services.

Pre-certification is not a guarantee of coverage.

1. had its origins prior to the Exchange Participant ‘s effective date of coverage;
2. a Physician was consulted prior to the Exchange Participant ‘s effective date of coverage;
3. treatment or medication was received prior to the Exchange Participant ‘s effective date of coverage; or
4. would have caused any prudent person to seek medical advice or treatment, prior to the Exchange Participant’s effective date of coverage.

1. Hospital – any hospital accredited by the Joint Commission on the Accreditation for Health Organizations, including Veterans Administration Hospitals and Department of Defense Hospitals.
2. Physicians – any provider licensed in the state or country where the services were provided. These include: Doctor of Medicine (MD), Doctor of Osteopathy (DO), Doctor of Dental Surgeries (DDS or DMD), Podiatrist (POD) and Psychologist (Ph.D.).
3. Certified Nurse Midwife – Must be a licensed registered nurse and certified as a nurse midwife by the American College of Nurse Midwives.
4. Other Providers – Nurse anesthetist, nurse practitioner, psychiatric social worker, respiratory therapist, speech therapist, occupational therapist, optician, optometrist, physicians’ assistant, private duty nurse, technical surgical assistant, registered physical therapist or physiotherapist. All of the above mentioned providers must be licensed or certified in the jurisdiction where the services were provided.
5. Registered Nurse - a graduate nurse who has been registered or licensed to practice by a State Board of Nurse Examiners or other state authority, and who is legally entitled to place the letters R. N. after his or her name.

1. Usual - an amount a professional provider routinely charges for a given service.
2. Customary - an amount which falls within the range of charges for a given service billed by most professional providers in the same locality who have similar training and experience.
3. Reasonable - an amount that is Usual and Customary or an amount not considered excessive in a particular case because of unusual circumstances.
4. If the charge is in excess of the UCR, no payment with respect to the excess is made, and the excess will not qualify as a Covered Expense under the ASPE health bene t plan.

1. An Identification Card is valid, when filled out in its entirety, including the full and complete name of the Exchange Participant, program organization name and telephone number, and the exact dates of coverage.
2. The program organization shall not enroll anyone in the ASPE health benefit plan who is not an “Eligible Exchange Participant” as defined in this statement. Enrollment of a person who does not meet Individual Eligibility Requirements will nullify the coverage and release the program organization from any liability associated with loss or claim.
3. The program organization shall not enroll an Eligible Person in the ASPE health benefit plan for a period outside the Enrollment Period. Enrollment of an Eligible Exchange Participant for a period outside the Enrollment Period as defined will nullify the coverage and release the program organization from liability associated with losses and claims occurring outside the enrollment period.
4. An identification card is not valid if the program organization has not submitted an enrollment form to the program organization as required.
5. An identification card is not valid for anyone other than the Exchange Participant as defined above.