Term | Definition |
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Administrator | A private company contracted by the US Department of State to administer the ASPE health benefit plan. The current administrator is Seven Corners. |
Ambulatory Surgical Facility | Means an establishment which, may or may not be part of a Hospital and which meets the following requirements:
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Appeal | When a claim has been denied, an Exchange Participant has the right to appeal the decision. The Exchange Participant must submit detailed justification, supported by pertinent documentation to the Administrator for review. |
ASPE | Accident and Sickness Program for Exchanges, the self-funded health benefit plan offered to US Department of State exchange program Exchange Participants administered by Seven Corners, Inc. |
Assignment of Benefits | A section on the ASPE claim form that, when signed and dated by the Exchange Participant, authorizes the Administrator to make payment directly to the health care provider. |
Benefit Year | The one-year period that begins on your start date in the ASPE program. |
Certificate of Coverage – “Proof of Coverage” | A letter providing evidence of your prior health coverage. Upon request this document is provided by Seven Corners. |
Claim / Claim Form | A written request for payment for medical services. Claims are submitted along with receipts and any other relevant documentation to Seven Corners after treatment has been received. Claim forms are available here |
Complications | A secondary condition, either Injury or Sickness, which develops or is in conjunction with an already existing Injury or Sickness. |
Complications of Pregnancy | Any medical condition that is distinct complication from a normal pregnancy, but is adversely affected by or caused by pregnancy. Complications of pregnancy includes: acute nephritis, nephrosis, cardiac decompensation, missed abortion, a medically necessary caesarean section, ectopic pregnancy which is terminated, a spontaneous termination of pregnancy occurring when a viable birth is not possible, and similar serious adverse medical conditions caused by or affected by pregnancy. Not included in Complications of pregnancy: false labor and/or occasional spotting. In addition, Physician prescribed rest during pregnancy, morning sickness, preeclampsia, and conditions involved in a difficult pregnancy not medically classified as a distinct complication of pregnancy. |
Congenital Anomalies | A physical abnormality or condition that is present at birth, whether inherited or caused by the environment. |
Copay | Copay is the specified dollar amount that a patient is expected to pay directly to the provider at the time of service. |
Covered Services | Medical services or supplies that are allowable by the ASPE health benefit plan, related to medical conditions that are not pre-existing per the ASPE health benefit plan definition and when provided by a provider acting within the scope of their license. In order to be considered a covered service, charges must be incurred while your coverage is in force. |
Covered Expense | Expenses for medical services or supplies that are:
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Covered Services | Medical services or supplies that are allowable by the ASPE health benefit plan, related to medical conditions that are not pre-existing per the ASPE health benefit plan definition and when provided by a provider acting within the scope of their license. In order to be considered a covered service, charges must be incurred while your coverage is in force. |
Covered Person | An Exchange Participant in an eligible USDOS sponsored exchange program who is enrolled in the ASPE health benefit plan. “Eligible Program” does not include those for which USDOS support is primarily for administrative or facilitative support rather than direct participant costs. “Participants” does not include escorts, escort / interpreters, staff of organizations receiving grant support directly or indirectly from the USDOS, independent consultants associated with these organizations, or dependents of program participants. |
Durable Medical Equipment (DME) | Durable Medical Equipment means medical equipment which:
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Eligible Exchange Participant | See Covered Person definition above. |
Emergency | A sudden, unexpected onset of a medical condition that, in the reasonable opinion of the Exchange Participant, is of such a nature that failure to render immediate care by a licensed medical provider would place the Exchange Participant’s life in danger, resulting in the loss of life or limb, or cause serious impairment to the Exchange Participant’s health. |
Enrollment | Exchange Participants are eligible to participate in ASPE when they are registered or enrolled in the program by their commission or cooperating agency. The commission or cooperating agency issues each Exchange Participant and ASPE identification card. |
EOB | Is an acronym for Explanation of Benefits. Although EOBs often look like a medical bill, the EOB tells you what portion of a claim was paid to the Health Care Provider and what portion of the payment, if any, is your responsibility. |
Exclusions | Any services or supplies related to non-covered plan benefits. |
Experimental | Any treatment, procedure, facility, equipment, drug, device or supply which:
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Health Care Provider | A licensed physician, hospital or clinic that provides medical services. |
Hospital | An institution which:
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Identification Card | A card issued by the ASPE health benefit plan that bears the member’s name, identifies the membership by number and may contain information about his or her coverage. |
Injury | An accidental bodily injury sustained by an Exchange Participant while covered under the ASPE health benefit plan and which occurs independent of all other causes. |
Inpatient | A person who is a resident patient, using and paying for the room and board facilities of a Hospital. |
Intensive Care Facility | An intensive care unit, cardiac care unit, or other unit or area of a Hospital:
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Loss | The financial loss associated with an accident or illness for a claim submitted to the Administrator. |
Medicare | The program of health care for the aged and disabled established by Title XVIII of the Social Security Act of 1965, as amended. |
Mental Health Care Provider | A licensed physician, licensed clinical psychologist or a master of social work (MSW), acting within the scope of his or her license who is not the Exchange Participant or a member of the Exchange Participant’s immediate family, who may provide services that are medically necessary for mental and nervous disorders only. |
Mental or Nervous Disorder | Neurosis, psychoneurosis, psychosis, or mental or nervous disease or disorder of any kind. |
Outpatient | A person who receives medical services and treatment on an Outpatient basis in a Hospital, Physician’s office, Ambulatory Surgical Center, or similar centers, and who is not charged room and board for such services. |
Pharmacy Network | The retail and mail service pharmacy network. |
Perilous Activity |
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Physician | A qualified, licensed health care practitioner, acting pursuant to a license, who is not the Exchange Participant or a member of the Exchange Participant’s immediate family. |
Physiotherapy | A physical or mechanical therapy, diathermy, ultrasonic, heat treatment in any form, manipulation or massage. |
Pre-Certification | Seven Corners must be contacted to confirm coverage and benefits:
Pre-certification is not a guarantee of coverage. |
Pre-Existing Condition | Any condition which:
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Preferred Provider | Providers of service who have been selected or have decided to become part of a preferred network to work with an insurer to help control costs to patients. |
Providers of Service | When you are ill or injured, your coverage helps pay the hospital and your physician as well as appropriate charges for other approved health care professionals. These providers include but are not limited to:
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Right of Recovery | When payments for a given medical treatment have been made in excess of the amount necessary, the USDOS has the right to recover such overpayments. The USDOS will notify the Exchange Participant of the overpayment and request reimbursement from the health care provider / Exchange Participant. If the health care provider does not reimburse USDOS for the overpayment, USDOS reserves the right to set the overpayment against any other benefits payable to the Exchange Participant. |
Sickness | An illness, disease, or physical condition of an Exchange Participant commencing while coverage is in force. |
Telemedicine | The use of telecommunications technologies to provide long-distance or remote clinical health care. |
Usual, Customary and Reasonable (UCR) | The payment amount as determined by a nationally recognized MDR fee schedule based upon geographic location. The Administrator purchases the MDR fee schedule from Ingenix, and the Administrator reserves the right of final determination of
the amount payable for any service or supply. The following is the basis for determination of UCR:
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Valid Identification Card (ID) | The identification card filled out by the program organization in accordance with the rules outlined below.
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Claims
Fax: 317-575-6467
Email: usdos.claims@sevencorners.com