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3. It is not primarily for the convenience or personal comfort of the Covered Person, Physician, other
caregiver or family member;
4. It is the most appropriate level of service, drugs, Supplies or equipment that can be safely provided to the
Covered Person. With respect to Inpatient Care, appropriate level of service means that the medical
condition requires Inpatient Care and that safe and effective treatment cannot be rendered as an
Outpatient.
5. It is not Investigative or Experimental or is not of an educational nature or is not provided primarily for
medical or other research;
6. It is not considered Maintenance Care or Custodial Care; and
7. It is care requiring the credentials and technical skills of the Professional Healthcare Provider.
The fact that a Physician or other health care professional may prescribe, recommend, order or approve a
service or supply does not, by itself, determine Medical Necessity or make such service or supply eligible for
benefits, even if not expressly excluded under the Plan. The Plan Administrator or the Claim Administrator
reserves the right to decide, in its discretion, if a service or supply is Medically Necessary. The determination
will consider, but not be limited to, the findings and assessment of the following entities:
1. The Office of Medical Application of Research of the National Institutes of Health, the Office of
Technology Assessment of the United States Congress, the Federal Centers for Medicare & Medicaid
Services (CMS) or any similar entities;
2. The National Medical Associations, Societies and Organizations;
3. The FDA; or
4. The Plan Administrator or Claim Administrator's own medical and legal consultants and advisors.
If any of the entities used to determine the Medical Necessity of a drug, device, supply, treatment or any other
medical service, reverses, modifies, or establishes its policy for such expenses and makes such changes
retroactive, the Plan will not make payment for retroactive Incurred Expenses. The Plan will not seek refund
for it previous payments, nor make payments for any previously denied expenses, affected by such retroactive
changes.
MEDICARE - The coverage of health care costs provided under the provisions of the Federal Social Security
Act (42 USC 1395 et seq.) as amended.
MENTAL ILLNESS/MENTAL ILLNESS CARE - Treatment for a diagnosed mental disease or disorder
or a functional nervous disorder or eating disorder, as shown in the most current edition of American
Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders. See also Illness.
NETWORK PROVIDER - An organization, Physician, Hospital, Pharmacy or other covered Professional
Healthcare Provider that, at the time Covered Services or Supplies are provided, is part of the Participating
Provider Network (s) selected by the plan. The Network Provider has a contract or agreement with the
Network organization to bill negotiated charges or scheduled allowances for Covered Services or Supplies
when Incurred by Covered Persons.
NO-FAULT AUTOMOBILE COVERAGE - The basic reparations provisions of a state law that provides
payments without determining fault in connection with Injuries or conditions sustained in the use or operation
of an automobile or other vehicle as mandated under the applicable law.
NON-OCCUPATIONAL - A disease or Injury that does not arise and is not caused or contributed to, by or
because of, any disease or Injury that arises out of or during any employment or occupation for compensation
or profit.
NONPARTICIPATING PROVIDER - See Out-of-Network Provider.
NURSE ANETHETIST - See Certified Nurse Anesthetist.
ORTHOTICS - An external appliance or device intended to correct any defect in form or function of the
human body.
