Plan para optimizar el consumo de Energía en la Ventilación Mecánica

 provides services under the supervision of a staff of one or more physiciansto diagnose and treat ill or injured bed patients hospitalized for surgical, medical or psychiatric conditions, and

 is certified by the Joint Commission on the Accreditation of Healthcare Organizations, an equivalent body, or as accepted by Capital.

Hospital does not include: residential or nonresidential treatment facilities; nursing homes; skilled nursing facilities; facilities that are primarily providing custodial, domiciliary or convalescent care; or ambulatory surgical facilities.

Host Blue: A local Blue Cross and/or Blue Shield Licensee serving a geographic area other than Capital’s service area that has contractual agreements with providers in that geographic area, which participate in the

BlueCard program, regarding claim filing or payment for covered health care services rendered to Capital’s memberswho utilize services of such providerswhen traveling outside of Capital’sservice area.

Identification Card (ID Card): The card issued to the memberthat evidences coverageunder the terms of the

group contract.

Immediate Family: The subscriber'sor member'sspouse, domestic partner, parent, step-parent, brother, sister, mother-in-law, father-in-law, sister-in-law, brother-in-law, daughter-in-law, son-in-law, child, step-child, grandparent, or grandchild.

Infertility: The medically documented diminished ability to conceive, or to conceive and carry to live birth. A couple is considered infertile if conception does not occur after a one-year period of unprotected coital activity without contraceptives, or there is the inability on more than one occasion to carry to live birth.

Infusion Therapy Provider: An entity that meets the necessary licensing requirements and is legally authorized to provide home infusion/IV therapy services.

Inpatient: A memberwho is admitted as a patient and spends greater than 23 hours in a hospital, a rehabilitation hospital, a skilled nursing facilityor a non-residential substance abuse treatment facilityand for whom a room and board charge is made. This term may also describe the services rendered to such a member. The term

inpatientdoes not apply to a memberwho is admitted to a substance abuse treatment facilityfor non-hospital

residential services.

Investigational: For the purposes of the group contract, a drug, treatment, device, or procedure is investigational if:

 it cannot be lawfully marketed without the approval of the Food and Drug Administration (“FDA”) and final approval has not been granted at the time of its use or proposed use;

 it is the subject of a current Investigational new drug or new device application on file with the FDA;

 the predominant opinion among experts as expressed in medical literature is that usage should be substantially confined to research settings;

 the predominant opinion among experts as expressed in medical literature is that further research is needed in order to define safety, toxicity, effectiveness or effectiveness compared with other approved alternatives; or  it is not investigational in itself, but would not be medically necessaryexcept for its use with a drug, device,

In determining whether a drug, treatment, device or procedure is investigational, the following information may be considered:

 the member’smedical records;

 the protocol(s) pursuant to which the treatment or procedure is to be delivered;

 any consent document the patient has signed or will be asked to sign, in order to undergo the treatment or procedure;

 the referred medical or scientific literature regarding the treatment or procedure at issue as applied to the injury or illness at issue;

 regulations and other official actions and publications issued by the federal government; and

 the opinion of a third party medical expert in the field, obtained by Capital, with respect to whether a treatment or procedure is investigational.

Level of Coverage: The level of payment made by Capitalto a participating provideror a non-participating providerdescribed in the Summary of Cost-Sharing and Benefits section of this Certificate of Coverage. Licensed Practical Nurse (LPN): A nurse who has graduated from a formal practical or vocational nursing educations program and is licensed by the appropriate state authority.

Long-Term Acute Care Hospital (LTACH): An acute care hospitaldesigned to provide specialized acute care for medically stable, but complex, patients who require long periods of hospitalization (average 25 days) and who would require high-intensity services. LTACHs are often described as a "hospital within a hospital" because they generally are located within a short-term acute care hospital. In Pennsylvania, LTACHs are licensed by the Pennsylvania Department of Health as an acute care facility.

Mail Service Dispensing: The dispensing of maintenance prescription drugsthrough the designated mail service pharmacyin quantities up to a ninety (90) day supply per prescription order.

Mail Service Pharmacy: A duly licensed mail service pharmacy, designated by Capital, where prescription orders

are received through the mail or other means and from which prescription drugsare shipped to membersvia the United States Postal Service, United Parcel Service, or other delivery service.

Marketplace: Shall mean a Marketplace established and operated within Pennsylvania by the United States Secretary of Health and Human Services under section 1321(c)(1) of PPACAor operated by the Commonwealth of Pennsylvania in accordance with PPACA’sprovisions. Also called an “Exchange.”

Medicaid: Hospital or medical insurance benefits financed by the United States Government under Title XIX of the Social Security Act of 1965 and its related regulations, each as amended.

Medical Necessity (Medically Necessary): Shall mean:

 services or supplies that a physicianexercising prudent clinical judgment would provide to a memberfor the diagnosis and/or direct care and treatment of the member’s medical condition, disease, illness, or injury that are necessary;

Definitions