An injury caused by an external force or element such as a blow or fall that requires immediate medical attention, including animal bites and poisonings. Note: Injuries to the teeth while eating are not considered accidental injuries. Dental care for accidental injury is limited to dental treatment necessary to repair sound natural teeth.

The period from entry (admission) as an inpatient into a hospital (or other covered facility) until discharge. In counting days of inpatient care, the date of entry and the date of discharge count as the same day.

An authorization by the enrollee or spouse for us to issue payment of benefits directly to the provider. We reserve the right to pay you, the enrollee, directly for all covered services.

January 1 through December 31 of the same year. For new enrollees, the calendar year begins on the effective date of their enrollment and ends on December 31 of the same year.

The Blue Cross and Blue Shield Association, on behalf of the local Blue Cross and Blue Shield Plans.

A collaborative process of assessment, planning, facilitation and advocacy for options and services to meet an individual's health needs through communication and available resources to promote quality, cost-effective outcomes (Case Management Society of America, 2002). Each Blue Cross and Blue Shield Plan administers a case management program to assist Service Benefit Plan members with certain complex and/or chronic health issues. Each program is staffed by licensed healthcare professionals (Case Managers) and is accredited by URAC. For additional information regarding case management, call us at the telephone number listed on the back of your Service Benefit Plan ID card.

Coinsurance is the percentage of our allowance that you must pay for your care. You may also be responsible for additional amounts.

A copayment is a fixed amount of money you pay when you receive covered services.

Any surgical procedure or any portion of a procedure performed primarily to improve physical appearance through change in bodily form, except for repair of accidental injury or to restore or correct a part of the body that has been altered as a result of disease or surgery or to correct a congenital anomaly.

Cost-sharing is the general term used to refer to your out-of-pocket costs (e.g., deductible, coinsurance and copayments) for the covered care you receive.

Services we provide benefits for, as described in this brochure.

Treatment or services, regardless of who recommends them or where they are provided, that a person not medically skilled could perform safely and reasonably or that mainly assist the patient with daily living activities, such as:

1. Personal care, including help in walking, getting in and out of bed, bathing, eating (by spoon, tube or gastrostomy), exercising or dressing
2. Homemaking, such as preparing meals or special diets
3. Moving the patient
4. Acting as companion or sitter
5. Supervising medication that can usually be self-administered
6. Treatment or services that any person can perform with minimal instruction, such as recording pulse, temperature and respiration; or administration and monitoring of feeding systems

Custodial care that lasts 90 days or more is sometimes known as Long Term Care. The carrier, its medical staff and/or an independent medical review determine which services are custodial care.

A deductible is a fixed amount of covered expenses you must incur for certain covered services and supplies in a calendar year before we start paying benefits for those services. See page 17 of the Service Benefit Plan Brochure.

Equipment and supplies that:

• Are prescribed by your physician (i.e., the physician who is treating your illness or injury)
• Are medically necessary
• Are primarily and customarily used only for a medical purpose
• Are generally useful only to a person with an illness or injury
• Are designed for prolonged use
• Serve a specific therapeutic purpose in the treatment of an illness or injury

A drug, device or biological product is experimental or investigational if the drug, device or biological product cannot be lawfully marketed without approval of the U.S. Food and Drug Administration (FDA); and, approval for marketing has not been given at the time it is furnished.

Note: Approval means all forms of acceptance by the FDA.

A medical treatment or procedure or a drug, device or biological product, is experimental or investigational if:

• Reliable evidence shows that it is the subject of ongoing phase I, II or III clinical trials or under study to determine its maximum tolerated dose, its toxicity, its safety, its efficacy or its efficacy as compared with the standard means of treatment or diagnosis; or
• Reliable evidence shows that the consensus of opinion among experts regarding the drug, device or biological product or medical treatment or procedure, is that further studies or clinical trials are necessary to determine its maximum tolerated dose, its toxicity, its safety, its efficacy or its efficacy as compared with the standard means of treatment or diagnosis.

Reliable evidence shall mean only:

• published reports and articles in the authoritative medical and scientific literature;
• the written protocol or protocols used by the treating facility or the protocol(s) of another facility studying substantially the same drug, device or biological product or medical treatment or procedure; or the written informed consent used by the treating facility or by another facility studying substantially the same drug, device or biological product or medical treatment or procedure.

Each Local Plan has a Medical Review department that determines whether a claimed service is experimental or investigational after consulting with internal or external experts or nationally recognized guidelines in a particular field or specialty.

For more detailed information, contact your Local Plan at the customer service telephone number located on the back of your Service Benefit Plan ID card or use the Contact Us feature on this Web site.

Health care coverage that you are eligible for based on your employment or your membership in or connection with a particular organization or group, that provides payment for medical services or supplies or that pays a specific amount of more than $200 per day for hospitalization (including extension of any of these benefits through COBRA).

A comprehensive, structured outpatient treatment program that includes extended periods of individual or group therapy sessions designed to assist members with mental health and/or substance abuse conditions. It is an intermediate setting between traditional outpatient therapy and partial hospitalization, typically performed in an outpatient facility or outpatient professional office setting. Program sessions may occur more than one day per week. Timeframes and frequency will vary based upon diagnosis and severity of illness.

The maximum amount the Plan will pay on your behalf for covered services you receive while you are enrolled in your option. Benefit amounts accrued are accumulated in a permanent record regardless of the number of enrollment changes.

We determine whether services, drugs, supplies or equipment provided by a hospital or other covered provider are:

• Appropriate to prevent, diagnose or treat your condition, illness or injury
• Consistent with standards of good medical practice in the United States
• Not primarily for the personal comfort or convenience of the patient, the family or the provider
• Not part of or associated with scholastic education or vocational training of the patient
• In the case of inpatient care, cannot be provided safely on an outpatient basis

The fact that one of our covered providers has prescribed, recommended or approved a service or supply does not, in itself, make it medically necessary or covered under this Plan.

Conditions and diseases listed in the most recent edition of the International Classification of Diseases (ICD) as psychoses, neurotic disorders or personality disorders; other nonpsychotic mental disorders listed in the ICD; or disorders listed in the ICD requiring treatment for abuse of or dependence upon, substances such as alcohol, narcotics or hallucinogens.

An intensive facility-based treatment program during which an interdisciplinary team provides care related to mental health and/or substance abuse conditions. Program sessions may occur more than one day per week and may be full or half days, evenings and/or weekends. The duration of care per session is less than 24 hours. Timeframes and frequency will vary based upon diagnosis and severity of illness.

Our Plan allowance is the amount we use to determine our payment and your coinsurance for covered services. Fee-for-service plans determine their allowances in different ways. If the amount your provider bills for covered services is less than our allowance, we base our payment and your share (coinsurance, deductible and/or copayments), on the billed amount. We determine our allowance as follows:

• PPO providers — Our allowance (which we may refer to as the "PPA" for "Preferred Provider Allowance") is the negotiated amount that Preferred providers (hospitals and other facilities, physicians and other covered healthcare professionals that contract with each local Blue Cross and Blue Shield Plan and retail and Internet pharmacies that contract with Caremark) have agreed to accept as payment in full, when we pay primary benefits.

  Our PPO allowance includes any known discounts that can be accurately calculated at the time your claim is processed. For PPO facilities, we sometimes refer to our allowance as the "Preferred rate." The Preferred rate may be subject to a periodic adjustment after your claim is processed that may decrease or increase the amount of our payment that is due to the facility. However, your cost-sharing (if any) does not change. If our payment amount is decreased, we credit the amount of the decrease to the reserves of this Plan. If our payment amount is increased, we pay that cost on your behalf.

• Participating providers — Our allowance (which we may refer to as the "PAR" for "Participating Provider Allowance") is the negotiated amount that these providers (hospitals and other facilities, physicians and other covered healthcare professionals that contract with some local Blue Cross and Blue Shield Plans) have agreed to accept as payment in full, when we pay primary benefits. For facilities, we sometimes refer to our allowance as the "Member rate." The member rate includes any known discounts that can be accurately calculated at the time your claim is processed and may be subject to a periodic adjustment after your claim is processed that may decrease or increase the amount of our payment that is due to the facility. However, your cost-sharing (if any) does not change. If our payment amount is decreased, we credit the amount of the decrease to the reserves of this Plan. If our payment amount is increased, we pay that cost on your behalf.

• Non-participating providers — We have no agreements with these providers. We determine our allowance as follows:

  • For inpatient services at hospitals, and other facilities that do not contract with your local Blue Cross and Blue Shield Plan ("Non-member facilities"), our allowance is based on the average amount paid nationally to contracting and non-contracting facilities for covered room, board and ancillary charges for your type of admission. For inpatient stays resulting from medical emergencies or accidental injuries or for routine deliveries, our allowance is the billed amount

  • For outpatient, non-emergency surgical services at hospitals and other facilities that do not contract with your local Blue Cross and Blue Shield Plan ("Non-member facilities"), our allowance is the average amount for outpatient surgical services that we pay nationally to contracting and non-contracting facilities. For other outpatient services by Non-member facilities and for outpatient surgical services resulting from a medical emergency or accidental injury, our allowance is the billed amount (minus any amounts for noncovered services)

  • For physicians and other covered healthcare professionals that do not contract with your local Blue Cross and Blue Shield Plan, our allowance is equal to the greater of 1) the Medicare participating fee schedule amount for the service or supply in the geographic area in which it was performed or obtained (or 60% of the billed charge if there is no equivalent Medicare fee schedule amount) or 2) 100% of the 2008 Usual, Customary and Reasonable (UCR) amount for the service or supply in the geographic area in which it was performed or obtained. Local Plans determine the UCR amount in different ways. Contact your Local Plan if you need more information. We may refer to our allowance for Non-participating providers as the "NPA" (for "Non-participating Provider Allowance")

  • For prescription drugs furnished by retail and Internet pharmacies that do not contract with Caremark, our allowance is the average wholesale price (AWP) of a drug on the date it is dispensed, as set forth in the most current version of First DataBank's National Drug Data File

  • For services you receive outside of the United States and Puerto Rico from providers that do not contract with us or with World Access, Inc., our allowance is an Overseas Fee Schedule that is based on amounts comparable to what Participating providers in the Washington, D.C., area have agreed to accept.

Non-participating providers are under no obligation to accept our allowance as payment in full. If you use Non-participating providers, you will be responsible for any difference between our payment and the billed amount (except in certain circumstances — see page 120 of the Service Benefit Plan Brochure). In addition, you will be responsible for any applicable deductible, coinsurance or copayment amounts.

Note: For certain covered services from Non-participating professional providers, your responsibility for the difference between the Non-participating Provider Allowance (NPA) and the billed amount may be limited.

In only those situations listed below, when the difference between the NPA and the billed amount for covered Non-participating professional care is greater than $5,000 for an episode of care, your responsibility will be limited to $5,000 (in addition to any applicable deductible, coinsurance or copayment amounts). An episode of care is defined as all covered Non-participating professional services you receive during an emergency room visit, an outpatient visit or a hospital admission (including associated emergency room or pre-admission services), plus your first follow-up outpatient visit to the Non-participating professional provider(s) who performed the service(s) during your hospital admission or emergency room visit.

• When you receive care in a Preferred hospital from Non-participating professional providers such as a radiologist, anesthesiologist, certified registered nurse anesthetist (CRNA), pathologist, neonatologist or pediatric sub-specialist; and the professional providers are hospital-based or are specialists recruited from outside the hospital either without your knowledge and/or because they are needed to provide immediate medical or surgical expertise

• When you receive care from Non-participating professional providers in a Preferred, Member or Non-member hospital as a result of a medical emergency or accidental injury (see page 73 of the Service Benefit Brochure).

For more information, see Differences between our allowance and the bill in Section 4 of the Service Benefit Plan brochure.

Written assurance that benefits will be provided by:

• The Local Plan where the services will be performed
• The Retail Pharmacy Program (for prescription drugs and supplies purchased through Preferred retail and Internet pharmacies) or the Mail Service Prescription Drug Program
• The Blue Cross and Blue Shield Association Clinical Trials Information Unit for certain organ/tissue transplants we cover only in clinical trials. See Section 5(b).

For more information, see the benefit descriptions in Section 5 and How to get approval for . . . Other services in the Service Benefit Plan brochure. See Section 5(e) for special authorization requirements for mental health and substance abuse benefits.

Services that are not related to a specific illness, injury, set of symptoms or maternity care.

A tooth that is whole or properly restored (restoration with amalgams only); is without impairment, periodontal or other conditions; and is not in need of the treatment provided for any reason other than an accidental injury. For purposes of this Plan, a tooth previously restored with a crown, inlay, onlay or porcelain restoration or treated by endodontics, is not considered a sound natural tooth.

A defined number of consecutive days associated with a covered organ/tissue transplant procedure.

"Us," "we," and "our" refer to the Blue Cross and Blue Shield Service Benefit Plan and the local Blue Cross and Blue Shield Plans that administer it.

"You" and "your" refer to the enrollee (the contract holder eligible for enrollment and coverage under the Federal Employees Health Benefits Program and enrolled in the Plan) and each covered family member.