September 6, 2010
  TABLE OF CONTENTS
  4.3.1 Covered Charges - Generally
  "Covered Charges" are charges made for covered Hospital charges or covered medical charges described below, subject to the following:

A. The charge must be for a service or supply prescribed by a Physician.

B. The charge must be for a service or supply which is necessary in connection with the diagnosis or therapeutic treatment of an Injury or Illness. In determining whether a service or supply, what portion of a service or supply or what length of Hospital confinement or amount of treatment is included in this definition, a service or supply must be:

  1. Ordered by a Physician and be commonly and customarily recognized by the Physician’s profession in the United States as safe, effective, appropriate and reasonably necessary treatment of the diagnosed Injury or Illness; and
  2. Received in the most cost-efficient manner and type of setting that can be used safely (for example, in the Physician’s office instead of in a hospital).


Necessary services and supplies must not be:

  1. Educational, Experimental or Investigatory in nature, nor provided primarily for research;
  2. For Custodial Care (care comprised of services and supplies which are provided to a Covered Person primarily to assist him in the activities of daily living);
  3. For maintenance care (maintenance care means care intended primarily to maintain a level of physical or mental function; including, but not limited to manipulation of spinal subluxation which is symptomatically stationary or physical therapy which is not expected to result in significant improvement in the patient’s condition);
  4. Only for the convenience of the patient or Physician.


C. Charges made by an HMO or PPO provider must not exceed the applicable negotiated fee. Non-Network and Out-of-Area charges must not exceed the lesser of (1) the usual charges made by the provider for the same or similar care, services or supplies, or (2) reasonable and customary charges for the same or similar medical care, services or supplies (taking into account the fees and prices generally charged for cases of comparable nature and severity at the time and place such medical care, services or supplies are rendered or received).

Usual, reasonable and customary charges are determined as follows:

  1. Usual the charge most frequently made for the covered services or supplies by a Physician or Practitioner;
  2. Reasonable the charge that meets the Usual and Customary criteria or in the opinion of an appropriate Peer Review Committee it merits special consideration based on the complexity involved, the degree of professional skill required and other pertinent factors;
  3. Customary the charge made for covered services or supplies by those of similar professional standing in the same geographic area.


D. The charge must not be excluded by the Exclusions described in Section 4.4, beginning on page 83.

E. The charge must also meet the requirements for the care described in Section 4.3.4 (beginning on page 72) or 4.3.5 (beginning on page 81) if it is for any of the services or supplies described in those sections. No other charges due to such care are covered.

F. The charge will be considered incurred on the day the service was rendered or the supply was furnished.
  TABLE OF CONTENTS
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