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certain terms?
A
Affiliated Hospital
A duly licensed hospital included in the list of affiliated hospitals of Maxicare with which Maxicare has an existing and valid service agreement where a Member can avail of Medical Services pursuant to this Agreement.
Affiliated Medical Clinic
A duly licensed medical healthcare facility included in the list of affiliated medical clinics of Maxicare which has an existing and valid affiliation agreement with Maxicare where a Member can avail of Medical Services pursuant to this Agreement.
Affiliated Medical Staff
A group of medical practitioners and other allied health professionals who are affiliated and authorized by Maxicare to deliver the required Medical Services to Members.
Affiliated Physician or Specialist
A duly licensed physician or specialist affiliated by Maxicare and named in the list of Maxicare’s affiliated physician with whom Maxicare has made arrangements to provide the required services under this Agreement.
B
Balance Billing
It is the act of an Affiliated Physician and other health practitioners to charge Members for the difference between their desired higher professional fees and the agreed Maxicare standard professional fees for services rendered
C
Confinement/ Hospitalization
The state of being admitted in an Affiliated Hospital or Affiliated Medical Clinic.
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In-Patient Medical Services
The hospitalization services which include accommodations, medicines and supplies, procedures and/or surgery whenever medically necessary, furnished to a patient admitted in an Affiliated Hospital.
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Maxicare Coordinator
A duly licensed medical practitioner designated by Maxicare in an Affiliated Hospital or Affiliated Medical Clinic to direct and supervise the extension of Medical Services to Members, and who may render medical advice, prescribe medication or treatment, issue referrals to Affiliated Specialists, and request for laboratory examination and hospitalization, upon consultation by Members.
Medically Necessary
A Medical Service, as determined by Maxicare, which is (a) consistent with the diagnosis and customary medical treatment of the condition, (b) in accordance with the standards of managed care and good medical practice, (c) not for the convenience of the Member or the Affiliated Physician or Specialist, (d) performed in the most cost effective manner required by the medical condition and (e) consistent with the terms and conditions of this Agreement.
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Reasonable Charges
Professional fees of non-Affiliated Physicians for services rendered to Members which do not exceed the standardized professional fees/terms of the Affiliated Physicians/Specialists. In cases where Maxicare does not have a standard professional fee for the professional service rendered, Maxicare reserves the right to determine the amount of reasonable charges for the said service.
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A
Affiliated Hospital
A duly licensed hospital included in the list of affiliated hospitals of Maxicare with which Maxicare has an existing and valid service agreement where a Member can avail of Medical Services pursuant to this Agreement.
Affiliated Medical Clinic
A duly licensed medical healthcare facility included in the list of affiliated medical clinics of Maxicare which has an existing and valid affiliation agreement with Maxicare where a Member can avail of Medical Services pursuant to this Agreement.
Affiliated Medical Staff
A group of medical practitioners and other allied health professionals who are affiliated and authorized by Maxicare to deliver the required Medical Services to Members.
Affiliated Physician or Specialist
A duly licensed physician or specialist affiliated by Maxicare and named in the list of Maxicare’s affiliated physician with whom Maxicare has made arrangements to provide the required services under this Agreement.
B
Balance Billing
It is the act of an Affiliated Physician and other health practitioners to charge Members for the difference between their desired higher professional fees and the agreed Maxicare standard professional fees for services rendered
