The date on which the coverage of an insurance policy goes into effect at 12:01 a.m.
Surgery for a condition that is not considered an emergency.
A determination of whether or not a person meets the requirements to participate in the plan and receive coverage under the plan.
The total dollar amount allowed by EmblemHealth for a covered service. Eligible expenses are set forth in EmblemHealth's Schedule of Allowances.
An emergency is a medical or behavioral condition of which the onset is sudden. It manifests itself by symptoms of such severity that a prudent lay person with an average knowledge of medicine and health could reasonably expect that the absence of immediate medical attention would result in: placing the health of the afflicted person in serious jeopardy; placing the health of an individual with a behavioral health condition or others in serious jeopardy; causing serious impairment of the individual's bodily functions; causing serious dysfunction of any bodily organ or part; causing serious disfigurement of the afflicted individual.
Care for a medical or behavioral condition, the onset of which is sudden, that manifests itself by symptoms of sufficient severity, including severe pain, that a prudent layperson, possessing an average knowledge of medicine and health, could reasonably expect the absence of immediate medical attention to result in: (a) placing the health of the person afflicted with such condition in serious jeopardy, or in the case of a behavioral condition placing the health of such person or others in serious jeopardy, (b) serious impairment to such person's bodily functions; (c) serious dysfunction of any bodily organ or part of such person,- or (d) serious disfigurement of such person.
Employee Retirement Income Security Act (ERISA)
This law, enacted in 1974, applies to employee benefit plans, including health benefits. The law is designed to protect the interest of employees and requires full disclosure to the employees of their rights under the plan.
An individual who is enrolled and eligible for coverage under a health plan contract. Also called "Member".
See 'Explanation Of Benefits'.
See 'Explanation Of Medicare Benefits'.
See 'Exclusive Provider Organization'.
See 'Employee Retirement Income Security Act'.
Essential Benefits include ambulatory care; emergency services; hospitalization; maternity and newborn care; mental health and substance use disorder services, including behavioral health treatment; prescription drugs; rehabilitative and habilitative care; laboratory services; preventive and wellness services and chronic disease management; pediatric services including oral and vision care; and any other services set forth in regulations issued pursuant to the Patient Protection and Affordable Care Act.
Specific conditions or circumstances that are not covered under the benefit agreement. It is very important to consult the benefit contract to understand what services are not covered benefits.
Exclusive Provider Organization (EPO)
A healthcare benefit arrangement that is similar to a preferred provider organization in administration, structure and operation but which does not cover out-of-network care.
An appeal of a non-certification in a case involving urgent care.
Procedures that are mainly limited to laboratory research.
The date indicated in an insurance contract as the date coverage expires at 12:00 midnight.
Explanation of Benefits (EOB)
A form sent to the enrollee after a claim for payment has been processed by the health plan. The form explains the action taken on that claim. This explanation usually includes the amount paid, the benefits available, reasons for denying payment, or the claims appeal process.
Explanation of Medicare Benefits (EOMB)
A statement detailing the amount of benefits paid or denied for services reported on a member's claim for services under the Medicare program.
Extended Care Facility
An institution devoted to providing medical, nursing or custodial care for an individual over a prolonged period of time as during the course of a chronic disease or during the rehabilitation phase after an acute illness.
Coverage that supplements basic hospital and surgical medical coverage designed to cover a broad scope of extra hospital and medical costs. These costs may include provider home and office visits, prosthetics, ambulance services and hospitalization longer than the time allotted by the regular hospital plan. These benefits are usually subject to a deductible, coinsurance, lifetime maximum and out-of-pocket limits.