Laserfiche WebLink
• between the Claim Administrator and the particular Provider. (See provisions of this Agreement <br /> regarding "CLAIM ADMINISTRATOR'S SEPARATE FINANCIAL ARRANGEMENTS WITH <br /> PROVIDERS.") I <br /> F. "Coinsurance" means a percentage of an eligible expense that a Covered Person is required I <br /> to pay toward a Covered Service. � <br /> G. "Covered Employee" means the person to whom coverage under the Plan has been ex- <br /> tended by the Employer and to whom the Claim Administrator has directly or indirectly issued <br /> an identification card bearing the number of the Employer. For purposes of providing benefits <br /> under the Plan, Covered Employee does not mean any person who has selected Medicare as <br /> his/her primary coverage. <br /> H. "Covered Person" means the Covered Employee and such employee's legal spouse and/or <br /> unmarried dependent children as specified in the Plan. <br /> I. "Covered Service"means a service or supply specified in the Plan for which benefits will be pro- <br /> vided. <br /> J. "Creditable Coverage" means coverage under: <br /> (a) Group health plan; <br /> (b) Health insurance coverage for medical care under any hospital or medical service policy <br /> or HMO contract offered by a health insurance issuer; <br /> (c) Medicare (Part A or B of Title XVIII of the Social Security Act); <br /> (d) Medicaid (Title XIX of the Social Security Act); <br /> � (e) CHAMPUS (Title 10 U. S. C. Chapter 55); <br /> (fl The Indian Health Service or of a tribal organization; <br /> (g) State health benefits risk pool; <br /> (h) Federal Employees Health Benefits Program; <br /> (i) Public health plan maintained by a State, county or other political subdivision of a State; <br /> (j) Section 5(e) of the Peace Corps Act. <br /> K. "ERISA" means the Employee Retirement Income Security Act of 1974, as amended. <br /> L. "In-Network Services" means Covered Services received by a Covered Person from a PPO <br /> Provider. <br /> M. "Inpatient" means the Covered Person is a registered bed patient and treated as such in a <br /> health care facility. <br /> N. "Medicare Secondary Payer("MSP")" means those provisions of the Social Security Act set <br /> forth in 42 U.S.C. §1395 y(b),and the implementing regulations set forth in 42 C.F.R. Part 411, <br /> as amended,which regulate the manner in which certain employers may offer group health care <br /> coverage to Medicare-eligible employees, their spouses and, in some cases, dependent chil- <br /> dren. (See provisions of this Agreement regarding"MEDICARE SECONDARY PAYER("MSP") <br /> PROVISIONS."). <br /> O. "Net Claim Payment" means the net benefit payment calculated by the Claim Administrator, <br /> upon submission of a Claim, in accordance with the benefits specified in the Plan, plus any re- <br /> � lated Surcharges.All Net Claim Payments shall be calculated on the basis of the Provider's Eli- <br /> gible Charge for Covered Services rendered to the Covered Person,less the ADP if applicable, <br /> irrespective of any separate financial arrangement between the Claim Administrator and the <br /> - 17 - <br />