EOC-EmployerGroup101920

Definitions VHP ensures members have ease of access to personal health records. As a Member, you may request a copy of VHP’s Notice of Privacy Practices by contacting VHP’s Member Services, or view this information at www.valleyhealthplan.org.

Active Labor means a labor at a time at which either of the following would occur: 1. There is inadequate time for safe transfer to another hospital prior to delivery; or 2. A transfer may pose a threat to the health and safety of the patient or the unborn child.

Acute Condition means a medical condition that involves a sudden onset of symptoms due to an illness, injury, or other medical problem that requires prompt medical attention and that has a limited duration.

Advance Health Care Directive means a formal document, signed by you in advance of a severe illness or injury, which will guide your care if you become so incapacitated that you cannot make an informed decision Agreement means the Group Service Agreement, including but not limited to this Combined Evidence of Coverage and Disclosure Form, any and all applications and information submitted by the Group and Members in applying for Coverage, attachments, addenda, and any amendments that may be added in the future. The Agreement contains the exact terms and conditions of your Coverage. It incorporates all of the contracts, promises, and agreements exchanged by the Group and VHP. It replaces any and all prior or concurrent negotiations, agreements, or communications, whether written or oral, between both parties with respect to the contents of the Agreement.

Authorization means a system whereby a written (or oral followed by a written) approval is given by the Medical Director or designee for a Member to receive and/or have VHP pay for certain Medically Necessary Covered Services.

Behavioral Health Treatment means professional services and treatment programs, including applied behavior analysis and evidence-based behavior intervention programs, that develop or restore, to the maximum extent practicable, the functioning of an individual with pervasive developmental disorder or autism and that meet all of the following criteria: 1. Treatment is prescribed by a physician or a psychologist, licensed pursuant to California law; 2. Treatment is provided under a treatment plan prescribed by a qualified autism service (QAS)

provider and administered by a QAS provider, or a QAS professional or QAS paraprofessional supervised and employed by the QAS provider; 3. The treatment plan has measurable goals developed and approved by the QAS provider that

is reviewed every six months and modified where appropriate; and 4. The treatment plan is not used to provide or reimburse for respite, day care, educational service, or participation in the treatment program.

Benefit(s) means the Covered Services as covered under the Benefit Plan.

Benefit Plan means the Covered Services contained in this Combined Evidence of Coverage and Disclosure Form. Any date referenced in this Benefit Plan begins at 12:01am, Pacific Standard Time.

Cal-COBRA (California Continuation Benefits Replacement Act) means the California legislation that requires health plans to offer continued access to group health care coverage provided to employee, and their dependents, of employers with 2 to 19 eligible employees who are not currently offered continuation coverage under COBRA and whose coverage would end due to termination, 101  V A L L E Y H E A L T H P L A N E V I D E N C E O F C O V E R A G E A N D D I S C L O S U R E F O R M