Table of Contents (continued) ii Premium...............................................................................................................................................21 Primary Care Provider .........................................................................................................................22 Rider.....................................................................................................................................................22 Room and Board ..................................................................................................................................22 Schedule of Benefits ............................................................................................................................22 Service Area.........................................................................................................................................22 Special Services (Hospital and Facility Ancillary Services) ...............................................................23 Subscriber.............................................................................................................................................23 Urgent Care..........................................................................................................................................23 Utilization Review ...............................................................................................................................23 Part 3 Emergency Services.....................................................................................................25 Inpatient Emergency Admissions ........................................................................................................25 Outpatient Emergency Services...........................................................................................................25 Post-Stabilization Care.........................................................................................................................25 Part 4 Utilization Review Requirements..................................................................................27 Pre-Service Approval Requirements....................................................................................................27 Referrals for Specialty Care............................................................................................................27 Pre-Service Review for Outpatient Services ..................................................................................27 Pre-Admission Review ...................................................................................................................29 Concurrent Review and Discharge Planning..................................................................................30 Individual Case Management...............................................................................................................31 Part 5 Covered Services .........................................................................................................33 Admissions for Inpatient Medical and Surgical Care ..........................................................................33 General and Chronic Disease Hospital Admissions .......................................................................33 Rehabilitation Hospital Admissions ...............................................................................................36 Skilled Nursing Facility Admissions..............................................................................................36 Ambulance Services.............................................................................................................................36 Autism Spectrum Disorders Services ..................................................................................................37 Cardiac Rehabilitation..........................................................................................................................38 Chiropractor Services...........................................................................................................................38 Cleft Lip and Cleft Palate Treatment ...................................................................................................38 COVID-19 Testing and Treatment ......................................................................................................39 Dialysis Services..................................................................................................................................39 Durable Medical Equipment ................................................................................................................40 Early Intervention Services..................................................................................................................41 Emergency Medical Outpatient Services.............................................................................................41 Gender Affirming Services (Transgender-Related Services) ..............................................................41 Home Health Care................................................................................................................................42 Hospice Services..................................................................................................................................43 Infertility Services................................................................................................................................43 Lab Tests, X-Rays, and Other Tests ....................................................................................................44 Maternity Services and Well Newborn Care .......................................................................................45 Maternity Services..........................................................................................................................45 Well Newborn Care ........................................................................................................................46 Medical Care Outpatient Visits............................................................................................................47 Medical Formulas ................................................................................................................................49 Mental Health and Substance Use Treatment......................................................................................49