Part 2 – Explanation of Terms (continued) WORDS IN ITALICS ARE EXPLAINED IN PART 2. Page 23 Special Services (Hospital and Facility Ancillary Services) When you receive health care services from a hospital or other covered health care facility, covered services include certain services and supplies that the health care facility normally furnishes to its patients for diagnosis or treatment while the patient is in the facility. These special services include (but are not limited to) such things as:  The use of special rooms. These include: operating rooms; and treatment rooms.  Tests and exams.  The use of special equipment in the facility. Also, the services of the people hired by the facility to run the equipment.  Drugs, medications, solutions, biological preparations, and medical and surgical supplies that are used while you are in the facility.  Administration of infusions and transfusions and blood processing fees. These do not include the cost of: whole blood; packed red blood cells; blood donor fees; or blood storage fees.  Internal prostheses (artificial replacements of parts of the body) that are part of an operation. These include things such as: hip joints; skull plates; intraocular lenses that are implanted after corneal transplant, cataract surgery, or other covered eye surgery, when the natural eye lens is replaced; and pacemakers. They do not include things such as: ostomy bags; artificial limbs or eyes; hearing aids; or airplane splints. Subscriber The subscriber is the eligible person who signs the enrollment form at the time of enrollment in this health plan. Urgent Care This health plan provides coverage for urgent care. This is medical, surgical, or psychiatric care, other than emergency medical care, that you need right away. This is care that you need to prevent serious deterioration of your health when an unforeseen illness or injury occurs. In most cases, urgent care will be brief diagnostic care and treatment to stabilize your condition. (For purposes of filing a claim or a formal appeal or grievance review, Blue Cross Blue Shield HMO Blue considers “emergency medical care” to constitute “urgent care” as defined under the Employee Retirement Income Security Act of 1974, as amended (ERISA). As used in this Subscriber Certificate, this urgent care term is not the same as the “urgent care” term defined under ERISA.) Utilization Review This term refers to the programs that Blue Cross Blue Shield HMO Blue uses to evaluate the necessity and appropriateness of your health care services and supplies. Blue Cross Blue Shield HMO Blue uses a set of formal techniques that are designed to monitor the use of, or evaluate the clinical necessity, appropriateness, efficacy or efficiency of health care services, procedures or settings, and drugs. These programs are designed to encourage appropriate care and services (not less care). Blue Cross Blue Shield HMO Blue understands the need for concern about underutilization. Blue Cross Blue Shield HMO Blue shares this concern with its members and health care providers. Blue Cross Blue Shield HMO Blue does not compensate individuals who conduct utilization review activities based on denials. Blue Cross Blue Shield HMO Blue also does not offer incentives to health care providers to encourage inappropriate denials of care and services. These programs may include any or all of the following:  Pre-admission review, concurrent review, and discharge planning.  Pre-approval of some outpatient services, including drugs (whether the drugs are furnished to you by a health care provider along with a covered service or by a pharmacy).