DEFINITIONS Allowed Amount. The lower of the following amounts:  The actual fee the provider, facility, or vendor charged for the Service.  160 percent of the Medicare fee for the Service, as indicated by the applicable Current Procedural Terminology (CPT) code or Healthcare Common Procedure Coding System (HCPCS) code shown on the current Medicare fee schedule. The Medicare fee schedule is developed by the Centers for Medicare and Medicaid Services (CMS) and adjusted by Medicare geographical practice indexes. When there is no established CPT or HCPCS code indicating the Medicare fee for a particular Service, the Allowed Amount is 70 percent of the actual fee the provider, facility, or vendor charged for the Service. Ancillary Service. Services that are:  Related to emergency medicine, anesthesiology, pathology, radiology, and neonatology, whether provided by a physician or non-physician practitioner.  Provided by assistant surgeons, hospitalists, and intensivists.  Diagnostic Services, including radiology and laboratory Services.  Provided by a Non-Participating Provider if there is no Participating Provider who can furnish such Service at the facility.  Provided as a result of unforeseen, urgent medical needs that arise at the time the Service is provided, regardless of whether the Non-Participating Provider or Non-Participating Facility satisfies the notice and consent requirements under federal law. Annual Open Enrollment. A period of time defined by HCA when a Subscriber may change to another health plan offered by the PEBB Program and make certain other account changes for an effective date beginning January 1 of the following year. Behavioral Health Emergency Services Provider. Emergency Services provided in any of the following settings, which are licensed or certified by the Washington Department of Health:  A crisis stabilization unit.  An evaluation and treatment facility that can provide directly, or by direct arrangement with other public or private agencies, emergency evaluation and treatment, outpatient care, and timely and appropriate inpatient care to persons suffering from a mental disorder.  An agency certified to provide outpatient crisis services.  A triage facility.  An agency certified to provide medically managed or medically monitored withdrawal management services.  A mobile rapid response crisis team that is contracted with a behavioral health administrative services organization operating to provide crisis response services in the behavioral health administrative services organization’s service area. Benefit Summary. A section of this EOC which provides a brief description of your medical Plan benefits and what you pay for covered Services. Evidence of Coverage (EOC). This Evidence of Coverage document provided to the Subscriber that specifies and describes benefits and conditions of coverage. After you enroll, you will receive a postcard that explains how you may either download an electronic copy of this EOC or request that this EOC be mailed to you. EWCLGHDHP1983ACT0124 8 WAPEBB-CD-ACT