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Key terms

List of key terms in the ExxonMobil Medical Plan – Aetna POS II A and POS II B options

Approved Clinical Trial

A phase I, phase II, phase III, or phase IV clinical trial that is conducted in relation to the prevention, detection, or treatment of cancer or other life- threatening disease or condition and meets any of the following three conditions:

  • Federally funded trials. The study or investigation is approved or funded (which may include funding through in-kind contributions) by one or more of the following:
  • The National Institutes of Health.
  • The Centers for Disease Control and Prevention.
  • The Agency for Health Care Research and Quality.
  • The Centers for Medicare & Medicaid Services.
  • Cooperative group or center of any of the entities described in clauses (a) through (d) or the Department of Defense or the Department of Veterans Affairs.
  • A qualified non-governmental research entity identified in the guidelines issued by the National Institutes of Health for center support grants.

Any of the following if certain conditions are met:

  • The Department of Veterans Affairs.
  • The Department of Defense.
  • The Department of Energy.
  • The study or investigation is conducted under an investigational new drug application reviewed by the Food and Drug Administration; or
  • The study or investigation is a drug trial that is exempt from having such an investigational new drug application.
  • The conditions for this clause (g) are that the study or investigation has been reviewed and approved through a system of peer review that the Secretary of Health and Human Services determines: to be comparable to the system of peer review of studies and investigations used by the National Institutes of Health, and assures unbiased review of the highest scientific standards by qualified individuals who have no interest in the outcome of the review.
  • The study or investigation is conducted under an investigational new drug application reviewed by the Food and Drug Administration; or
  • The study or investigation is a drug trial that is exempt from having such an investigational new drug application.

Balance Bill

The difference between the Plan’s reimbursement for out-of-Network services and what the Provider charges. 

Barred employee

An employee who is covered by a collective bargaining agreement except to the extent participation is provided under such agreement.


The person or entity that receives benefits when you die. The Plan provides a standard list of beneficiaries but you may name another beneficiary if you wish.

Behavioral health condition 

Neurosis, psychoneurosis, psychopathy, psychosis, or mental or emotional disease or behavioral disorder or disturbance with a diagnosis code from the American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders (5th ed. 2013) (DSM-V), or its successor publication, and which is appropriately treated by the Behavioral health Network. Such a condition will be considered a behavioral health condition, regardless of any organic or physical cause or contributing factor.

Behavioral health provider 

A person, including a psychiatrist, psychologist, psychiatric nurse or social worker, therapist, or other clinician with at least a master’s degree, who provides inpatient or outpatient treatment for a behavioral health condition, who is licensed in the state of practice and who is acting within the scope of that license (if applicable). If the person is not subject to a licensing requirement, the person must provide treatment consistent with that which would be provided by the type of providers listed above.

Benefit service

Generally, all the time from the first day of employment until you leave the company’s employment. Excluded are:

  • Unauthorized absences,
  • Leaves of absence of over 30 days (except military leaves or leave under the Federal Family and Medical Leave Act),
  • Certain absences from which you do not return,
  • Periods when you work as a non-regular employee, as a special agreement person, in a service station, car wash, or car-care center operations, or
  • When you are covered by a contract that requires the company to contribute to a different benefit program, unless a special authorization credits the service.

Benefit predetermination

The review of proposed treatment or services before the expense is incurred to determine if, and to what extent, charges will be covered by the Plan. 

Case management

Review provided by medical professionals who consult with the patient and/or care providers to determine effective, cost-efficient ways to treat illnesses and utilize plan benefits.

Change in status

Life or work event that allows you to make changes to your elections during the plan year and outside of annual enrollment.


A person under age 26 who is:

  • A natural or legally adopted child of an employee,
  • A grandchild, niece, nephew, cousin, or other child related by blood or marriage to an employee, or the spouse of an employee (separately or together) is the sole court appointed legal guardian or sole managing conservator,
  • A child for whom the employee has assumed a legal obligation for support immediately prior to the child’s adoption by the employee or,
  • A stepchild of an employee.
  • Child does not include a foster child.

Claims administrator / processor 

Aetna Life Insurance Company, or affiliates, for claims other than outpatient prescription drugs, and Express Scripts for retail and home delivery of outpatient prescription drugs.

Claims fiduciary

For the purpose of section 503 of Title 1 of the Employee Retirement Income Security Act of 1974, as amended (ERISA), the claims fiduciary is the person with complete authority to review all denied claims for benefits under the Plan. Each claims fiduciary has the right to adopt reasonable policies, procedures, rules and interpretations of the Plan to promote orderly and efficient administration. A claims fiduciary may not act arbitrarily and capriciously, which would be an abuse of its discretionary authority.

Concurrent care claims

Concurrent claims are any claims that involve an ongoing approved course of treatment. Typically, concurrent claims will be handled as either a pre-service claim or urgent care claim, depending on the circumstances.

Copayments and coinsurance

Your share of covered services (including out-patient prescription drugs) and behavioral health and substance use disorder expenses. For some services, such as hospital stays, the coinsurance will be a percentage of the cost of the service once the deductible has been satisfied. For other services, such as office visits to a POS II provider, the copayment will be a fixed amount. For outpatient prescription drugs there is a percentage copayment up to a per-prescription maximum.

Covered medical expense

For treatment of injury or sickness — a medically necessary expense incurred by a covered person that is not excluded from coverage, and

For treatment of behavioral health or substance use disorder— a medically necessary expense that is certified in advance of actual treatment or an out-of-network inpatient treatmentthat is provided according to the terms of the Plan, and that is not otherwise excluded from coverage.

Covered person 

Any person identified on the books of the employer as an employee, extended part-time employee, eligible family member, or survivor who:

Complies with the established enrollment requirements and makes any required contributions, and

Is not eligible for any other medical plan to which ExxonMobil contributes on their behalf.

Custodial care

Care that helps meet personal needs and daily living activities. Such care, even if ordered by a doctor and performed by a licensed medical professional such as a nurse, is not covered by the Plan. Examples are:

  • Routine patient care such as changing dressings, periodic turning and positioning in bed
  • Administering oral medications
  • Care of a stable tracheostomy (including intermittent suctioning)
  • Care of a stable colostomy/ileostomy
  • Care of stable gastrostomy/jejunostomy/nasogastric tube (intermittent or continuous) feedings
  • Care of a bladder catheter (including emptying/changing containers and clamping tubing)
  • Watching or protecting you
  • Respite care, adult (or child) day care, or convalescent care
  • Institutional care. This includes room and board for rest cures, adult day care and convalescent care
  • Help with walking, grooming, bathing, dressing, getting in or out of bed, toileting, eating or preparing foods
  • Any other services that a person without medical or paramedical training could be trained to perform
  • Any service that can be performed by a person without any medical or paramedical training


The amount of covered expenses you must pay each calendar year before the Plan begins sharing the cost. Fixed amount copayments do not apply toward this amount. Outpatient prescription drug copayments are not subject to nor do they count toward the annual deductible. The deductible is applied to your claims in the order Aetna processes them, not when the provider collects the money from you. This means if you pay your deductible to one provider, it may not be applied to your annual deductible if Aetna has received and processed other claims first. Please be sure to always get an itemized bill and retain proof of your payment, should you need to recover money from your provider.

Eligible employees

Most U.S. dollar-paid employees of Exxon Mobil Corporation and participating affiliates are eligible. The person must be classified on the employer’s books and records as an employee.

The following are not eligible to participate in the Plan: leased employees as defined in the Internal Revenue Code, or special agreement persons as defined in the plan document. Generally, special-agreement persons are persons paid by the company on a commission basis, persons working for an unaffiliated company that provides services to the company, and persons working for the company pursuant to a contract that excludes coverage of benefits.

Eligible family members

Eligible family members are generally your:


A child who is described in any one of the following paragraphs (1) through (3):

has not reached the end of the month during which age 26 is attained, or 

is totally and continuously disabled and incapable of self-sustaining employment by reason of mental or physical disability, provided the child:

(a) meets the Internal Revenue Service’s definition of a dependent, and
(b) was covered as an eligible family member under this Plan immediately prior to age 26 when the child’s eligibility would have otherwise ceased, and    
(c) met the clinical definition of totally and continuously disabled before age 26 and continues to meet the clinical definition through subsequent periodic reassessment reviews, or           

is recognized under a qualified medical child support order as having a right to coverage under this Plan.

A child aged 26 or over who was disabled but who no longer meets the requirements of paragraphs two (2) above, ceases to be an eligible family member 60 days following the date on which the applicable requirement is not met.

Please note: An eligible employee’s parents are not eligible to be covered.


A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson (including the parent of a minor child or the guardian of a disabled individual), who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in:

  • Placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy,
  • Serious impairment to bodily function, or
  • Serious dysfunction of any bodily organ or part.
  • With respect to emergency services furnished in a hospital emergency department, the Plan does not require prior authorization for such services if you arrive at the emergency medical department with symptoms that reasonably suggest an emergency condition, based on the judgment of a prudent layperson, regardless of whether the hospital is an in-network provider.

The Plan covers medically necessary emergency services including the following:

  • Initial services. A medical screening examination within the capability of a hospital emergency department or freestanding independent emergency department, including ancillary services routinely available in the emergency department, to determine whether an “emergency medical condition” exists.
  • Post-stabilization services. Additional services covered under the plan that are furnished by a nonparticipating provider or nonparticipating emergency facility after a participant or beneficiary is stabilized and as part of outpatient observation or an inpatient or outpatient stay with respect to the visit in which the initial services were provided

Expatriate employees

Expatriate employees include service-oriented employees employed by non-U.S., non-participating employers who are temporarily working in the United States either under a visa that requires coverage by an ExxonMobil plan of such employee while in the United States or in an assignment in the United States and the terms of the assignment require proof of adequate medical coverage. Expatriate employees include regular employees working on an assignment outside the United States where the terms of the assignment require proof of adequate medical coverage.

Experimental or investigational

A medical treatment or procedure, or a drug, device, or biological product, is experimental or investigational if any of the following apply:

The drug, device, or biological product cannot be lawfully marketed without approval of the U.S. Food and Drug Administration (FDA), and approval for marketing has not been given at the time it is furnished; [Note: Approval means all forms of acceptance by the FDA].

Reliable evidence shows that it is the subject of ongoing phase I, II, or III clinical trials or under study to determine its maximum tolerated dose, its toxicity, its safety, its efficacy, or its efficacy as compared with the standard means of treatment or diagnosis, or

Reliable evidence shows that the consensus of opinion among experts regarding the drug, device, or biological product or medical treatment or procedure, is that further studies or clinical trials are necessary to determine its maximum tolerated dose, its toxicity, its safety, its efficacy, or its efficacy as compared with the standard means of treatment or diagnosis. Reliable evidence shall mean only:

  • Peer reviewed, published reports and articles in the authoritative medical and scientific literature,
  • The written protocol or protocols used by the treating facility or the protocol(s) of another facility studying substantially the same drug, device, or biological product or medical treatment or procedure, or
  • The written informed consent used by the treating facility or by another facility studying substantially the same drug, device, or medical treatment or procedure.

Explanation of benefits (EOB)

The summary you receive after your claim is processed. Codes referred to on the EOB are explained on the document.

Extended-care facility 

An institution that meets the following criteria:

  • Provides 24-hour skilled nursing care and related services for the rehabilitation of injured or sick persons.
  • Has policies developed with the advice of and subject to the review of professional personnel to cover nursing care and related services.
  • Has a physician, a registered professional nurse or a medical staff responsible for the execution of such policies.
  • Requires that every patient be under the care of a physician and makes a physician available to furnish medical care in an emergency.
  • Maintains clinical records on each patient and has appropriate methods for dispensing drugs and biologicals.
  • Provides for periodic review by a group of physicians to examine the need for admissions, adequacy of care, duration of stay and the medical necessity of continuing stay of patients.
  • Is licensed pursuant to law or is approved by an appropriate authority as qualifying for licensing.
  • Does not include a place that is primarily for custodial care.

ExxonMobil Medical Plan

The Plan sponsored by Exxon Mobil Corporation which provides medical benefits for eligible employees and their family members.

ExxonMobil Retiree Medical Plan (EMRMP)

The Plan sponsored by Exxon Mobil Corporation which provides medical benefits for eligible retirees, survivors and their family members, and includes the Retiree Medical Plan (RMP) and the Medicare Primary Option (MPO) as parts.


An institution which:

  • Is licensed as a hospital (if licensing is required),
  • Is operated pursuant to law for the care and treatment of sick and injured persons,
  • Provides 24-hour nursing care and has facilities both for diagnosis and surgery, except in the case of a hospital primarily concerned with the treatment of chronic conditions, and
  • Is not a hotel, rest home, nursing home, convalescent home, place for custodial care, or home for the aged.

For purposes of this definition, hospital shall also mean, with respect to treatment of substance abuse, a treatment facility, residential facility, or a clinic licensed or approved for such treatment by the appropriate authority for the jurisdiction in which the facility or clinic is located.

Incidental charges

Aetna’s current standards for incidental charges are based on the Current Procedural Terminology (CPT) codes and guidelines authored and revised by the American Medical Association since 1966. CPT coding has become the most widely accepted format, by both government and private health insurance programs, in reporting physician procedures. CPT coding furnishes health care providers with a uniform system to accurately describe medical services. CPT coding guidelines explain that services commonly carried out as an integral component of a total service or procedure should not be reported as a separate procedure.

When a claim is submitted with multiple CPT codes, Aetna uses the CPT guidelines to determine whether the charges should be considered as separate costs or if the charges are typically considered as one cost. If Aetna determines that the charges should have been submitted together under one CPT code, the separate charges would be considered incidental to the primary procedure, and the amount allowed for reimbursement would be the amount for the primary procedure.

Example: Your provider administers an immunization and submits separate charges: one for the medication administered in the immunization and another for administering the shot. In most cases, an immunization should be submitted for payment using one CPT code. If it is submitted as two separate charges, Aetna uses the CPT guidelines and pays only one CPT code for the cost of the medication. The charge for administering the shot is considered to be incidental and is not paid.

Network providers have agreed to accept incidental charges reductions; however, you are responsible for incidental expenses when you use a non-network provider or if you have signed a statement in the provider’s office saying you will be responsible for incidental charges.

Multiple surgeries (including bilateral procedures)

When multiple surgeries are performed, a health industry standard calculation method is used to reflect the cost savings that accompany services rendered during the same operative session. Contact Aetna Member services for additional details on the amounts allowed.

Multiple imaging diagnostic tests

When certain multiple imaging diagnostic tests (e.g., MRIs, CT scans, ultrasounds) are performed on the same date of service, the amount allowed for reimbursement is 100% of the fee schedule (network) or reasonable and customary charge (non-network) for the first diagnostic test and 50% for subsequent tests ordered during a single encounter. 

Medical necessity or medically necessary

  • Legal,
  • Ordered by a physician for medical treatment,
  • Reasonably required for the treatment or management of the condition for which it is ordered, and
  • Commonly and customarily prescribed by the United States medical community as treatment or management of the condition for which it is ordered.

When determining medical necessity, Clinical Policy Bulletins (CPBs) published by Aetna, the claims administrator may be used.

CPBs are based on objective, credible sources, such as the scientific literature, guidelines, consensus statements and expert opinions. These CPBs may be found on the Aetna website at

Medical pre-certification 

Certification obtained prior to a hospital inpatient stay (including behavioral health and substance abuse) to give notice of inpatient admission and the proposed care. If you do not pre-certify hospital stay, you will be responsible for the first $500 of eligible expenses. Refer to the Aetna National Precertification list for details of services requiring precertification.

Medical POS II (point of service)

A network of established physicians, hospitals and other medical care providers whose credentials have been screened according to Aetna’s standards and who have agreed to provide their services at negotiated rates. The POS II option is a network specifically selected by the Plan — it is part of Aetna’s Choice® POS II. This network is referred to in this SPD as the Medical POS II.


The term Medicare means the program of medical care benefits provided under Title XVIII of the Social Security Act of 1965 as amended. Prescription drug coverage under the ExxonMobil Medical Plan is considered creditable coverage and the Notice of Creditable Coverage is provided annually.

No volitional control

Charges incurred if you had no volitional control in determining the provider will be reimbursed at 80% after the deductible for the EMMP POS II B and 75% after the deductible for the EMMP POS II A option, as though a network provider was used.

Non-network charges incurred through the use of a network facility for radiologists, anesthesiologists, pathologists, neonatologists, intensivists, will also be reimbursed at 80% after the deductible for the EMMP POS II B and 75% after the deductible for the EMMP POS II A option, as though a network provider was used. However, charges incurred through the use of a non-network facility for non-network radiologists, anesthesiologists, pathologists, neonatologists, intensivists, and hospitalists continue to be reimbursed as non-network.

Reimbursement to non-network providers will be limited to a reasonable and customary amount, rather than billed charges. In the event you are billed for any balance at a network facility or in an emergency situation at a non-network facility, by a non-network physician, you may submit the balance to Aetna for additional processing. Only amounts that are above the reasonable and customary fee schedule will be considered for additional reimbursement. Charges for services not covered by the Plan will not be reprocessed. If you do and you are enrolled in the automatic rollover process to your Health Care Flexible Spending Account (HCFSA), an overpayment from the HCFSA may result from the additional processing. You should contact Aetna to discuss options to return the overpaid HCFSA funds back into the account.


Providers and facilities that participate in the Medical POS II network available under the EMMP POS II option.


Providers and facilities located in the Medical POS II network areas, but which do not participate in a network available under this Plan.


A registered graduate nurse (RN), a licensed vocational nurse (LVN), or a licensed practical nurse (LPN).

Out-of-network area

Geographic areas that do not fall within the Medical POS II network.

Out-of-pocket limit 

The amount of covered medical expenses you pay in one year before the Plan begins paying 100%. The EMMP POS II A and B options have different out-of-pocket limits. The out-of-pocket limit is accumulated in the order Aetna processes the claims. After the out-of-pocket limit is reached, the Plan pays 100% of most covered expenses for the remainder of that  Calendar year. Certain expenses that you pay do not apply to the out-of-pocket limit. The annual deductible and your percentage copayments for eligible expenses apply to the out-of-pocket limit. The following charges do not apply to the out-of-pocket limit:

  • Charges above reasonable and customary limits.
  • Charges not covered by the Plan.
  • Charge of $500 for non-compliance with medical pre-admission review process.
  • Charge of $500 for failure to pre-certify inpatient non-network and out-of-network behavioral health or substance use disorder services.
  • Copayments for outpatient prescription drugs.
  • Charges for a private hospital room above the cost of the hospital’s most common rate for a semiprivate room.

Outpatient prescription drug

A prescription drug or medicine obtained through either a retail pharmacy or through a mail service prescription program (including insulin and associated diabetic supplies if acquired through a prescription). A prescription drug or medicine, including injections, obtained or administered in a physician’s office or in a hospital are not considered outpatient prescription drugs.


Physician means a person acting within the scope of their license and holding the degree of Doctor of Medicine (M.D.), Doctor of Osteopathy (D.O.), Doctor of Dental Surgery (D.D.S.), Doctor of Podiatry (D.P.M.), Doctor of Optometry (O.D.), or Doctor of Chiropractic (D.C.), or who is duly licensed as an Orthoptist, a Physician Assistant or Nurse Practitioner. Primary Care Physician means a Physician engaged in general practice, family practice, internal medicine, pediatrics or obstetrics/gynecology who provides basic health services to covered persons.

Post-service claims

All claims for benefits after medical services have been provided, such as requests for reimbursement or payment for the provided services.


A written pre-determination request will result in a detailed response as to whether a treatment or service is covered under the Plan and whether the proposed cost is within reasonable and customary limits, thus ensuring all parties are aware of the financial consequences, providing all circumstances described in the request remain unchanged. Please note that a pre-determination, either verbal or written, is not a guarantee of payment, as claims are paid based on the actual services rendered and in accordance with Plan provisions.

Pre-service claims

Requests for approval required before medical care, such as preauthorization or a decision on whether a treatment or procedure is medically necessary.

Primary participant 

The term primary participant refers to the participant whose identification number is used. The primary participant is the employee, retiree, survivor or an individual who elected COBRA coverage. Covered family members use the primary participant’s identification number to access all medical benefits.

Private duty nursing

Continuous, substantial and complex in-home nursing care requiring services that can only be provided by a licensed medical professional, has been prescribed by a treating physician, provided on an hourly basis and is determined to be medically necessary. Private duty nursing provides more individual and continuous skilled care than the care that can be provided in a skilled nurse visit through a home health agency.

Qualified Medical Child Support Order 

A Qualified Medical Child Support Order (QMCSO) is a court decree under which a court order mandates health coverage for a child. A QMCSO must include, at a minimum:

  • Name and address of the employee covered by the health plan.
  • The name and address of each child for whom coverage is mandated.
  • A reasonable description for the coverage to be provided.
  • The time period of coverage.
  • The name of each health plan to which the order applies.
  • You may obtain, without charge, a copy of the Plan’s procedures governing QMCSO determinations by written request to the Administrator-Benefits.

Reasonable and customary limits

Allowable amounts for services are determined by reasonable and customary (R&C) limits.

Aetna uses the industry-wide standard for R&C limits. Aetna’s network is based on a percentage of the Medicare allowable rate or on reasonable & customary limits for the geographical area as determined by Aetna. For professional services, R&C limit is based on the Medicare Fee Schedule of charges for similar services in the same geographic area and set at:

  • For facility claims, at 170% of Medicare Fee Schedule of charges for similar services in the same geographic area.
  • For professional claims, at 150% of Medicare Fee Schedule of charges for similar services in the same geographic area.

R&C limits apply only to non-network providers and services.

Example: A non-network provider charges $80 for a particular medical procedure, the reasonable and customary limit is $30, and the network provider charge is $25. Only $30 of the $80 charge will be allowed for payment. At the 60% benefit level for the EMMP POS II B option, the Plan will pay $18 and you will be responsible for paying $12 plus the $50 difference between the reasonable and customary limit and the non-network charge for a total of $62. If you used a Medical POS II provider, you would be charged only the network-negotiated rate of $25 at the 80% network reimbursement level for the EMMP POS II B option. You would have paid only $5 for the same service.

Regular employee 

An employee of a participating employer, whether or not the person is a director, who, as determined by the participating employer, regularly works a full-time schedule, and is not employed on a temporary basis. The definition includes a person who regularly works a full-time schedule but who, for a limited period of time, is approved for a part-time regular work arrangement under the participating employer’s work rules relating to part-time work for regular employees.


Generally, a person at least 55 years old who retires as a regular employee with 15 or more years of benefit service or someone who is retired by the company and entitled to long-term disability benefits under the ExxonMobil Disability Plan after 15 or more years of benefit service, regardless of age.

Retirees who have been rehired as regular or non-regular employees are not eligible for the ExxonMobil Retiree Medical Plan.

Retiree Medical Plan

One of the parts of the ExxonMobil Retiree Medical Plan which provides medical benefits for Pre-Medicare eligible retirees, survivors and their family members. It includes the Retiree Medical POS II and other self-funded options.

Room and board

Room, board, general-duty nursing and any other services regularly furnished by the hospital as a condition of being hospitalized. It does not include professional services of physicians or private-duty nursing.


Type of plan in which the employer takes on most or all of the cost of benefit claims and the insurance company manages the payments.

Spouse; marriage

All references to marriage shall mean a marriage that is legally recognized under the laws of the state or other jurisdiction in which the marriage takes place, consistent with U.S. federal tax law. All references to a spouse or a married person shall refer to individuals who have such a marriage.

Surgical procedure 

This term refers to the following:

  • A cutting operation.
  • Suturing a wound.
  • Treating a fracture.
  • Reduction of a dislocation.
  • Radiotherapy (excluding radioactive isotope therapy) if used in lieu of a cutting operation for removal of a tumor.
  • Electrocauterization.
  • Diagnostic and therapeutic endoscopic procedures.
  • Injection treatment of certain conditions.
  • Laser treatments.

Note: Minor procedures such as biopsies or removal of moles or warts, even if performed in a doctor’s office, are considered surgery.

Survivor/ surviving spouse

A surviving unmarried spouse or child of a deceased ExxonMobil regular employee or retiree.


An employee who is classified as a non-regular employee, but who has been characterized as a Trainee and has graduated from high school.  This definition does not apply to individuals not on the U.S. payroll who are in the U.S. on a trainee assignment and are not on an expatriate assignment into the U.S. 

Urgent care 

Conditions or services that are non-preventative or non-routine and needed in order to prevent the serious deterioration of a person’s health following an unforeseen illness, injury or condition. Urgent care includes conditions that could not be adequately managed without immediate care or treatment but do not require the level of care provided in an emergency room. Treatment of such a condition outside of an emergency room is paid according to the network status of the provider or facility. For example, out-of-network urgent care furnished by an out-of-network provider or facility is reimbursed at the out-of-network benefit level.

Urgent care claims

Special kind of pre-service claim that requires a quicker decision because your health would be threatened if the plan took the normal time permitted to decide a pre-service claim. If a physician with knowledge of your medical condition tells the plan that a pre-service claim is urgent, the plan must treat it as an urgent care claim.


The scope of “visit” to a participating health care facility includes: the furnishing of equipment and devises, telemedicine services, imaging services, laboratory services, and preoperative and postoperative services, regardless of whether the provider furnishing such items or services is at the facility. This applies to OON emergency services and non-emergency services by OON ancillary providers in participating facilities


Calendar year, January 1 through December 31.

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