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Not associated with an occupational injury or disease; and Reasonable.

Medical necessity does not include any service or supply that is for the psychological support, education, or vocational training of the participant. Medical necessity does not include implant of any artificial organ for any reason whatsoever.

Network: A group of providers under contract with the Network Administrator to participate in the Plan’s AHS State Network.

Network Administrator: the organization under contract with the State and School Employees Health Insurance Management Board, which contracts with covered providers to provide negotiated discounts in a defined geographic area. The Network Administrator is responsible for the selection of and ongoing contracting with covered providers. The Network Administrator for the Plan is the Advanced Health Systems (AHS).

Non-occupational Injury or Disease: an injury or disease that does not:

Arise out of (or in the course of) any work for pay or profit; or Result in any way from an injury or disease that does.

A disease will be deemed to be non-occupational regardless of cause if proof is furnished that the person:

Is covered under any type of workers’ compensation law, and Is not covered for that disease under such law.

Non-participating Pharmacy: a pharmacy that has not contracted with the Pharmacy Benefit Manager to be a participating provider of prescription drugs to Plan participants.

Non-participating Provider: a covered provider who has not contracted with the Network to deliver covered medical services or supplies to Plan participants.

Orthotic Device: an orthopedic appliance or apparatus used to support, align, prevent, or correct deformities or to improve the function of movable parts of the body.

Out-of-Area Participant: a Plan participant whose principal/primary residence is located outside the geographic boundaries of the State of Mississippi. Plan participants meeting the requirements of a full-time student dependent are not considered out-of-area participants.

Out-of-Network Review: the process by which Intracorp determines if the Plan will allow in- network level benefits for services provided by a non-participating provider.

Partial Hospitalization: inpatient psychiatric treatment, other than full twenty-four hour programs, in a treatment facility licensed or certified by the state in which services are rendered. The term includes day, night, and weekend treatment programs.


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