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usually a physician, must be medically necessary, must not be experimental/investigative, and must not otherwise be excluded in order to be covered under the Plan.

Proof of Loss: written evidence of expenses incurred or payable for services or supplies covered under the terms of this Plan.

Prosthetic Device: an artificial device that replaces all or part of an absent body part, or replaces all or part of the function of a permanently inoperable or malfunctioning body part. Rehabilitative Care: coordinated use of medical, social, educational, or vocational services, beyond the acute care stage of disease or injury, for the purpose of upgrading the physical and functional ability of a patient disabled by disease or injury so that the patient may independently carry out ordinary daily activities.

Residential Facility: a licensed facility providing an inpatient rehabilitation program for the treatment of alcohol or drug abuse or mental or nervous conditions.

Retired Employee: a covered employee who has left employment and qualifies for retirement benefits under a retirement plan approved by the Mississippi Public Employees’ Retirement System (PERS).

Surviving Spouse: the covered spouse of a deceased employee who was eligible to retire or the covered spouse of a deceased retiree who was covered under the Plan at death.

Utilization Review: evaluation of the necessity, appropriateness, and efficiency of the use of medical services, procedures, and facilities.

Valid Assignment: an assignment of benefits to participating providers or to a covered provider that has not been offered an agreement to participate in the Plan’s network.


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