Whenever the following words or terms are used in this section of your booklet, whether capitalized or uncapitalized, they shall have the meanings stated below:

“Access Line” - A toll-free telephone number available twenty-four (24) hours each day, seven (7) days each week to provide general assistance, referrals and access to the identity and location of any network assessor, provider or facility.

“Allowable Charges” - The fee or charge usually made by the provider of mental health or chemical dependency services, which may not exceed the prevailing charge in the area for a service of the same nature and duration.

“Alternate Care Treatment” - A planned, medical therapeutic program for persons with mental disorders or chemical dependency problems which includes diagnosis, medical care, and treatment when the patient does not require full-time hospitalization, but does need more intensive care than traditional outpatient visits.

“Assessor” - An network provider specifically selected by for skills in evaluation, diagnosis and referral.

“Authorization” - A decision, issued in writing by the Medical Director or his/her designee, that benefits under this program are payable for certain services that an eligible participant or dependent will receive or has received.

“Chemical Dependency” - Psychological or physical dependence on alcohol or other mind-altering drugs that requires diagnosis, care and treatment.

“Coordination of Benefits” - The coordination of the payment of benefits between two or more payers of benefits, on a primary or secondary payer basis, to avoid duplication of benefit payments.

“Copayment” - The payment to be collected directly by the network provider or facility from the eligible participant for Covered Services. The copayment is collected at the time the service is rendered or as otherwise agreed upon by the eligible participant and the network provider or facility.

“Covered Services” - See “Mental Health and Chemical Dependency Services.”

“Custodial Care” - Care rendered to a patient who:

1. Is disabled mentally or physically and such disability is expected to continue and be prolonged;
2. Requires a protected, monitored, or controlled environment whether in an institution or in a home;
3. Requires assistance to support the essentials of daily living; and
4. Is not under active and specific psychiatric treatment that will reduce the disability to the extent necessary to enable the patient to function outside the protected, monitored, or controlled environment.

A determination that custodial care is required is not precluded by the fact that a patient is under the care of a supervising or attending physician or other provider, and services are being ordered and prescribed to support and generally maintain the patient’s condition, or provide for the patient’s comfort, or ensure the manageability of the patient.

“Dependent” - Any person who is a “dependent” of an eligible participant under the eligibility requirements of the Western Teamsters Welfare Trust.

“Domiciliary Care” - Inpatient institutional care provided to an eligible participant or dependent, not because it is medically necessary, but because the care in the home setting is not available, is unsuitable, or members of the patient’s family are unwilling to provide the care. Institutionalization because of abandonment constitutes domiciliary care.

“Eligible Participant” - Any participant who, under the eligibility rules of the Western Teamsters Welfare Trust, is entitled to indemnity medical benefits under this Plan.

“Emergency” - The sudden onset of a condition manifesting itself by acute symptoms of sufficient severity that, in the absence of immediate medical attention and/or Mental Health and Chemical Dependency Care Services, could reasonably result in:

• Serious injury to life or limb;
• Permanently placing the eligible participant’s health in jeopardy; or
• Causing serious and permanent dysfunction to the eligible participant.

“Experimental” - Medical care that is essentially investigatory or an unproved procedure or treatment regimen that does not meet the generally accepted standards of usual professional medical practice in the general medical community.

“Hospital” - Any duly licensed and accredited acute care psychiatric facility or psychiatric unit in a general acute care hospital which provides inpatient care and is engaged in providing facilities and services for the diagnosis and treatment of mental disorders.

“Inpatient” - An eligible participant or dependent who has been admitted to a hospital or alternate care program for bed occupancy for purposes of receiving necessary Mental Health or Chemical Dependency Services, with the reasonable expectation that the eligible participant will remain in the institution at least twenty-four (24) hours.

“Medical Director” - A physician licensed to practice medicine in the state of California, employed by to coordinate and monitor the quality assurance, utilization management, provider and facility service responsibilities for .

“Medically Necessary Service” (also “Medically Necessary” or “Medical Necessity”) - A health care service, treatment or supply which meets all of the following conditions:

1. It is rendered for the treatment or diagnosis of a Mental Disorder or Chemical Dependency;
2. It is “appropriate”, that is: (a) it is consistent given the symptoms and the diagnosis; (b) the type, level and length of service or supply, and setting are needed to provide safe and adequate care and treatment; (c) it is in keeping with the generally accepted standards for good medical practice within the organized medical community; (d) for a hospital stay, acute care as an inpatient must be required for treatment or diagnosis and safe and adequate care cannot be received on an outpatient basis or in a less restrictive setting, and; (e) to the extent that it is rendered by a professional, the professional is properly licensed or certified pursuant to applicable state and federal law and the care, treatment, or supply falls within the professional’s permissible scope of practice as provided by applicable state and federal law and the rules and regulations of any supervising professional organization;
3. It is not mainly for the convenience of , the eligible participant or dependent, or the eligible participant’s or dependent’s health care provider;
4. It is rendered in an environment in which Mental Health or Chemical Dependency Services are performed at the least restrictive level of care providing effective treatment;
5. In the case of ambiguity, is determined to be a medically necessary service by the Quality Assurance/Utilization Management Program.

“Mental Disorder” - A Mental Disorder is a mental or nervous condition that meets all of the following conditions:

1. It is a clinically significant behavioral or psychological syndrome or pattern;
2. It is associated with a painful symptom such as distress;
3. It impairs a patient’s ability to function in one or more major life activities; and
4. It is a condition listed as an Axis I Disorder (except for V-codes) of the then latest edition of the Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) by the American Psychiatric Association (DSM-IV).

“Mental Health and Chemical Dependency Services” - Services which are medically necessary and clinically appropriate for the treatment of a Mental Disorder or Chemical Dependency. Mental Health or Chemical Dependency Services must be furnished by a professional provider and can include, but are not limited to, outpatient individual and group therapy sessions, inpatient hospitalization, day treatment programs, evening programs and intensive outpatient treatment.

“Network Facility” - An contracted network hospital or an approved alternate care program certified by applicable State and Federal laws which furnishes Mental Health or Chemical Dependency Services to eligible participants and dependents, and has agreed, by signing a facility provider agreement with , to accept the provisions of the applicable agreement, including the facility-specific compensation, as the total charge, whether paid in full by or requiring cost-sharing by the eligible participant.

“Network Provider” - A professional mental health care provider (i.e., licensed clinical social worker, psychologist or psychiatrist) who furnishes Mental Health or Chemical Dependency Services to eligible participants and dependents and has agreed, by signing an individual network provider agreement with , to accept the provisions of the applicable agreement, including the contractually agreed upon compensation, as the total charge, whether paid in full by or requiring cost-sharing by the eligible participant.

“Other Plan” or “Plan” - Any plan which provides full or partial benefits for Mental Health or Chemical Dependency Services and which meets the definition of other similar plans as set forth in the Coordination of Benefits section of the Indemnity Medical Plan.

“Outpatient” - An ambulatory eligible participant receiving Covered Services who has not been admitted to a hospital or facility.

“Payer” or “Group” - The Western Teamsters Welfare Trust.

“Pre-admission Certificate” - The process of evaluating and certifying the necessity of a non-emergency admission to a facility provider. Pre-admission certification must be obtained from the Medical Director or his/her designee.

“Provider” or ”Professional Provider” - A clinical social worker, marriage family child counselor, psychologist or psychiatrist, who is properly licensed or certified by applicable state and federal laws to provide mental health or chemical dependency services.