Definitions for CHC Members

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Below are questions we are frequently asked. Simply Click on the question and you will see our answer. If after reading the answers in this section, you still have unanswered questions, please contact CHC HERE.

Questions and Answers

A Medical Provider is defined as any person performing a Medical Service such as a medical doctor, dentist, vision and hearing professional, nurses and other persons meeting the requirements of their professional organization's affiliation. Your primary doctor is called a Primary Care Physician (PCP). A Medical Provider is also a medical facility such as a hospital and an Urgent Care Facility.

You can use any Medical Provider you choose. There is no "In Network – Out of Network" requirement. However, we recommend you check pricing before selecting any Medical Provider or receiving treatment. Otherwise the cost of the Medical Service may be outside acceptable, usual and customary limits and may be a Denied Coverage as solely determined by CHC. For any Alternative Medical Service, CHC may ask you to provide a referral from a PCP.

A Medical Service is generally classified by: (a) its cost and (b) the Medical Event causing the Medical Service. A Medical Service that has a cost of up to $250 is generally classified as a Routine Medical Service. Over $250, the Medical Service is generally classified as a Non-Routine Medical Service. A Routine Medical Service is generally an Included Coverage. Otherwise the Medical Service may be designated a Non-Routine Medical Service, Denied Coverage or Excluded Coverage as determined solely by CHC.

  • Routine Medical Service: The general definition is a Medical Service for general health and well-being prescribed or ordered by a Medical Provider. A Routine Medical Service is usually a single office visit costing $250 or less. Some examples are doctor office visits, lab and imaging tests, usually associated with an annual wellness exam, and minor medical treatments for a medical, dental, vision and hearing Medical Service.
  • Non-Routine Medical Service: The general definition is: (a) a Medical Service for an unexpected or unplanned Medical Event such as for an Injury, or a Non-Critical or Critical illness, (b) when there is more than one office visit for the same Medical Event or (b) when a Medical Service cost exceeds $250.
    Some general examples are:
    • Injury: A broken bone, a laceration or any type of injury resulting from an Accident.
    • Non-Critical Illness: Fever, mild Arthritis, Abdominal pain, Hernia procedure, Tooth extraction or crown.
    • Critical Illness: Heart Attack, Stroke, Cancer, Kidney failure, Diabetes, Paralysis.
  • Future Medical Service: The general definition is a Medical Service to be performed at a future date. A Future Medical Service requires CHC's prior written approval to be an Included Coverage. We require at least three opinions from Medical Providers before a Future Medical Service can be approved. For approval, you must send to CHC: (a) the name of the Medical Provider, (b) a statement describing the medical procedure and the medical reason for the medical procedure, and (c) the Medical Provider's estimated cost.
  • Alternative Medical Service: The general definition is a wide variety of medical services, practices, products, and therapies not generally covered by traditional insurance or is considered "Alternative" or "Non-Traditional" by the American Medical Association or the federal government. Some examples are holistic, acupuncture, chiropractic and eastern treatments.
  • Elective Medical Service: The general definition is; (a) a non-medically necessary or "vanity" medical service or (b) a medical service not prescribed by a Medical Provider. An Elective Medical Service is a Denied Coverage.
  • Medical Equipment and Product: The general definition is any apparatus, equipment or merchandise that is prescribed by a Medical Provider (Collectively called a "Medical Product"). A Medical Product includes, but is not limited to, eyeglasses, contacts, crutches, etc. A Medical Product is a Non-Routine Medical Service and each Medical Product must be approved in writing by CHC before being classified an approved Included Coverage.
  • Prescription Medications: The definition for a Prescription Medication is a medication requiring a Medical Provider's authorization. Prescription Medications are usually an Included Coverage if: (a) you selected the Prescription Medications coverage as shown in the Table, and (b) the Prescription Medications currently being taking are disclosed in Addendum A. Otherwise, a Prescription Medication requires our prior written approval to be an Included Coverage unless the Prescription Medication is part of a Non-Routine Medical Service, is an Approved Cost and is less than the Prescription Medications MRA. Any medication not prescribed by a Medical Provider is a Denied Coverage.

The general definition is; (a) a non-medically necessary or "vanity" medical service or (b) a medical service not prescribed by a Medical Provider. An Elective Medical Service is a Denied Coverage.

MRA is the Maximum Reimbursement Amount that will be reimbursed for all Medical Services and Prescription Medications. The respective MRA is decreased when Medical Claim reimbursements are paid.

A Medical Claim is defined as a request from the Primary Member for reimbursement or the payment for a Medical Service. A Medical Sub-Claim is the individual Medical Provider bills included with a Medical Claim. A Non-Routine Medical Claim usually has more than one Medical Sub-Claim. For convenience, a Medical Claim with Medical Sub-Claims is collectively referred to as a Medical Claim.

Note: A Co-Pay is due and payable for each Medical Claim and Medical Sub-Claim.

The Explanation of Benefits, referred to as an EOB, contains information on the processing of your Medical Claim. Within approximately fifteen days of receiving your Medical Claim Form and the Medical Claim Documents, CHC will respond by sending you an EOB. Each EOB will show each Medical Sub-Claim received. Some Medical Claims may require more than one EOB to show all related Medical Sub-Claims. An EOB will be sent for each Medical Processing event relating to a change or update of the Medical Claim.

The EOB also shows how your Medical Claims are paid, Account Balances, as well as current and historic financial informatio

A Pre-Existing Medical Condition is defined as any physical, mental, dental, vision or hearing medical condition that existed, was diagnosed or treated by a Medical Provider or otherwise became known to you within five years immediately prior to the Effective Date.

Any Pre-Existing Medical Condition for any CHC Member must be disclosed to CHC. Otherwise the Pre-Existing Medical Condition cost is a Denied Cost.

A Medical Event is any type of injury or illness requiring a Medical Service.

A Life Threatening Medical Condition is a Medical Condition that; (a) likely could cause the end of life if not immediately treated by a Medical Provider, and (b) requires hospitalization for more than 24 hours, and (c) requires immediate attention on the day the Medical Event occurred or (d) is a very severe injury that cannot be immediately treated by a PCP or at an Urgent Care Facility and is immediately referred to a hospital ER.

Medical Financing gives you a "stand-by" source of cash to pay your medical bills after your CHSA is depleted and your MRA has been reduced to $0. Medical Financing is offered by several third-party companies to pay your medical bills.

Contact CHC for additional information and qualifying.

The Benevolent Fund's purpose is to help lower income, CHC Members pay medical costs. The Benevolent Fund is managed by CHC and is funded by donations from CHC Members and other parties.

Contact CHC for additional details.

Coverage Area is where you can receive medical treatment and your Medical Claims will be processed. With CHC your coverage area options are the U.S. or World-Wide. If you travel outside the U.S., you should have the World-Wide coverage.