2021 Archdiocese of Atlanta Meritain Group Plan Doc - Manual / Resource - Page 57
Over-the-counter nutritional supplements or infant formulas will not be considered eligible even if prescribed
by a Physician.
(34) Occupational Therapy: Rehabilitative occupational therapy rendered by a qualified Physician or a licensed
occupational therapist under the recommendation of a Physician. Expenses for Maintenance Therapy or
therapy primarily for recreational or social interaction will not be considered eligible. Eligible expenses will be
payable as shown in the Medical Schedule of Benefits.
(35) Outpatient Pre-Admission Testing: Outpatient pre-admission testing performed within 7 days of a
scheduled inpatient hospitalization or Surgery. Eligible expenses will be payable as shown in the Medical
Schedule of Benefits.
(36) Oxygen: Oxygen and rental of equipment for its administration.
(37) Phenylketonuria: Special dietary treatment for phenylketonuria (PKU) when recommended by a Physician.
(38) Physical Therapy: Physical therapy rendered by a qualified Physician or a licensed physical therapist under
the recommendation of a Physician. Maintenance Therapy will not be considered eligible. Eligible expenses
will be payable as shown in the Medical Schedule of Benefits.
(39) Physician Services: Services of a Physician for medical care or Surgery.
Telemedicine: Services related to the delivery of clinical medicine via real-time telecommunications
such as telephone, the Internet, mobile app, or other communications networks or devices that do not
involve direct patient contact.
Services performed in a Physician's office on the same day for the same or related diagnosis. Services
include, but are not limited to: examinations, supplies, injections, x-ray and laboratory tests (including
the reading or processing of the tests), cast application and minor Surgery. If more than one Physician
is seen in the same clinic on the same day, only one Copay will apply.
Diagnostic x-ray and laboratory services which are ordered on the same day as the office visit, but
performed or read at a later date and/or at another facility will be considered a separate benefit and
will be payable subject to the Deductible and Coinsurance.
For multiple or bilateral surgeries performed during the same operative session which are not incidental
or not part of some other procedure and which add significant time or complexity (all as determined by
the Medical Plan) to the complete procedure, the charge considered will be: (i) 100% for the primary
procedure; (ii) 50% for the secondary procedure, including any bilateral procedure; and (iii) 50% for
each additional covered procedure. This applies to all Surgical Procedures, except as determined by
the Medical Plan.
For surgical assistance by an Assistant Surgeon, the charge will be 25% of the Usual and Customary
Charge for the corresponding Surgery.
Eligible expenses will be payable as shown in the Medical Schedule of Benefits
(40) Podiatry: Treatment for the following foot conditions: (a) routine foot care needed due to a diabetic condition;
(b) bunions, when an open cutting operation is performed; (c) non-routine treatment of corns or calluses; (d)
toenails when at least part of the nail root is removed; or (e) any Medically Necessary Surgical Procedure
required for a foot condition.
(41) Private Duty Nursing: Private duty nursing care by a licensed nurse (R.N., L.P.N. or L.V.N.). Covered
charges for this service will be included to the following extent:
Inpatient Nursing Care. Charges are covered only when care is Medically Necessary and not Custodial
in nature and the Hospital's Intensive Care Unit is filled or the Hospital has no Intensive Care Unit.
Inpatient Private Duty Nursing must be supported by a certification from the attending Physician.