AMERICAN SPECIALTY HEALTH PLANS GROUP SUBSCRIBER AGMT 1998

.... ! ~ 1.10. Experimental or Investigational Chiropractic Care. Experimental or Investigational Chiropractic Care is chiropractic care that is essentially investigatory or an unproven procedure or treatment regimen that does not meet the generally accepted standards of usual Chiropractic practice in the general community. 1.11 Grievance Procedure is the procedure for reviewing Member complaints unrelated to the quality or appropriateness of chiropractic services. 1.12 Group. Group is the employer, association, labor union trust, or other entity identified on the Cover Sheet. 1.13 Health Plan. Health Plan is the Health Plan described in this Agreement. 1.14 Health Plan Premiums. Health Plan Premiums are amounts set forth in the Cover Sheet to be paid to ASHP by Group on behalf of Members in consideration of the benefits provided under this Health Plan. 1.15 ASHP Enrollment Kit. ASHP Enrollment Kit is the kit of information supplied by ASHP to prospective Members which summarizes this Agreement and may contain the ASHP Enrollment Form. 1.16 Maximum Benefit. Maximum Benefit is the maximum amount which ASHP will pay for any Chiropractic Services provided on an annual basis to a Member by Participating Chiropractors. 1.17 Medically Necessary Services. Medically Necessary Services are Covered Services which are: 1) Necessary for the treatment of Neuromuscular-skeletal Disorders; 2) Established as safe and effective and furnished in accordance with generally accepted chiropractic standards to treat Neuromuscular-skeletal Disorders; 3) Appropriate for the symptoms, consistent with the diagnosis, and otherwise in accordance with the generally accepted Chiropractic practice and professionally recognized standards; 4) Pre-Authorized by ASHP, except for an initial examination by a Participating Chiropractor and Emergency Services. 1.18 Medicare. Medicare is the name commonly used to describe Health Insurance Benefits for the Aged and Disabled provided under Public Law 89-97, as amended. 1.19 Member is any Subscriber or Dependent. 1.20 Member Services Department. Member Services Department is the person or persons designated by ASHP to whom oral and written Member complaints may be addressed. The Member Services Department may be contact by telephone at 1-800-678-9133 or by writing to the Member Services Department, at: American Specialty Health Plans, Inc. 8989 Rio San Diego Drive, Suite 250 San Diego, CA 92108 1.21 Neuromuscular-skeletal Disorder. Neuromuscular-skeletal Disorders are misalignments of the skeletal structure and muscular weakness, osteopathic imbalances, and disorders related to the spinal cord, neck and joint.