The following definitions are provided to assist students with navigating the insurance and health care landscape.
Experimental/investigational
A drug, device, medical treatment, or procedure is experimental or investigational if: (a) the drug or device cannot be lawfully marketed without the approval of the U.S. Food and Drug Administration and approval for marketing has not been given at the time the drug or device is furnished, (b) the drug, device, medical treatment or procedure, or the patient informed consent document utilized with the drug, device, treatment or procedure, was reviewed and approved by the treating facility’s Institutional Review Board or other body servicing a similar function, or if federal law requires such review or approval, (c) Reliable Evidence shows that the drug, device, medical treatment or procedure is the subject of ongoing phase 1 or phase 2 clinical trials, or is otherwise under study to determine its maximum tolerated dose, its toxicity, its safety, its efficacy or its efficacy as compared with a standard means of treatment or diagnosis, (d) reliable evidence shows that the prevailing opinion among experts regarding the drug, device, medical treatment or procedure is that further studies or clinical trials are necessary to determine its maximum tolerated dose, its toxicity, its safety, its efficacy or its efficacy as compared with a standard means of treatment or diagnosis. Reliable evidence shall mean only published reports and articles in the authoritative medical and scientific literature; the written protocol or protocols used by the treating facility or the protocols of another facility studying substantially the same drug, device, medical treatment, or procedure; or the written informed consent used by the treating facility or another facility studying substantially the same drug, device, medical treatment, or procedure.
Medically necessary
A service or supply that is, as determined by Student Health Service, necessary and appropriate for the diagnosis or treatment of a sickness or injury based on generally accepted current medical practice. A service or supply will not be considered as medically necessary if: (a) it is provided only as a convenience to the covered person or provider, (b) it is not the appropriate treatment for the covered person’s diagnosis or symptoms, (c) it exceeds in scope, duration, or intensity that level of care which is needed to provide safe, adequate, and appropriate diagnosis or treatment. The facts that any particular physician may prescribe, order, recommend, or approve a service or supply does not, of itself, make the service, or supply medically necessary.
Protected Health Information (PHI)
Any individually identifiable health information created or received by the Plan, whether oral or recorded, in any form or medium, that relates to the past, present, or future physical or mental health or condition of an individual, the provisions of health care to an individual or the past, present, or future payment for the provision of health care to an individual. For purposes of the Security Standards, PHI shall mean Individually Identifiable Health Insurance Information that is transmitted by electronic media, maintained in electronic media, or transmitted or maintained in any other form or medium consistent with the provisions of 45 C.F.R. § 160.103, as amended from time to time.
Plan
The program of health care services provided by the Washington University School of Medicine Student Health Services.
Plan administrator
Washington University School of Medicine.
Plan sponsor
Washington University School of Medicine.
Reasonable and customary charges
The charges which are the smallest of: (a) the actual charge, (b) the charge usually made for a covered service by the provider that furnishes it, and (c) the prevailing charge made for a covered service in the geographic area by those of similar professional standing.
Security incident
The attempted or successful unauthorized access, use, disclosure, modification, or destruction of information or interference with system operations in an operation system, consistent with the provisions of C.F. R. § 164.304, as amended from time to time.
Security standards
The Security Standards for the protection of electronic PHI as set forth in 45 C.F.R. § 164.302-164.318, as amended from time to time.