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1.3 COINSURANCE. means the Member's percentage share for any Covered Service provided at less than 100 percent. 1.4 COPAYMENT means a fixed dollar amount that the Member's Health Plan requires the Member to pay for a Covered Service. 1.5 COVERED SERVICES are those health services and supplies provided to Members by Participating Providers which qualify for payment under the terms of a Member's Health Plan, as described in the applicable Certificate or policy, including any amendments thereto. 1.6 CREDENTIALING is the collection, verification and review of information by Company to determine whether a provider is eligible to participate in the Provider Networks. The Company shall have sole discretion in determining whether to participate with any applicant. 1.7 DEDUCTIBLE means the dollar amount that the Member must pay each calendar year before Company begins to make payments. 1.8 HEALTH PLAN means any group or individual, insured or self-funded health care plan issued and/or administered by Company or by another entity with access to the applicable Provider Network pursuant to an agreement with Company, including, but not limited to, The Regence Group, Regence BlueShield or any of its affiliates, and or other state and federal programs. 1.9 MEDICAL GROUP means a group of physicians and/or other health care providers who provide services under the same tax identification number. 1.10 MEDICAL GROUP PROVIDER means a member, employee or contractor of the Medical Group who is duly licensed or legally authorized to render health care services in the state of Washington and who is obligated, by virtue of his/her membership in, contractual relationship with or employment by Medical Group, to provide services to Members. 1.11 MEDICAL EMERGENCY is the emergent and acute onset of a symptom or symptoms, including severe pain, that would lead a prudent lay person acting reasonably to believe that a health condition exists that requires immediate medical attention, and that failure to provide medical attention would result in serious impairment to bodily functions or serious dysfunction of a bodily organ or part, or would place the person's health in serious jeopardy. 1.12 MEDICAL. NECESSITY Except for services subject to WAC 284-43-7000, "Medically Necessary" or "Medical Necessity" means health care services or supplies that a physician or other health care provider, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing or treating an illness, injury, disease or its symptoms, and that are (a) in accordance with generally accepted standards of medical practice; (b) clinically appropriate, in terms of type, frequency, extent, site and duration, and considered effective for the patient's illness, injury or disease; and (c) not primarily for the convenience of the patient, physician, or other health care provider, and not more costly than an alternative service or sequence of services or supply at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient's illness, injury or disease. For these purposes, "generally accepted standards of medical practice" means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, Physician Specialty Society recommendations and the views of physicians and other health care providers practicing in relevant clinical areas and any other relevant factors. For services subject to WAC 284-43-7000, "Medical Necessity" or "Medically Necessary" shall have the meaning set forth in WAC284-43-7020. Asuris MGA Agreement (Rev. 05/2017) A18816854AA Page 2 of 20