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1.10 Medical Management Program means a program consisting of but not limited to authorization; concurrent medical review; primary case management; and a quality assurance program, with the objective to assure that health care services provided to Participants are Medically Necessary and delivered in an appropriate setting. 1.11 Medical Necessity or Medically Necessary means a medical service or medical supply, as determined by the Medical Management Program, which meets all of the following criteria: 1.12 1.13 1.14 1.15 1.16 1.17 1.18 1.19 FCHN-PRO-042016 1. It is required for the treatment or diagnosis of a covered medical condition; 2. It is the most appropriate supply or level of service that is essential for the diagnosis or treatment of the Participant's covered medical condition; 3. It is known to be effective in improving health outcomes for the Participant's covered medical condition in accordance with sufficient scientific evidence and professionally recognized standards; 4. It is not furnished primarily for the convenience of the Participant or the provider of services; and 5. It represents the most economically efficient use of medical services and supplies that may be provided safely and effectively to the Participant. Medical Necessity alone does not determine coverage. Participant means any person who is eligible to receive Covered Services under the terms and conditions of a specific Benefit Plan. Participating Provider or Provider means a physician or other provider licensed to provide health care services under applicable federal and/or state laws who has entered into a written agreement with FCHN to provide Covered Services to Participants pursuant to the terms of the applicable Benefit Plan and this Agreement. Payor means employers, insurance companies, associations, trusts, third-party administrators (TPA) and any other legal entity which (i) has an obligation to administer and pay for Covered Services provided to a Participant under a Benefit Plan, and (ii) has entered into or is subject to a written agreement with FCHN. Primary Care Provider ("PCP") means a Participating Provider who is an allopathic or osteopathic physician or other licensed healthcare provider, practicing in the field of general practice, family practice, general internal medicine or general pediatrics, who meets FCHN's credentialing standards, and under the terms of this Agreement, agrees to provide Covered Services to Participants within the scope of his/her license. Provider Group means a clinic or group (i) comprised of health care professionals all of whom are licensed and/or certified under applicable federal and/or state laws and who bill as one entity, and (ii) which has contracted with FCHN to provide Covered Services to Participants. Provider Policies and Procedures means those policies and procedures established by FCHN which set forth FCHN's and Payors' policies and procedures including, but not limited to, billing and claims payment, provider credentialing, participant grievances, utilization review, and quality management. Specialist Provider means a Participating Provider who is an allopathic or osteopathic physician or other licensed healthcare provider who (i) practices in a particular specialty, (ii) is either Board certified or obtains Board certification within five (5) years after completing residency training, (iii) meets FCHN's credentialing standards, and (iv) under the terms of this Agreement, agrees to provide Covered Services to Participants within the scope of his or her license. Urgent Services means Covered Services provided when a Participant not residing in FCHN's Service Area is temporarily absent from his or her area of residence and (i) such services are Medically Necessary and immediately required as a result of unforeseen illness, injury, or condition, and (ii) ii was not reasonable given the circumstances for the Participant to obtain the services through a provider network in the Participant's area of residence. 2