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1.3 £01N.§UR A~I; means the Member's percentage share for any Covered Service provided at less than 100 percent. 1.4 QOPAYMENT means a lbcod 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 P.artlc lpa Hng Providers wnich qualify for payment under the terms or a Member's Health Plan , as described In the applicable Certificate or policy, includlng any amendments Uiereto. 1.6 ·CREDENTIALING is the co lledion , ver1fica1lo n and review or ll'lformauon by Company to determfne whether. a ptoVlder ls eligible to partJclpate in ti,e Provider Ne\works. The Co mpany shall nave sate dhJcretion in determining whether to participate with any applicant. 1.7 Q!;DUSaf.BLE means the dollar amount that the Member must pay each calendar year tie fore ComflllnY beg ins to make payments. 1.8 HEAL TH Pl.Alt means any group or Individual , insured or self.funded health care plan issued end/or administered by Company, or by ahother entity ,vtlh i:l~ess to the appllcable Provider Ne\wor~ punn.illnl lo an ag~ement with, Company , Includ ing , but not I ml\ed to , The Regenee Group, Regence BlueSh eld or any or 11!1 alllllate_s, and or other state and federal programs . 1.9 MEDICAL GROUP means a group of p"yslr.ians and/ot other health care providers who pro_vlde services under the same taK idenUlloallon number. 1.1 o MEDICAL GROUP PROVIDER. means a member, e·mployee or contracto r or the Medical Group who Is duly licensed or legally authorized to render health care &ervices In the state of Washington and who is obligated, by virtue of his/her membership In, contractual relatlonship •wllh or employment by Med ical Group, to provide s_ervlces lo Members . 1.11 Mfil)ICAL EMERGENCY la the emerge.nl arid acute onset or e symptom or symptoms, lnclu~lng ~evere pa in. that would teacl a pru dent lay p1m1on acting reasonably to beUeve tha t a health condition eKiets that requires Immediate medical attention , and that faUure lo prov ide medlcaJ attenl on would result Ii, serklus impairment to bodily functions or serious dysfunction of a 'bodily organ or part. or would place tlie person'e Ilea.Ith In serious Jeopardy . 1.12 MEDI AL !jg;essn;Y, Except for seNIC88 subject to WAC 284-43-7000 , "Medically Neceissary" or "Med lca l Necoes lly' means health care services or supplies Iha! a physic ian or other health care provider, eKetclslng prudent cllnlcal , Judgment, would provide to a i,atlent for 1he purpose of prevent.Ing , evaluaUng , dfagnoaing or trealfng an lllnesfi. lnJu(Y. d sesse or Its &ymploms , and that are (a) i.n accordance wlth generally accepted standards or medical practJce ; (b) clinically aj:)proprla!e , lh terms of type , frequency, extent , alt~ ahd du~tjon, and considered effective fo r the patient's illness, injury Of di&aase ; and {c) not i,rimarily for the convenience or the patient, physic ian, or other health care provider, end not more ~slly than an alternative cServlce o~ sequence or servlce3 or supply at least as likely 10 produce e-qulvalent therapeulic or dlagnosuc results as to the dlagnos fs or treatment of that pallent's Illness , Injury or disease. For lhess purposes, •genef&IIY llccepted standards or med[cal practice• means sta/ldards lhat are based on cre _alble scleriliflc e111dence publlshed In peer-revlewed m_ed !car tlterature generally rec ogn ized by the relevant medical community , Physlclan Spec1.alty, Society recommendations .and Iha views of physic ans and othe r health care providers practicing In t elallant clln fcal a1eas and · any other relevant factors . Fo r services subject to WAC 284-43--7000 , "Medical Necess ity' or •Medically Necessary • shall have the meaning sel'for1h in WAC284-43-7020. Asurls MGA Agreement (Rev, 0512017) A18816854M Page 2 af 20