ACKNOWLEDGEMENTSYour agreement that you understand and accept all of the statements and conditions described in the Acknowledgements section of the Altrua HealthShare Membership Enrollment Application. AUTO DENIALA medical condition that would render you ineligible to join the membership or if later discovered would render you ineligible to remain an active member. BALANCE BILLA practice in which doctors or other health care providers bill you for charges that exceed the allowed amount. CALENDAR YEARA calendar year is January 1st through December 31st of each year. CASE MANAGEMENTA collaborative process available by Altrua HealthShare to help you assess your eligibility, and to assist you with planning, choosing, and coordinating your best possible care. COMBINED MEMBERSHIPA member plus one or more qualified dependents participating in Altrua HealthShare under the same membership. COMMITMENTSThe requirements you acknowledge you must follow in order to maintain an active membership in Altrua HealthShare. COMPLAINANTAlso referred to as a grievant, a complainant is the person who filed the grievance, including the member, a representative designated by the member, or other individual with authority to act on behalf of the member. DATE OF SERVICE (DOS)The date medical services were provided to you. DEPENDENTYour spouse and/or any of your unmarried children (by birth, legal adoption, or marriage) through the age of 22, whom you’ve included on your Membership Enrollment Application. EFFECTIVE DATEThe date your membership begins. ELIGIBLEA status indicating that you have met the conditions that qualify for sharing as described in the Membership Guidelines, and your medical needs fall within the sharing limits. EMERGENCYAn emergency is defined as treatment that must be rendered to the patient immediately for the alleviation of the sudden onset of an unforeseen illness or injury that, if not treated, would lead to further disability or death. Enrollment DATEThe date when Altrua HealthShare receives your completed Membership Enrollment Application. EOS (EXPLANATION OF SHARING)A statement sent to you and your providers once your sharing of medical needs have been processed, are pending, or are denied. This statement specifies the amount you owe—your Member Responsibility Amount (MRA)—and the amounts that were shared by the membership. ESCROW INSTRUCTIONSAuthorized detailed instructions given to Altrua HealthShare to manage the membership escrow account as the escrow agent. GRIEVANCEA written or oral expression of dissatisfaction regarding the membership or the membership plan and may include a complaint, dispute, request for reconsideration or appeal made by a member or the member’s representative to Altrua HealthShare. GRIEVANCE INTAKE FORMA form used to handle a member’s written or oral expression of dissatisfaction regarding the membership or their membership plan. HEAD OF HOUSEHOLDThe oldest participating member in your household, whether you’re an individual member with no dependents, a husband or father, a wife or mother, or a child. HEALTHCARE CREDIT (HC)The Altrua HealthShare membership provides HC to all members. The HC may be used for any healthcare needs including office and specialist visits, laboratory services, preventative visits, radiology services, alternative medicine, chiropractic treatment, dental check-ups and cleanings, vision exams, and other services that the member feels necessary to maintain good health and that is in agreement with the Membership Guidelines. HCs are reimbursable to the member only, and may not be used towards the Per Incident MRA. For HC to be applied toward medical needs, the member is first responsible for payment of 25% of expenses incurred for services. After the 25% payment by the member and application of the HC, if there is a remaining balance, it is the member’s responsibility. The HC begins to accumulate upon the membership effective date, however, there is a 90-day waiting period to utilize them. The HC is credited at the start of each new calendar quarter and is prorated to include only months of active membership. HOUSEHOLDIf you’re an individual member with no dependents, it’s you. If you’re a member or a dependent, it’s the members of your family group who have been accepted to a combined membership. INCIDENT Illness or accident under which treatment qualifies for sharing by the membership, subject to the per incident MRA. An incident includes signs, symptoms, medical treatment or testing that lasts until one of the following events occurs: 1) a certain medical condition is cured according to medical records 2) treatment is at a routine maintenance level; or 3) you experience 90 days without testing or treatment for that particular condition. The medical bills incurred from the first test to the last treatment before the licensed medical provider releases you to a regular, routine maintenance regimen are considered a single incident. If 90 days pass and you receive no further testing or treatment, any future bills you incur will be considered a separate incident. INELIGIBLEA status indicating that you have failed to meet the conditions that qualify for sharing as described in the Membership Guidelines, or that your medical needs do not fall within the sharing limits. LEGAL REPRESENTATIVE Any adult who has decision-making capacity and who is willing to act on behalf of a member. A legal representative would include an individual who has authority, by law or by agreement from the individual receiving treatment, to act in the place of the individual. This includes parents, legal guardians or properly appointed agents, such as those identified in Power of Attorney documents, or individuals designated by state law. LICENSED MEDICAL PROFESSIONALAn individual who has successfully completed a prescribed program of study in a health care field and who has obtained a license to practice in that field. Some examples of licensed medical professionals are doctors, nurses, chiropractors, physical therapists, and physician assistants. MATERNITYA mother’s or child’s medical needs relating to prenatal care and newborn delivery, including routine hospital expenses for your newborn child. MEDICAL NEEDSCharges or expenses for medical services that are provided to you by a facility or by a licensed medical professional to address your illnesses, accidents, injuries, or routine medical needs. MEDICAL REVIEWThe process by which licensed medical professionals review medical records to make eligibility determinations in accordance with the Membership Guidelines. MEDICALLY NECESSARYA service, procedure, or medication that is necessary to restore or maintain your physical health in the most cost-effective way. MEMBERA person or persons enrolled in the Altrua HealthShare membership (whether you are the member or a qualified dependent) Active member: Your status when you have met all membership obligations, providing you remain eligible for sharing of medical needs. Inactive member: Your status when you have failed to meet membership obligations, making you ineligible for sharing of medical needs. Married individual member: Your status when you have met all membership requirements to qualify for an eligible maternity with proof of marriage certificate. MEMBER APPEALA member’s request for reconsideration of a decision. MEMBER PORTALYour personal online membership access where you can manage your membership. MEMBERSHIP ENROLLMENT APPLICATIONAn electronic application that you must complete to enroll in Altrua HealthShare for membership. This electronic form looks at the 10 years of medical history prior to your Membership Enrollment Date. You will be notified of any membership limitations based on the completion of the medical history questionnaire provided at enrollment. Any information not disclosed during the enrollment process could result in a retroactive membership limitation or denial of your membership. MEMBERSHIP FORMSAn electronic form used by the membership. Membership cancellation request form: An electronic form you must complete and provide to Altrua HealthShare in order to cancel your membership. Membership commitment form: An electronic form you must complete and provide annually to Altrua HealthShare to demonstrate your commitment to the membership, Acknowledgements, Statement of Standards, Commitments and the Escrow Instructions Membership needs processing form (NPF): An electronic form you must complete and provide to Altrua HealthShare to request eligibility for sharing of your medical needs. Membership update form: An electronic form you must complete and provide to Altrua HealthShare when details of your membership change. MEMBERSHIP GUIDELINESYour reference for acknowledging your commitments, assessing your eligible and ineligible medical needs, and understanding how contributions are shared in accordance with the Escrow Instructions. MEMBERSHIP LIMITATIONA two-to five-year waiting period on the eligibility for sharing of medical needs, or associated medical conditions, eligible for sharing. An associated condition is one that is caused directly and primarily by the medical condition that is specifically ineligible. The membership limitation is issued during the application process and may be subject to medical record review. Retroactive limitation: A two-to five-year waiting period on the eligibility for sharing of medical needs or associated medical needs for an illness or medical condition for which you have received medical advice or treatment at any time during the 10-year look back period preceding your membership effective date. This limitation will be retroactive to your membership effective date because you failed to disclose it on the Membership Enrollment Application. MEMBERSHIP PLANPOH Platinum, POH Gold and POH Bronze sharing options that are available with different per incident Member Responsibility Amount (MRAs) and sharing limits, as selected and approved on your Membership Enrollment Application. MONTHLY CONTRIBUTIONSThe money you contribute each month for sharing among the Altrua HealthShare members. MRA (PER INCIDENT MEMBER RESPONSIBILITY AMOUNT)The portion of an eligible medical need that does not qualify for sharing and that is your obligation to pay before the membership shares in eligible medical needs. NOTICE OF ACTION (NOA)A formal letter telling members that a medical service or medical need has been denied, deferred, or modified (such as a denial letter). OFFICE VISITA visit to a doctor’s office or urgent care facility to address your illness, your specialty medical need, your emergency, or to obtain your preventative care (for example, when you schedule a wellness visit). PRE-EXISTING CONDITIONAn illness or medical condition for which you have received medical advice or treatment at any time during the time frame specified in the medical history questionnaire on your Membership Enrollment Application preceding your effective date. RECREATIONAL VEHICLEA licensed or unlicensed motor vehicle operated on land or water, or a licensed motor vehicle with less than four wheels. SHARINGThe process in which the membership shares on eligible medical needs. SHARING LIMITSThe amount(s) the membership will share on your behalf. Annual limit: The maximum amount shared for eligible medical needs per member, each calendar year. The calendar year starts on January 1st and continues through December 31st. Lifetime limit: The maximum amount shared for eligible medical needs over your lifetime of membership. STATEMENT OF STANDARDSThe religious and moral philosophy that you agree to live by during your membership. TELEMEDICINEA program that allows you to access remote medical services via real-time, two-way communication with a contracted network of third-party telemedicine providers. UNITSA unit is one qualifying individual member. Two units are two qualifying members. Three units are three or more qualifying members. No household’s monthly contribution will exceed that of three units, regardless of the number of members in the household. USUAL, CUSTOMARY, AND REASONABLE (UCR)The allowed amount for a medical service in a geographic area based on what providers in the area usually charge for the same or similar medical service. WAITING PERIOD A period of time from the membership effective date that a member must wait before specific medical needs are eligible for sharing. WITHDRAWNWhen a membership is cancelled upon your request or when you’ve failed to meet your membership obligations.