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RESOLUTION
RE: AMENDMENT TO AGREEMENT BETWEEN WELD COUNTY AND PACIFIC
MUTUAL LIFE INSURANCE COMPANY.
WHEREAS, heretofore, Weld County, by Resolution did
enter into a contract with Pacific Mutual Life Insurance
Company for group insurance covering Weld County employees
under various group insurance policies, including group
policy No. GM-8864, and amendments thereto, and
WHEREAS, now Pacific Mutual Life Insurance Company has
submitted an additional amendment to the aforementioned group
policy No. GM-8864, entitled "Amendment No. 4" , and
WHEREAS, the Board of County Commissioners of Weld County,
Colorado, believe it to be in the best interest of the County
to accept the aforementioned Amendment No. 4 to the aforementioned
group policy as proposed, covering its said group policy as
hereinabove mentioned and on the basis recited herein.
NOW, THEREFORE, BE IT RESOLVED, by the Board of County
Commissioners, Weld County, Colorado, that the hereinabove
mentioned Amendment No. 4 submitted by Pacific Mutual Life
Insurance Company amending group policy No. GM-8864, a copy
of which is attached hereto and made a part hereof by ref-
erence, be, and hereby is , approved.
BE IT FURTHER RESOLVED, that the Board be and hereby
is authorized to execute Amendment No. 4 to the aforementioned
group policy, to-wit: GM-8864 as submitted, and to make the
same effective forthwith.
The above and foregoing Resolution was , on motion duly
made and seconded, adopted by the following vote on the 6th
day of October, A.D. , 1976.
BOARD OF COUNTY COMMISSIONERS
//�� �, ,� WELD COUNTY, COLORADO
ATTEST: \M ` n'v.,'A- tt``€ " / L c4. �
7., k
County Clerk and Recorder Vii' - ( lll�'!
Viand lerk to the Boa 5{
BY: 1-7'�fol /i ("th,
`"'__ ' Deputy Cou ty Clerk(' rte, 6 dam,--
PP 0170pe AS TO
0417.04116.
County Attorney
f}.. 760623
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HOt ; 'FE IGE COPY
AMENDMENT Na 4
Attached to and part of Group Policy No. GM-8864 by and between Pacific Mutual Life In
Company, and the Policyholder,
WELD COUNTY, COIARADO.
The Policyholder and Pacific Mutual hereby agree that the policy is amended, as of the effective d:
stated on each amended page, by deleting from the policy the page or pages thereof listed under
Column I and inserting into the policy the attached page or pages listed under Column II, each marl I
by "Amendment No. 4 effective January 1, 1976",
• COLUMN I - PAGES DELETED COLUMN II - PAGES INSERTED
10A 10A
119-3-c (1) and (2) 118-3-c (1) and (2)
11C-1-c - 11C-1-c
11D 11D
11E-1-c 11E-1-c
12 12
13 13
14 14
IN WITNESS WHEREOF, the parties hereto have, by their duly authorized representatives set their hands
on the date set forth beneath their respective signatures.
POLICYHOLDER PACIFIC MUTUAL LIFE INSURANCE COMPANY a,,Lee/tSignature of Officer President jfriTITLE ( A.a i n 4 At7, r
Boa r O r (Ott/1.4r C at!a'S/Ost'.Yz5 Secretary
DATE ele 'lar /l/ /9/e' ATTEST I� i LLcat •
Registrar
C, 'fit ? % / L.
DATE LyL t
GR-4827-B SS
I
^CCEliENSIVE MAJOR MEDICAL EXPENSE BENS^ (Continued)
I
EXCEPTIONS. For the purposes of this policy. anything herein to the contrary notwithstanding, eligible charges shall in no
event include:
(i) charges i i red,,in a nnec> on with a bodily injury arising out of , or in the course of, any employment for wage or
profit or d .ease coo d b4's i iyrkmen's compensation act or similar legislation or the maritime doctrine or main-
tenance, yglr and dare 4 '; .
yy{{ Yi
(ii) charges for or in connedi ion with any eye examinations, glasses, hearing aids, or the fittir4 of any thereof;
y L,
(iii) charges incurred for cosmetic surgery unless necessary for repair or alleStion of da"1nage resulting from an rodent
occurring while a covered person; T 33
F
I
(iv) chargestqlincurred for any dental ser ff e
vices and supplies for treatment of(a) the teeth, (b) ie gums or than for tumors,
apd (c) biller associated sttfuctures prima,41y in connection with the treatment or replacement of to th, unless the charges
4e necessary for repair or alleviation o4amage to sound natural teeth resulting from an accident ccurring while a
covered person;
(v) charges incurred for callus or corn paring, toenail trimming, or foot massage;
(vi) charges for or in connection with travel or transportation, whether by ambulance or otherwise, except that charges for
professional ambulance service used to transport the covered person directly to and from a hospital where treatment is
,t given for an illness will not be excluded by this exception;
Si) charges with respect to confinement in a hospital owned or operated by the United States Government, or with respect
- to any surgical, medical, or other treatment received in such a hospital, or with respect to a hospital confinement or any
surgical or other treatment for which no charge is made that the Individual or qualified dependent is required to pay;
(viii) charges incurred during confinement in a hospital owned or operated by a State, Province or political subdivision unless
there is an unconditional requirement to pay such charges without regard to any rights against others, contractual or
otherwise;
(ix) charges for medical examination of any covered person for "check-up" purposes when not incident and necessary to the
treatment of an illness, except that this item (ix)shall not apply to (a) the first $90 of such charges incurred, other than
for routine immunizations, during each calendar year on behalf of a qualified dependent who is less than two years of age,
and (b) an additional amount consisting of the charges incurred for routine immunizations of a qualified dependent who is
less than two years of age;
(x) charges for or in connection with any illness caused by any act of war, whether declared or undeclared, or by any atomic
explosion or other release of nuclear energy (except only when being used solely for medical treatment of an illness of a
covered person);
(xi) charges incurred for or in connection with the treatment of alcoholism or narcotism;
(xii) charges for any services or supplies other than those which are certified by a physician who is attending the Individual or
qualified dependent as being required for the treatment of the illness, except that this item (xii) shall not apply to charges
for circumcision, dilation and curettage, or any of the charges specified in parts (a) or(b)of item (ix) above;
(xiii) charges incurred for any services rendered for pregnancy or for resulting childbirth or miscarriage or for prenatal or postnatal
care that are in excess of the charges paid or payable under the "Pregnancy Expense Benefits" section, except that in the
case of Caesarean section, abortion, miscarriage, dilation and curettage, or medical or surgical complications of a
pregnancy, no charges shall be excluded if they otherwise qualify as eligible charges;
•
1
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GR-231 (8864) AMENDMENT NO, 4 EFFECTIVE JANUARY 1, 1976 Page 10A
COMPREHENSIVE MAJOR MEDICAL EXPENSE BENEFITS(Continued)
•
HOSPITAL AND CONVALESCENT HOSPITAL EXPENSE BENEFITS. For the purposes of this section,
(I) eligible charges shall be the charges which are used in determining benefits under this section, except to the extent
modified under this section and the section entitled "Exceptions": ant
(i ) successive periods of confinement in a hospital or convalescent hospital shall be considered one period of confinement
unless the subsequent confinement commences after complete recovery from the illness causing the previous confine-
ment, or unless the subsequent confinement is due to causes entirely urrelated•to the causes of the previous confine-
ment or, in the case of an Individual, unless the subsequent confinement commences after the Individual has returned
to active work on full-time and completes two weeks of continuous active service or, in the case of a qualified depende
unless the subsequent confinement is separated from the previous confinement by a period of at least three months: and
(111) a charge made by an outside agency for professional ambulance service when used to transport the covered person to
and from a local hospital where treatment is given fa an illness, or for laboratory examinations, x-ray examinations,
whole blood or blood plasma, anesthetics(but not for the administration thereof), and drugs or scums for use during
a period of confinement with respect to which benefits are payable under this section, shall be deemed to be a charge
made by the hospital or convalescent hospital if in connection with treatment while the covered person is confined in
the hospital or convalescent hospital; and
(Iv) when treatment for an accidental bodily injury is performed outside a hospital, charges such as those for bandages,
dressings, splints, casts, tetanus anti-toxin injections, etc. , which would have been incurred if the treatment had
been performed in a hospital shall be deemed to be charges made by a hospital.
If an Individual or qualified dependent, while a covered person, becomes confined in a hospital or convalescent hospital for
treatment of an illness or receives treatment on an out-patient basis, the Insurance Company shall, subject to the terms of
this policy, pay a benefit in an amount equal to the eligible charges actually made by the hospital or convalescent hospital,
consistent with its rates then in effect, to the Individual or qualified dependent with respect to such confinement, but not
exceeding the following amounts:
(a) for daily service charges. including any flat daily charges for routine services, an amount equal to the applicable
maximum eligible charges for Daily Service Charges shown in the Schedule of Benefits for each day of such confine-
ment; and
(b) for all charges by the hospital or convalescent hospital, including daily service charges, an amount equal to the ap-
plicable maximum eligible charges fur All Hospital Charges shown in the Schedule of Benefits:
less, in the event such charges are subject to the cash deductible, as determined from the Schedule of Benefits, and the cash
deductible applicable to such covered person has not been satisfied, an amount equal to the part(or all) of such cash deduc-
tible that has not been satisfied;
provided, however, that
(l) no benefits shall be payable for charges for confinement in a convalescent hospital unless(a) a physician certifies
that such confinement is necessary for the continued treatment by the physician of an Illness, (b) such confinement
follows at least five days of hospital confinement as an in-patient, and(c) such confinement begins within seven
days after termination of hospital confinement;
(2) no benefits shall be payable with respect to any charges for private duty nosing, professional surgical or medical
care: or personal services such as radio, telephone, newspapers and the like; a for equipment or supplies for we
other than during a period of confinement with respect to which benefits are payable under this section: and
(3) The requirement that a covered person must be confined in a hospital for treatment of an illness in order for the charges ft
such confinement to qualify as eligible charges shall not apply with respect to hospital charges for routine nursery care of
qualified dependent who is born as a result oT a pregnancy for which benefits are payable under this policy.
The Schedule of Benefits is set forth on the next page.
•
GR-231(8864) AMENDMENT NO. 4 EFFECTIVE JANUARY 1, 1976 Page 116-3-c(1)
COMPREHENSIVE MAJOR MEDICAL EXPENSE BENEFITS(Continued)
•
SCHEDULE OF BENEFITS
Classifications of Individuals
One class applicable to all
Hospital Expense Benefits
Daily Service Charges
-maximum eligible charges for each day in which the covered person occupies:
(a) hospital accommodations other than an intensive care unit the hospital's charge for semi-
private accommodations not to
exceed $68
(b) an intensive care unit
(including coronary, special, and respiratory care) 250%of charges specified in(a)
above for the first ten days in
such unit and 100%thereafter •
(e) accommodations in a convalescent hospital 501*of charges specified in(a)
above
All Hospital Charges(including daily service charges)
-maximum eligible charges during any period of confinement 100 of the first $5,000 of such
charges plus 80%of the balance
of such charges
The eligible charges used in determining benefits under this section are subject to the cash deductible described in the
section entitled "Cash Deductible", except eligible charges incurred for treatment of an illness on an out-patient basis or
for treatment of bodily injuries sustained in an accident.
GR-231(8864) AMENDMENT NO, 4 EFFECTIVE JANUARY 1, 1976 Page 112-3-e(2)
•
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-COMPREHENSIVE MAJOR MEDICAL EXPENSE BENEFITS (Continued)
<t'SGICAL EXPENSE BENEFITS. For the purposes of this section, eligible charges shall he the charges which are used in determining
benefits 'ruder this section, except to the extent modified under this section and the section entitled "Exceptions".
II an Individual or a qualified dependent, while a covered person, undergoes a surgical or radiotherapy procedure enumerated in
the Relative Value Schedule of Surgical and Radiotherapy Procedures for the treatment of an illness, the Insurance Company shall,
subject of the terns of this policy, pay a benefit in an amount equal to one hundred percent of the el
actually tirade to the Individual or qualified dependent for: igible charges
(a) the surgical procedure, if such procedure is performed by a physician; and
(b) services rendered by a physician assisting with such surgical procedure; and
(c) anesthesia services rendered by a physician or professional anesthetist for the administration of an anesthetic in connection
with such surgical procedure; and
(d) the radiotherapy procedure, if such procedure is performed by a physician or professional radio-therapist;
but not exceeding an amount equal to one hundred percent of the applicable Dollar Unit Value for Surgical Expense Benefits
shown in the Schedule of Benefits multiplied by the Relative Value specified for such procedure or services in the Relative
Value Schedule of Surgical and Radiotherapy Procedures.
If two or more surgical or radiotherapy procedures are performed, payment shall be made for each procedure in accordance with
the terms of the foregoing paragraph, provided that:
(1) if multiple or bilateral surgical procedures, which add significant time or complexity to patient care, are performed at
the same operative session, the total Relative Value for such procedures shall not, unless otherwise specified in the
Relative Value Schedule of Surgical and Radiotherapy Procedures, exceed the Relative Value of the major procedure
plus 50^/0 of the Relative Value of each of the lesser procedures as specified in said Relative Value Schedule; and
(2) if an incidental surgical procedure(such as incidental appendectomy, lysis of adhesions, excision of previous scar,
puncture of ovarian cyst. etc.) is performed through the same incision, payment shall be made only for that onepro-
cedure for which the largest Relative Value is specified in said Relative Value Schedule.
SCHEDULE OF BENEFITS
Classifications of Individuals
One class applicable to all
•
Surgical Expense Benefits
Dollar Unit Value for Surgical Expense Benefits:
Surgery $30
Anesthesia • $ 9
•
Radiotherapy $ 7
The eligible charges used in determining benefits under this section are not subject to the cash deductible described in the
section entitled "Cash Deductible",
•
GR-231 (8864)
AMENDMENT NO, 4 EFFECTIVE JANUARY 1, 1976 Page 11C-1-c
.01
COMPREHENSIVE MAJOR MEDICAL EXPENSE BENEFITS (Continued)
Vii , ( •s / i
pill
MEDICAL CARE EXPENSE BENEFITS. For ill purpose use thlsssec$on, aliglble charges shall be the charges (ch are used in
determining benefits midi this'section, except to the extent modified under this section and the section en fled "Exceptions".
t
If an Individual or qualified dependent, while a covered person, receives any necessary medical servi endjnerated in the
Schedule of Medical Services in connection with the therapeutic treatment of an illness, the Insuranc ompany shall, subject
to the terms of this policy, pay a benefit in an amount equal to one hundred percent of the el ble charges actually
made to the individual or qualified dependent for such service, but not exceeding an amount equal to .one hundred percent
of the applicable Dollar Unit Value for Medical Care Expense Benefits shown in the Schedule of Benefits multiplied by the
Relative Value specified in the Schedule of Medical Services for such service; provided, however, that
(1) no benefits shall be payable with respect to charges which are related to the performance of any surgical operation or to
any post-operative care, except charges incurred after the applicable number of days of follow-up care indicated in the
Schedule of Surgical and Radiotherapy Procedures for services which are reasonably necessary for the therapeutic treatment
of an illness; and
(2) no benefits shall be payable with respect to any charges for x-ray examinations, drugs, medicines or supplies, except as
may be provided under other sections of this policy; and
(3) the requirement that medical services must be received in connection with the therapeutic treatment of an illness in
order for the charges for those services to qualify as eligible charges shall not apply to the charges of a physician for
cam of a dependent child during the first two years of the child's life, except that unless the charges are for routine
immunizations or for therapeutic treatment of an illness, the amount of those charges that qualify as eligible charges
shall not exceed $90 per year; and
(4) benefits for treatment of mental infirmity rendered outside of a hospital shall not be payable for more than 26 treatments
during a calendar year and shall not exceed (a) 80%of the Daily Psychiatric Maximum shown in the'Schedule of Benefits
for all treatment rendered during each of the first 10 days of treatment during a calendar year, or (b) 500 of the Daily
• Psychiatric Maximum for all treatment rendered during each of the next 16 days of treatment during that year.
Medical Care Expense Benefits
Dollar Unit Value for Medical Care Expense Benefits: $3.50
Daily Psychiatric Maximum The Relative Value specified in the Schedule of Medical Services
for the treatment rendered multiplied by the Dollar Unit Value
shown above
The eligible charges used in determining benefits under this section are not subject to the cash deductible described in the
section entitled "Cash Deductible".
•
•
GR-231(8864)
AMENDMENT NO, 4 EFFECTIVE JANUARY 1, 1976 PAGE 11D
I
•
• - COMPREHENSIVE MAJOR MEDICAL EXPENSE BENEFITS (Continued)
DIAGNOSTIC LABORATORY AND X-RAY EXPENSE BENEFITS. For the purposes of this sectiop, eligible charges shall be the
charges which are used in determining benefits under this section, except to the extent modified under this section and the section
entitled "Exceptions".
If an Individual or qualified dependent, while a covered person, incurs eligible charges for a necessary laboratory or x-ray procedun
enumerated in the Schedule of Diagnostic Laboratory and X-Ray Procedures for diagnostic purposes in connection with the therapeuti
treatment of an illness, and if such person is not entitled to other benefits of any kind under this,policy by mason of such procedure,
the Insurance Company shall, subject to the terms of this policy, pay a benefit in an amount equal to one hundred percent of th
eligible charges actually made to the Individual or qualified dependent for such procedure consistent with the usual charges made
for such procedure, but not exceeding an amount equal to one hundred percent of the Dollar Unit Value for Diagnostic
Laboratory and X-Ray Expense Benefits shown in the Schedule of Benefits multiplied by the Relative Value specified for such
procedure in the Schedule of Diagnostic Laboratory and X-Ray Procedures.
SCHEDULE OF BENEFITS
Classifications of Individuals
One class applicable to all
Diagnostic Laboratory and X-Ray Expense Benefits •
Dollar Unit Value for Diagnostic laboratory and X-Ray Expense Benefits:
X-ray Procedures $7
Laboratory Procedures $6.50
The eligible charges used in determining benefits under this section are not subject to the cash deductible described in the
section entitled "Cash Deductible".
r�r
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GR-231(8864)
AMENDMENT NO. 4 EFFECTIVE JANUARY 1, 1976 PAGE 11 E-1-t
I
RELATIVE VALUE
• SCHEDULE OF SURGICAL AND 'RADIOTHERAPY PROCEDURES
•
Relative Value Follow-up Relative Value Follow-up
Days Days
Surgery Anesthesia Included Surgery Anesthesia Included
\BIX)MEN GOITRE
449511 Appendectomy 9.0 6.O+T 45 60240 Thyroidectomy,)Iotal
47600 Cholecystectomy 16.6 7.0+T 45 or complete 16.0';' 6.0+T 45
43620 total gastrectomy 28.0 7,0+T 90 60245 Subtotal or partial 14.5 1 6.0+1 45
49000 Exploratory laparotomy... 9.0 6.0+T 45 HERNIA
BREAST 49500 Inguinal, under age O
19180 Simple mastectomy. 5 years, with or without
complete. unilateral 8.0 3.0+T 45 hydrocelectomy,
19200 Radical,mastectomy, unilateral 7.0 4.0+T 45
including breast, 49505 age 5 or over,
pectoral muscles, and unilateral 8.5 4.0+T 45
axiliary lymph nodes, 49560 Ventral 11.0 6.0+T 45
unilateral 19.0 5.0+T 60 • MATERNITY
19621 Excision of cyst, 59120 Ectopic pregnancy, tubal,
bilateral 6.0 3.0+T -30
requiring salpingectomy
CHEST and/or oophorectomy,
•
31620 Bronchoscopy, abdominal or vaginal
diagnostic 3.6 6.0+T 30 approach 14.0 6.0+T 45
32440 Pneumonectomy, total .... 30.0 13.O+T 90 59520
(rider e n section,cl ssi 10.0 7.0+T 7
33600 Ventricular aneurysm.
V p )"'
with bypass 40.0 20.0+T 90 AMPUTATIONS
FAR, NOSE AND 24900 Arm through humerus,
THROAT closed 10.0 4.0+T 90
69660 Stapedectomy with 26950 Finger, any joint or
• phalanx, single 3.0 3.0+T 45
insertion of prosthetic 27880 Leg, through tibia and
stapes with feneslra- fibula,closed 14.0 3.0+T 90 •
tion of the oval window... 20.0 5.0+T 90 1 28825 Toe, interphalangeal
69500 Mastoidectomy, single .... 12.0 5.0+T I80 joint 3.0 2.O+T 45
31030 Antrotomy, radical .
(Caldwell-Luc), uni- t
lateral 12.0 4.0+T 90 • FRACTURES
30620 Reconstruction, func- '.4 23565 Radial and ulnar shaft
tional, of the internal fractures, closed mani-
nose(septa) dermo- pulative reduction 5.4 3.0+T 90
plasty) 10.0 4.0+T 90 27754 Tibia,shaft, fracture,
42840 Tonsillectomy,with open(compound),with un-.
or without adenoid- complicated soft tissue s
ectomy, under age closure, manipulative
12 years 4.0 5.0+T 30 reduction 6.5 3.0+T 90
42841 age 12 years or over 5.0 5.0+T 30 27504 Femur,shaft fracture
EYE (including supracondylar),
open(compound),with
66900 Extraction of lens, uni-
lateral uncomplicated soft tissue
(e.g., cataract, closure, manipulative
dislocated lens) 20.0 B.O+T 90 reduction 11.0 4.0+T 90
66620 Iridectomy, any type 24505 Humeral shaft fracture,
(independent procedure)... 12.0 6.0+T 45 closed (simple), closed
manipulative reduction 5.0 3.0+T 90
GENITO-URINARY TRACT
58260 Vaginal hysterectomy 19.0 6.0+T 45
58150 Total hysterectomy ARTH ROPI.ASTY
(corpus and cervix)with 27)30 Total hip and
or without tubes, and/or prosthesis 40.0 6.0+T 180
ovaries. one or both 17.0 6.0+T 45 27444 Total knee and.
58205 Total hysterectomy, prosthesis 28.0 3.0+T 120
extended, corpus cancer,
including partial REPAIR OF TENDON
saginectomy 26120 Fasciectomy, partial
with pelvic excision,simple(e.g., •
lymphadenectomy 24.0 6.0+T 120 local nodule or single
50420 Nephropexy: fixation band), of palmar fascia
or suspension of kidney (for Dupuytren's con-
(independent procedure) 16.0 6.0+T 90 tracture), palm and/or
50220 Nephrectomy, including finger 6.0 3.0+T 60
partial ureterectomy, . . 26400 Tendon repair or advance-
any approach including mcnt, flexor, single,
rib resection 20.0 6.0+T 90 primary . 7.0 3.0+T 120
52200 Cytourethroscopy,
with biopsy 26 3.0+T 7 RECTUM
55800 Prostatectomy, perinea), 46255 Hemorrhoidectomy, in-
subtotal 20.0 6.0+T 90 temal and external,
52600 Transurethral resection complete 7.0 4.O+T 90
of prostate, including 46230 Excision of external
control of post-operative hemorrhoid tags and/or
bleeding during hospitali- multiple papillae,
ration,complete 20.0 5.0+T 90 office 1.2 3.0+T 15
SKUII
620011 Elevation of depressed 63144)C'ordotomy, cervical or -
skull fracture, simple, thoracic, bilateral or
extradural I6.0 11.0+T 90 unilateral. one stage 32.0 8.0+1 90
61510 Excision of brain tumor, 63510 Injection procedure for
abscess or cyst. supraten- myelography, lumbar < 2.4 4.0+T 7
tonal - 34.0 II.O+T 90
61120 Burr holds)for yen- VEINS AND ARTERIES ,
tricular puncture(including 35340 Thromboendarterectomy,
injection of air or contrast with or without patch
media),not followed by other graft,abdominal aorta .... 30.0 15.0+T 30
surgery 10.0 9.0+T 30 37720 Ligation and division and
61130 when followed by other complete stripping of long
surgery 7.0 0 or short saphenous veins,
unilateral 7.0 3.0+1 30
SPINE ANDSPINALCORD 37721 bilateral 10,0 3.0+1 30
63000 I.aminectomy, one or two
segments,for decompression
of spinal cord and/or
nerve roots,cervical or
thoracic 32.0 10.0+1 90
(Continued on Reverse Side)
(;R-711 (CO-71) (8864) AMENDMENT NO. 4 EFFECTIVE JANUARY 1, 1976 Page 12
• RADIOTHERAPY Schedule Relative
Value
The Relative Value for treatment includes all technical expense, 77003 Benign skin lesions, per
professional radiological service and professional administrative treatment visit 2.0
service.• where applicable. including professional nuclear phys- 77006 Malignant skin lesions,
icist service, size 0-I cm, per
course 9.0
ASSISTING PHYSICIANS
The allowance for an assisting physician for an operation is
20% of the listed Relative Value for the Surgical Procedure, but
not less than a Relative Value of 1.7. •
ANESTHESIA
The total values for anesthesia services include pre- and post-operative visits. the cost and administration of •the anesthetic and the
administration of fluids and or blood incident to the anesthesia or surgery. When hypothermia and/or a pump oxygenator are employed in con-
junction with an anesthetic, the basic value will be 20 units.
No fee will be allowed for local infiltration anesthesia administered by the operating physician or assisting physician.
In procedures where no value is listed, the basic portion of the Calculated Value will be the same as listed for a comparable procedure.
Where unusual detention with the insured is essential for the safety and welfare of the insured, the necessary time will be valued on the
same basis as indicated below for anesthesia time.
CALCULATION OF TOTAL ANESTHESIA VALUES. All anesthesia values are determined by the addition of the listed Time Units. ("T"
equals Time Units).
A Basic Value is listed for most procedures. This includes the value of all anesthetic services and the allowance for the actual time spent
administering the anesthesia or in unusual detention with the insured.
Time Units are computed by allowing I unit for each 15 minutes of anesthesia time. Anesthesia time starts with the beginning of the ad-
ministration of the anesthetic agents and ends,when the anesthesiologist is no longer in persona' attendance (when the insured may be
safely placed under customary post-operative supervision),
LIMITATIONS
The Relative Values for all surgical procedures includes the surgery and the follow-up care for the period indicated in days in the column
headed"Follow-up Days Included".
When a surgical procedure or procedures arc carried out within the listed period of follow-up care for a previous surgery, the follow-up
periods will continue concurrently to their normal terminations.
Benefits shall not be payable for the attendance of two physicians on the same case at the same time except where it is warranted by the
necessity of supplementary skills.
For Surgical or Radiotherapy Procedures not shown on this Schedule,and which are not expressly excluded by the terms of this policy,Pacific Mutual
will determine the Relative Values for the procedure and for any anesthesia service in connection therewith.A procedure of equal gravity and severity
will be used as a basis for the Irsurance Company's determination.
MODIFIERS
The values for procedures listed in this section may be modified under certain conditions. These modifications may reflect bilateral or
multiple surgical operations, the supplemental skills of additional physicians, and other factors.
•
RELATIVE VALUE
' SCHEDULE OF MEDICAL SERVICES
•
•
Relative Relative
Value Value
TREATMENT IN THE HOSPITAL PSYCHIATRIC SERVICES
90200 Initial hospital care, brief or 90800 Psychotherapy, any type, office,
limited history and physical examination, home,or hospital, 50 minutes 12.5
including the initiation of diagnostic 90810 Group(maximum 8 persons per
and treatment program and preparation group)one and one- f hours,
of hospital records 7.5 per person per sessi 6.25
90215 Initial hospital care, intermediate • 90820 Convulsive therapy,. tro-
history and physical examination, in- convulsive or drug i ed; in-
cluding initiation of diagnostic and • patient or out-patient',with or
treatment program and preparation of without anesthesia by jrpating.
hospital records - 12.5 physician - 10.0
90220 Initial hospital care, comprehensive 90840 Psychologic testing, psychometric
history and physical examination, in- and/or projective tests,4th written •
cluding initiation of diagnostic and report,given by or under supervision
treatment program and preparation of of physician, per hour 10.4
hospital records 17.5
90240 Brief examination, evaluation and/or CONSULTATIONS
treatment, same illness 2.5 A consultation shall include those services
90250 Limited examination, evaluation rendered by a physician,whose opinion or
and/or treatment, same illness 5.0 advice is requested by another physician or
90270 Extended re-examination or an agency in the evaluation and/orireatment
re-evaluation 10.0 of a disease of an insured.
90600 Consultation requiring limited
examination and/or evaluation of a
given system but not requiring a
TREATMENT IN THE PHYSICIAN'S OFFICE comprehensive history and examination,
•90000 Brief evaluation, history, examination home,office or hospital •
97.5
and/or treatment 5.0 90610 Consultation requiring more extensive
90040 Brief examination, evaluation and/or examination and/or evaluation but not
requiring comprehensive history, and
treatment, same or new illness 3.0 examination, home, office or hospital 12.5
90050 Limited examination, evaluation and/or 90620 Consultation requiring comprehensive
treatment, same or new illness 4.0 history and examination and/or evaluation, •
office, home or hospital 17.5
90850 In-patient care including psycho-
therapy and supervision of milieu team
TREATMENT AT A PLACE OTHER THAN THE- or conference with family, 50 minutes 12.5
HOSPITAL OR THE PHYSICIAN'S OFFICE
90100 Brief evaluation, history, OTHER SERVICES
examination and/or treatment 7.5 99040 Detention, prolonged, with patient
90140 Brief examination, evaluation requiring attention beyond usual •
and/or treatment, same or new service, per hour 17.5
illness 5.0
90150 Limited examination, evaluation, SPECIFIC DIAGNOSTIC SERVICES
and/or treatment, same or new Allergy Testing. The Value for allergy tests prescribed as an aid
illness 7.5 in the diagnosis of disease is based on the type and number of
90170 Extended re-examination or tests performed and includes observations of the tests. No benefit
re-evaluation 10.0 will be paid unless tests are read and interpreted by a physician.
For Medical Services not shown on this Schedule, and which are not expressly excluded by the terms of this policy, Pacific Mutual will
determine the Relative Value of the service. A service comparable to the enumerated service of closest similarity will be used as a basis
for Pacific Mutual's determination. -
•
GR-231 (CO-71)(8864) AMENDMENT NO. 4 EFFECTIVE. JANUARY 1, 1976 Page 13
•
1 ,
RELATIVE VALUE
SCHEDULE OF DIAGNOSTIC LABORATORY AND X-RAY PROCEDURES
•
•
•
DIAGNOSTIC RADIOLOGY
Relative Relative
Value Value
HEAD AND NECK CEREBROSPINAL FLUID
70000 Pneumoencephalography, limited 10.0 89081 Cerebrospinal fluid"complete"
70100 Mandible, limited or unilateral 3.0 (cell count, protein, sugar, colloidal
70110 complete 4.0 gold and test for syphilis)• 4.5
70260 Skull,complete 5.0 86412 VDRL(quantitative) 1.5
CHEST URINE
71020 Chest "minifilm", two views 3.0 82575 Creatinine, clearance 3.0
71100 Ribs, unilateral 3.0 81000"Routine"urinalysis 0.6
71110 bilateral 5.0
SURGICAL PATHOLOGY
SPINE AND PELVIS 85105 Bone marrow interpretation 5.0
72010 Spine,entire,survey study 88101 Papanicolaou(cytology)smears,. 1.0
(A-P and lateral) 9.0 s
72250 Myelograph, lumbar or any HEMATOLOGY
other single level 8.0 85345 Lee-White Coagulation time 0.8
85055 Hematocrit (macro or micro) 0.4
UPPER EXTREMITIES 85610 Prothrombin time 1.0
73020 Shoulder, limited 1.6
73070 Elbow, limited 1.6 BACTERIOLOGY
87056 Antibiotic sensitivity(disc) 1.0
LOWER EXTREMITIES 87000 Smear(gram stain, etc.)' 0.6
73600 Ankle, limited 1.5 87002 TB smear(acid fast) 0.8
73620 Foot, limited 1.1
GASTROINTESTINAL TRACT
ABDOMEN PANCREAS-GASTRIC ANALYSIS
74000 Abdomen,single view(KUB) 2.0 89110 Bernstein test(acid perfusion) 4.0
74020 complete,includes decubitus •
and/or erect views 4.0
GASTROINTESTINAL TRACT SPECIFIC DIAGNOSTIC SERVICES
74240 Upper gastro intestinal tract, with -
or without delayed films, without CARDIOVASCULAR
KUB 7.0 93000 Electrocardiogram, with
74270 Colon. barium enema 4.0 interpretation and report 7.5
74300 Cholangiography,operative 5.0 93020 with exercise test 10.5
PATHOLOGY PULMONARY
94150 Vital capacity, total 2.0
CHEMISTRY
82465 Cholesterol, blood, total 1.4 94200 Maximal breathing capacity
84330 Sugar(glucose), blood 1 4 (maximum voluntary ventilation). 5.0
84520 Urea(BUN)blood 1.4 MISCELLANEOUS
95820 Electroencephalogram(EEG), awaki,
ENZYMES asleep(natural or induced)and
84075 Acid phosphatase(prostatic fraction) activation • 17.5
alkaline, blood and urine 1.4 95860 Electromyography, one extremity
and related paraspinal area 30.0
ENDCRINOLOGICAL STUDIES 89120 Feces-fat,qualitative screening
83210 Steroids, 17 hydroxycorticoids 2.5 and microscopic 0.4
•
For procedures not shown on this Schedule and which are not expressly excluded by the terms of this policy, Pacific Mutual will determine
the Relative Value of the procedure. A procedure comparable to the enumerated procedure of closest similarity will be used as the basis for
Pacific Mutual's determination.
•
•
•
•
GR-231 (CO-71)(8864) AMENDMENT NO. 4 EFFECTIVE JANUARY 1, 1976 Page 14
e
•
PACIFIC MUTUAL
PACIFIC MUTUAL LIFE INSURANCE COMPANY
DANIEL M.Del BIANCO DENVER GROUP AND PENSION OFFICE
GROUP SALES REPRESENTATIVE 155 S.MADISON STREET,SUITE 209
DENVER,COLORADO 90209
TELEPHONE 321-3190
July 29, 1976
Mr. Barton Buss
Weld County, Colorado
915 10th Street
Greeley, Colorado 80631
RE: AMENDMENT 4
Dear Mr. Buss:
I neglected to leave the above referenced Amendment with you the last
time I was up because I thought it should reflect the change in hospital
coinsurance.
I've been told this Amendment is for the time prior to the change and
will have to be signed also. I hope you'll have this in time to be
signed with Amendment 6 that I just previously sent you. When both
Amendments are signed, please return them to me at the above office
address.
Sincerely,
Daniel M. DelBianco
Group Sales Representative
DMD/ns
Enc.
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