This glossary is provided to assist members in understanding common terms used in managed care, like the care that is provided by Alliance Health or other medical providers.
Appeal: A review by the Plan of an adverse benefit determination.
Co-Payment: Also known as a “Copay” is a fixed amount paid by the Member for certain covered health care services. The copay amount may vary by service or provider. Example: A member cost of $1.00 for a generic prescription.
Emergency Medical Condition: A medical condition in which the symptoms appear quickly and are severe enough that a person with average knowledge of health and medicine would expect that, in the absence of immediate medical attention, the health or life of the person experiencing the symptoms is in jeopardy or they are at risk of serious damage to a bodily function, organ, or part.
Emergency Medical Transportation: Medically necessary ambulance transportation to the nearest appropriate facility where prompt medical services are provided in an emergency such as accident, acute illness or injury.
Emergency Room Care: Care given for a medical emergency, in a part of the hospital where emergency diagnosis and treatment of illness or injury is provided, when it is believed that one’s health is in danger and every second counts.
Emergency Services: Inpatient and outpatient services by a qualified provider needed to evaluate or stabilize an emergency medical condition.
Excluded Services: Services that are not covered by the PHP.
Grievance: An expression of dissatisfaction about any matter other than an adverse benefit determination. Grievances may include, but are not limited to, the quality of care or services provided, and aspects of interpersonal relationships such as rudeness of a provider or employee, or failure to respect the Member’s rights regardless of whether remedial action is requested. Grievance includes the Member’s right to dispute an extension of time proposed by the PHP to make an authorization decision.
Habilitation Services and Devices: Health care services that help a Member keep, learn, or improve skills and functioning for daily living. Examples include therapy for a child who isn’t walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology, and other services for people with disabilities in a variety of inpatient or outpatient settings.
Health Insurance: A type of insurance coverage that pays for your health and medical costs. Your Medicaid coverage is a type of insurance.
Home Health Care: Certain medically necessary services provided to Members in any setting in which normal life activities take place other than a hospital, nursing facility, or intermediate care facility. Services include skilled nursing, physical therapy, speech-language pathology, and occupational therapy, home health aide services, and medical supplies.
Hospitalization: Care in a hospital that requires admission as an inpatient for a duration lasting more than twenty-four (24) hours. An overnight stay for observation could be outpatient care.
Hospital Outpatient Care: Care for a Member in a hospital, or distinct part of a hospital, for professional services of a duration less than a 24-hour period regardless of the hour of admission, whether or not a bed is used, or whether or not the patient remains in the facility past midnight.
Medically Necessary: Those covered services that are within generally accepted standards of medical care in the community and not experimental.
Network: A group of doctors, hospitals, pharmacies, and other health care experts contracted by the PHP to provide health care services.
Non-participating Provider: Non-Par or non-participating providers are physicians or other health care providers that have not entered into an agreement with the PHP and are not part of the Network, unlike participating providers. They may also be called out-of-network providers.
Participating Provider: Par or participating providers are physicians or other health care providers that have an agreement with the PHP and are part of its Network. These agreements outline the terms and conditions of participation for both the payer and the provider.
Physician Services: Health care services a licensed medical physician, or physician extender such as a nurse practitioner or physician assistant, provides, orders, or coordinates.
Plan (or Health Plan): The company providing you with health insurance.
Preauthorization: The approval needed from your plan before you can get certain health care services or medicines.
Premium: The amount paid for health insurance monthly. In addition to a premium, other costs for health care, including a deductible, copayments, and coinsurance may also be required.
Prescription Drug Coverage: Refers to how the PHP helps pay for its Members’ prescription drugs and medications.
Prescription Drugs: Also known as prescription medication or prescription medicine, is a pharmaceutical drug that legally requires a medical prescription to be dispensed.
Primary Care Physician: A licensed medical doctor (MD) or doctor of osteopathy (DO) that provides and coordinates patient needs and initiates and monitors referrals for specialized services when required. See Primary Care Provider.
Primary Care Provider (PCP): The participating physician, physician extender (e.g. physician assistant, nurse practitioner, certified nurse midwife) or group practice/center selected by or assigned to the Member to provide and coordinate the Member’s health care needs and to initiate and monitor referrals for specialized services when required. Includes family practitioners, pediatricians, obstetricians, and internal medicine physicians.
Provider: A health care professional or a facility that delivers health care services, like a doctor, hospital, or pharmacy.
Rehabilitation Services and Devices: Health care services and equipment that help keep, get back, or improve skills and functioning for daily living that have been lost or impaired due to sickness, injury, or disablement. These services may include physical and occupational therapy, speech language pathology, and psychiatric rehabilitation services in a variety of inpatient or outpatient settings.
Specialist: A provider that focuses on a specific area of medicine or a group of patients to diagnose, manage, prevent or treat certain types of symptoms and conditions.
Urgent Care: Care for a health condition that needs prompt medical attention but is not an emergency medical condition. You can get Urgent Care in a walk-in clinic for a non-life-threatening injury (like the flu or sprained ankle).