ACCESS: The patient’s ability to obtain medical care.
ACUTE CARE: Care done in an inpatient hospital setting.
ADJUDICATE: To deny or pay a claim.
APPEAL: A request for your managed care organization to review a denial or a grievance again.
AUTHORIZED REPRESENTATIVE: Any person or group acting on behalf of the member and with the member’s written consent.
BEHAVIORAL HEALTH: An umbrella term that includes treatment of mental, emotional, or drug and alcohol use problems.
BENEFICIARY: Individual who is either using or eligible to use insurance benefits, including health insurance benefits, under an insurance contract. See also Member.
BENEFIT: Health services and supplies that PCHP will cover under your health insurance plan.
CARE PLAN: An action plan, based on a member’s needs, with goals and actions that focus on those needs.
CASE MANAGER: A trained person who does assessments, planning, and coordination for options and services to meet a person’s needs.
CHRONIC: Health problems that last more than a short time.
CLAIM: A bill sent to PCHP for services that were given to a member. A claim can be paid in full, in part, or denied.
COMPLAINT: A grievance that you communicate to your health insurer or plan.
COPAYMENT: A fixed amount (for example, $15) you pay for a covered health care service, usually when you receive the service. The amount can vary by the type of covered health care service.
CONDITION: A less-than-ideal state of health due to an illness or injury that needs care or services.
CONDITION MANAGEMENT GUIDANCE: Health care actions and education for people with chronic health conditions.
CONTRACT: Agreement between the State of Texas and the health plan to provide health care to members.
COVERED SERVICES: Health care services that PCHP has to provide to a member. This includes all services required by the contract, state and federal law, and all value-added services. Certain criteria might need to be met for the services to be covered.
DATE OF DISENROLLMENT: The last day of the month in which the member loses health plan eligibility.
DENIAL: Services not approved because:
- Medical criteria for coverage were not met
- The services are not part of the member’s benefits and coverage
- Policy and rules were not followed
DRUG FORMULARY: Varying list of prescription drugs approved by a given health plan for distribution to a covered person through specific pharmacies. See also Formulary.
DURABLE MEDICAL EQUIPMENT (DME): Equipment ordered by a health care provider for everyday or extended use. Coverage for DME may include but is not limited to: oxygen equipment, wheelchairs, crutches, or diabetic supplies.
EFFECTIVE DATE OF COVERAGE: The first day of the month for which a member is covered under Parkland Community Health Plan.
ELIGIBILITY: The decision that an individual meets the reasons for getting health care benefits as stated by the health plan.
EMERGENCY MEDICAL CONDITION: An illness, injury, symptom, or condition so serious that a reasonable person would seek care right away to avoid harm.
EMERGENCY MEDICAL TRANSPORTATION: Ground or air ambulance services for an emergency medical condition.
EMERGENCY ROOM CARE: Emergency services you get in an emergency room.
EMERGENCY SERVICES: Evaluation of an emergency medical condition and treatment to keep the condition from getting worse.
EXCLUDED SERVICES: Health care services that your health plan doesn’t pay for or cover for any member with the same benefit.
FORMULARY: An approved list of prescription drugs; a list of selected pharmaceuticals and their appropriate dosages felt to be the most useful and cost-effective for patient care. See also Drug Formulary.
FRAUD: Intentional misrepresentations that can result in criminal prosecution, civil liability, and administrative sanctions.
GRIEVANCE: A complaint to your health insurer or plan.
HABILITATION SERVICES AND DEVICES: Health care services such as physical or occupational therapy that help a person keep, learn, or improve skills and functioning for daily living.
HEALTH INSURANCE: A contract that requires your health insurer to pay your covered health care costs in exchange for a premium if:
HEALTH RISK ASSESSMENT: Age-based surveys used by health plan staff as a tool to assist in the discovery of a member’s health care needs.
HOME HEALTH CARE: Health care services a person receives in a home.
HOSPICE SERVICES: Services to provide comfort and support for persons in the last stages of a terminal illness and their families.
HOSPITALIZATION: Care in a hospital that requires admission as an inpatient and usually requires an overnight stay.
HOSPITAL: Any institution duly licensed, certified, and operated as a hospital.
HOSPITAL OUTPATIENT CARE: Care in a hospital that usually doesn’t require an overnight stay.
INPATIENT STAY: At least a 24-hour stay in a facility licensed to provide hospital care. Note: Some short overnight stays are covered under the outpatient benefit.
MANAGED CARE: The body of clinical, financial, and organizational activities designed to ensure the provision of appropriate health care services in a cost-efficient manner.
MANAGED CARE ORGANIZATION (MCO): A health plan, such as Parkland Community Health Plan, that seeks to manage care. Generally, this involves contracting with health care providers to deliver healthcare services on a capitated (per-member per-month) basis.
MEDICAID: The medical assistance entitlement program funded under Title XIX, Social Security Act and administered by Health and Human Services (HHSC).
MEDICAL HOME: Primary care model that focuses on the member as the center of their health care needs.
MEDICAL NECESSITY: Health care services or supplies needed to prevent, diagnose, or treat an illness, injury, condition, disease or its symptoms. The services must meet accepted standards of medicine.
MEDICAL NECESSITY CRITERIA: Proven guidelines that help PCHP clinical staff make decisions about the correct health services for a health condition.
MEMBER: Person covered by a health plan.
NETWORK: The facilities, providers, and suppliers Parkland Community Health Plan has contracted with to provide health care services. The contract allows PCHP to get a discount on the services billed.
NON-PARTICIPATING PROVIDER: A provider who doesn’t have a contract with your health plan to provide covered services to you. It may be more difficult to obtain authorization from your health plan to obtain services from a non-participating provider instead of a participating provider. In limited cases, such as when there are no other providers, your health plan can contract to pay a non-participating provider.
ORTHOTICS: Items that correct or relieve nerve, muscle, and bone problems; disease; injury; or deformity. Example: knee brace.
OUTPATIENT CARE: Care in a hospital that usually doesn’t require an overnight stay.
PARTICIPATING PROVIDER: A provider who has a contract with your health plan to provide covered services to you.
PCHP: Parkland Community Health Plan
PHYSICIAN SERVICES: Health care services a licensed medical physician (M.D. - Medical Doctor or D.O. - Doctor of Osteopathic Medicine) provides or coordinates.
PLAN: A benefit, like Medicaid, that provides and pays for your health care services.
PRACTITIONER: A person with a licensed or certified specialty who provides medical or behavioral health care services.
PRE-AUTHORIZATION: A decision by your health insurer or plan that a health care service, treatment plan, prescription drug, or durable medical equipment that you or your provider has requested is medically necessary. This decision or approval, sometimes called prior authorization, prior approval, or pre-certification, must be obtained prior to receiving the requested service. Pre-authorization isn’t a promise your health plan will cover the cost.
PREMIUM: The amount that must be paid for your health plan. Medicaid plans do not require premiums.
PRESCRIPTION DRUGS: Drugs and medicines that require a prescription.
PRESCRIPTION DRUG COVERAGE: A health plan benefit that pays for or reduces the cost of prescribed medications.
PREVENTIVE CARE: Health care that emphasizes prevention, early detection, and early treatment, thereby reducing the costs of healthcare in the long run.
PRIMARY CARE: Provides whole-person care for health needs from birth to death and not just for specific problems. Primary care sees that people receive complete care. Some examples of primary care are:
- Health promotion
- Disease prevention
- Treatment
- Rehabilitation and recovery
PRIMARY CARE PHYSICIAN OR PRIMARY CARE PROVIDER (PCP): A physician or provider who has agreed to provide a medical home to members. They are responsible for providing primary care to members and initiating referrals for care.
PRIOR AUTHORIZATION: The process of getting coverage approval for a service or medication before that service or medication is started. Without such prior approval, the service or medication is not covered or is reimbursed at a lower level. See also Pre-Authorization.
PROSTHETICS: Items that replace body parts. Example: Man-made leg.
PROVIDER: A physician (M.D. - Medical Doctor or D.O. - Doctor of Osteopathic Medicine), health care professional, or health care facility licensed, certified, or accredited as required by state law. See also Practitioner.
REFERRAL: A recommendation made by a provider that their patient (PCHP member) should visit another provider for certain types of care. Referrals to non-network providers must be approved by PCHP before the member visits the provider.
REHABILITATION SERVICES AND DEVICES: Health care services such as physical or occupational therapy that help a person keep or improve skills for daily living.
SKILLED NURSING CARE: Services from licensed nurses in your own home or in a nursing home.
SPECIALIST: A physician who focuses on a specific area of medicine to diagnose, manage, prevent, or treat certain types of symptoms and conditions.
SUPPLIES: Disposable items, typically for single use. Examples: Diabetic testing strips, sterile gauze, and waterproof pads for beds.
URGENT CARE: Care for an illness, injury, or condition serious enough that a reasonable person would seek care right away, but not so severe as to require emergency room care.
VALUE-ADDED SERVCES: Service the health plan covers above and beyond the State of Texas contract requirements.