Managed Care Definitions

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 formal process used by a provider of service and/or an individual to request review of a plan ruling because they disagree.

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. Claim can be paid in full, in part, or denied.

COMPLAINT: Any notice of displeasure with the services, treatment, or coverage with the health plan.

COPAYMENT: A fixed amount you pay for a covered health service, usually when you receive the services. Example:  $5 for an office visit.

CONDITION: A less than ideal state of health due to an illness or injury that needs care or services.

CONDITION MANAGEMENT GUIDANCE: Healthcare actions and education for people with chronic health conditions.

CONTRACT:  Agreement between the State of Texas and the health plan to provide healthcare to members.

COVERED SERVICES: Healthcare 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 was 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 healthcare provider for everyday use. DME may include items such as oxygen, wheelchairs, blood sugar testing devices, and crutches.

EFFECTIVE DATE OF COVERAGE: The first day of the month for which a member is covered under PCHP.

ELIGIBILITY: The decision that an individual meets the reasons for getting healthcare benefits as stated by the health plan.

EMERGENCY MEDICAL CONDITION: An illness, injury, 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.

EXCLUDED SERVICES: Healthcare services that your health insurance or plan does not 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 which can result in criminal prosecution, civil liability, and administrative sanctions.

GRIEVANCE: A complaint to your health insurer or plan.

HABILITATION SERVICES AND DEVICES: Healthcare 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 plan to pay for your covered healthcare costs:

  • The health condition needs medical services
  • PCHP covers the service
  • The medical benefit is for the needed medical services

HEALTH RISK ASSESSMENT: Age-based surveys used by health plan staff as a tool to assist in the discovery of a member’s healthcare needs.

HOME HEALTH CARE: Healthcare 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 healthcare services in a cost-efficient manner.

MANAGED CARE ORGANIZATION (MCO): A health plan that seeks to manage care. Generally, this involves contracting with healthcare 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 healthcare needs.

MEDICAL NECESSITY: Healthcare 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 PCHP has contracted with to provide healthcare services. The contract allows PCHP to get a savings on the services billed.

NON-PARTICIPATING PROVIDER: A provider who doesn’t have a contract with your health insurer or plan to provide covered services to you. It may be more difficult to obtain authorization from your health insurer or 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 insurer 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 insurer or plan to provide covered services to you.

PCHP: Parkland Community Health Plan

PHYSICIAN SERVICES: Healthcare 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 healthcare services.

PRACTITIONER: A person with a licensed or certified specialty who provides medical or behavioral healthcare services.

PRE-AUTHORIZATION: A decision by your health insurer or plan that a healthcare 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 insurance or plan will cover the cost.

PREMIUM: The amount that must be paid for your health insurance or plan.

PRESCRIPTION DRUGS: Drugs and medicines that by law require a prescription.

PRESCRIPTION DRUG COVERAGE: Health insurance or plan that helps pay for prescription drugs and medications.

PREVENTIVE CARE: Healthcare which 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 with PCHP 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.

PROSTHETICS: Items that replace body parts. Example: Man-made leg.

PROVIDER: A practitioner, group practice, program, or facility whose credentials, including, but not limited to, degree, licensure, certifications and specialists, have been reviewed. PCHP will accept or refuse the provider’s request to be part of the health plan. See also Practitioner.

REFERRAL: The coverage of a member to see a different clinician or specialist they see with PCHP contracted providers. Requests to see a non-PCHP contracted provider requires an approval before the member sees this provider.

REHABILITATION SERVICES AND DEVICES: Healthcare services such as physical or occupational therapy that help a person keep or improve skills and functioning 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 water-proof 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.