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Blue Choice

South Carolina Healthy Connections

Glossary

Use these links to find your terms quickly.
B  C  D  E  F  G  H  I  J  K  L  M  N  O  P  Q  R  S  T  U  V  W  X  Y  Z

A

  • Action-- an action is at least one of the following:
    • The denial or limited authorization of a requested service, including the type or level of service
    • The reduction, suspension or termination of a previously authorized service
    • The denial, in whole or in part, of payment for a service
    • The failure to provide services in a timely manner, as defined by the State
    • The failure of the Contractor to act within the required timeframes
    • For a resident of a rural area with only one MCO, the denial of a Medicaid member's request to exercise his or her right to get services outside the network
  • Actual Charge -- The amount a doctor or other health care provider actually bills a patient. You often see the phrase, "The actual charge may be different from the allowable charge." This means your health plan may only cover a portion of what your doctor charges you. For example, your doctor bills you $35.00 for an office visit. This is the actual charge. But your health plan may only accept $32.00 for an office visit. This is the allowable charge.=
  • Allowable Charge -- The most your health plan will pay for a covered service. You may see the phrase, "The actual charge may be different from the allowable charge." This means your health plan may only cover a portion of what your doctor charges you. For example, your doctor bills you $35.00 for an office visit. This is the actual charge. But your health plan may only accept $32.00 for an office visit. This is the allowable charge.
  • Appeal -- An appeal is a request for review of an action.
  • Approval -- The process of deciding whether or not a person's health plan will cover a specific service. Check your health plan carefully. You may find certain procedures, like surgery, require pre-approval. This means you need to check with your health plan to see if it will cover the service before you receive it. This simple approval process could save you money!
  • Approved Amount -- The amount your health plan says is reasonable for a covered service. This amount may be less than the actual amount. For example, your health plan may cover $29.00 for a doctor's office visit, even though your doctor may charge you $32.00 for that visit. The $29.00 is the approved amount.
  • Assignment -- When you authorize your health plan to pay benefits to your health care provider instead of sending payment to you. Are you covered by BlueChoice HealthPlan? If you are, your benefits are automatically paid (assigned) to our network providers.

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  • Benefit -- Services and supplies a health plan pays for. The term also refers to the amount a health plan will pay.
  • Benefit Period -- The period of time a health plan will pay for covered benefits. Benefit periods are usually one year. They don't always reflect a calendar year, so be sure and check your policy.

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  • Case Management -- A program that will pay for health care services your health plan usually will not cover if those services will help you get well faster or better. For example, a woman goes into premature labor and her doctor recommends a drug that will keep her from delivering the baby. Her health plan would not normally pay for this drug. But under case management, special members of the health plan's staff look at the woman's case. They realize if she were to have her baby early, the baby could risk its life and run up huge medical bills. So they cover the drug. A program that will pay for health care services your health plan usually will not cover if those services will help you get well faster or better. For example, a woman goes into premature labor and her doctor recommends a drug that will keep her from delivering the baby. Her health plan would not normally pay for this drug. But under case management, special members of the health plan's staff look at the woman's case. They realize if she were to have her baby early, the baby could risk its life and run up huge medical bills. So they cover the drug.
  • Coinsurance -- The dollar amount or percentage you pay. For example, if you have an "80/20 plan," your health plan would pay 80% of the bill and you would pay 20%. The 20% you pay is your coinsurance.
  • Copayment -- A small fee you pay for each doctor's office visit, medical service or prescription. For example, your health plan may have a $10 copayment for doctor's office visits. This means every time you visited your doctor, you would pay just $10.
  • Cost Sharing -- A method of dividing the cost of health care among consumers, insurance companies, employers and providers. For example, your employer may pay part of the premiums for your insurance. Your health plan will pay part of your health care bills, and you will pay part. If your doctor is part of your health plan's network, then he or she will cover part of the cost by negotiating a discount for his or her services. Everyone shares in the cost to keep costs down.
  • Covered Service -- Specific services your health plan will pay for.

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  • Deductible -- The amount of money you must pay before your health plan will pay its share. For example, if you have a health plan with a $250 deductible, you must reach that amount before your health plan begins paying. 

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  • Emergency Medical Condition -- A severe injury or illness (including pain). Your illness or injury must be so severe that if you don't get medical care right away, one of these might occur:
    • Serious risk to your health. If you're pregnant, this includes your health and your unborn child's health.
    • Serious damage to body functions.
    • Serious damage to any organs or body parts.
  • Exclusion -- Services or items your health plan doesn't cover.

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  • Fee for Service -- This is "traditional" insurance. You pay doctors and hospitals for each service you receive. Your health plan will pay a portion of the total cost.
  • Flexible Benefits Plan -- A health plan in which all employees may choose among two or more benefit options. Also called a cafeteria plan.
  • Fraud -- A deception that could result in your health plan paying for something it shouldn't. For example, if your doctor files a claim for a service you didn't receive, this is fraud.

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  • Grievance -- A grievance is an expression of dissatisfaction about any matter other than an action. Grievances may include, but are not limited to:
    • Quality of care or services provided
    • Aspects of interpersonal relationships, such as rudeness of a provider or employee
    • Failure to respect the member's rights

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    • HMO -- Health maintenance organization. When you sign up for an HMO, you choose one doctor to coordinate all your health care. This doctor, your "primary care physician," learns your entire medical history. He or she recommends care based on knowing you from head to toe. If you should ever need care from a specialist, your primary care physician will refer you to one in your health plan's network.
    • Home Health Agency (HHA) -- A facility that offers skilled nursing care and other services to patients in their homes. These include occupational, physical and speech therapies, medical social services and home health aide services. For example, your Aunt Lily has a stroke and has trouble speaking. She's not hurt enough to stay in a hospital, but needs some help learning to talk clearly again. A home health agency assigns a speech therapist to visit Aunt Lily at home and work with her.
    • Hospice -- An organization that helps dying patients and their families. Hospice programs help patients spend their last months at home instead of in a hospital or nursing home. Staff members help relieve pain, manage symptoms and offer counseling to patients and their families.

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    • Immunosuppressive Drugs -- Medicine that people who have received organ transplants must take to help prevent their bodies from rejecting the new organs. 

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    • Medically Necessary or Medical Necessity -- "Medically necessary" or "medical necessity" shall mean health care services that a physician, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing or treating an illness, injury, disease or its symptoms. The services are:
      • In accordance with generally accepted standards of medical practice.
      • Clinically appropriate, in terms of type, frequency, extent, site and duration.
      • Considered effective for the patient’s illness, injury or disease.
      • Not primarily for the convenience of the patient, physician or other health care provider.
      • Not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient’s illness, injury or disease.

    For these purposes, "generally accepted standards of medical practice" means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, Physician Specialty Society recommendations and the views of physicians practicing in relevant clinical areas and any other relevant factors.

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    • Open Access Plan -- A health plan that lets you visit any doctor in the plan's network. You do not need a referral from your primary care physician. 
    • Outpatient -- A patient who gets treatment at a hospital but doesn't stay there. For example, you go to the hospital in the morning for minor surgery. As soon as you wake up from the anesthesia, the doctor sends you home to recover. This is outpatient care because you didn't need to stay in the hospital. There may be some cases when you spend the night in a hospital, but still are considered an outpatient. It's always best to ask your doctor if you're getting outpatient or inpatient care, because your health plan may pay differently for each.

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    • Pre-existing Condition -- An injury or illness you had before you signed up for your current health plan for which you received a diagnosis or treatment. Many health plans do not cover pre-existing conditions. Or, they have a waiting period before you can get benefits for them. For example, you hurt your knee playing football a couple years ago and had to have surgery. When you sign up for a new health plan, you'll have to list your knee injury as a pre-existing condition.
    • Primary Care Physician -- A doctor who treats common illnesses and injuries. This doctor will coordinate all your medical care. You can choose a family practitioner, an internist or a pediatrician. Your doctor, your HMO and you form a team. You'll work together to find the right care to help you get healthy and stay well.

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    • Referral -- A referral is consent from your primary care physician to see a specialist for an illness or injury. You may also need a referral to have special treatments, such as x-rays or surgery. A referral saves you money by reducing unnecessary medical costs. Your primary care physician will decide if you need to see a specialist. He or she will help you choose a specialist that is right for you.

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    • Specialist -- A specialist is a doctor who treats certain illnesses or injuries. For example, a surgeon is a specialist. A doctor who treats allergies or heart problems is also a specialist. You may need a referral from your primary care physician to visit a specialist.

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    • Urgent Care -- Medical care for an illness or injury that is urgent but not life-threatening. You need urgent care to keep you from getting sicker or your injury from getting worse. Examples include deep cuts, severe diarrhea, ankle sprains, earaches, sore throats and fevers.