Ohio - UnitedHealthcare Community Plan - Glossary

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UnitedHealthcare Community Plan

Glossary

 

A

ABUSE – Harming someone on purpose (this includes yelling, ignoring a person's needs and inappropriate touching).

ADVANCE DIRECTIVE – A decision about your health care that you make ahead of time in case you are ever unable to speak for yourself. This will let your family and your doctors know what decisions you would make if you were able to.

APPEAL – An appeal is a dispute made by a member, his or her representative or a provider with the member's permission, challenging an action by the health plan to deny or limit authorization of a service, including the type or level of service or reduce, suspend, or terminate payment for a previously authorized service; or any failure to authorize services in a timely manner or decide a grievance or appeal within the required time frames.

AUTHORIZATION – An O.K. or approval for a service.

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B

BENEFITS – Services, procedures and medications that UnitedHealthcare Community Plan will cover for you.

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C

CLINICAL CARE MANAGEMENT – One-on-one help by a nurse providing education and coordination of UnitedHealthcare Community Plan benefits, tailored to your needs.

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D

DISENROLLMENT – To stop your membership in UnitedHealthcare Community Plan.

DME – Durable Medical Equipment includes things such as wheelchairs, walkers, diabetic glucose meter, IV poles that have to be used for a length of time. It can also be equipment that must be thrown away such as bandages, catheters and needles. DME must be requested by your doctor.

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E

EMERGENCY – A sudden and, at the time, unexpected change in a person's physical or mental condition which, if a procedure or treatment is not performed right away, could be expected to result in 1) the loss of life or limb, 2) signifcant impairment to a bodily function, 3) permanent damage to a body part or health of unborn child.

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F

FRAUD – An untruthful act (example: if someone other than you uses your member ID card and pretends to be you).

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G

GRIEVANCE – A grievance is an expression of dissatisfaction about the health plan, or a practitioner or any matter other than an action taken by the plan. Grievances can include issues with the quality of care or services provided, aspects of interpersonal relationships such as rudeness of a provider or employee, or failure to respect a member's rights.

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H

HEALTH INFORMATION – Facts about your health and care. This information may come from UnitedHealthcare Community Plan or a provider. It includes information about your physical and mental health, as well as payments for care.

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I

ID CARD – An identifcation card that says you are a UnitedHealthcare Community Plan member. You should have this card with you at all times.

IMMUNIZATION – A medicine (usually a shot) that protects, or "immunizes", a member from a disease. Children should receive different shots at different ages. These shots are often given during regular doctor visits.

INFORMED CONSENT – That all medical treatments have been explained to you; you understand and agree to them.

IN-NETWORK – Doctors, specialists, hospitals, pharmacies and other providers who have an arrangement with UnitedHealthcare Community Plan to provide health care services to members.

INPATIENT – When you are admitted into a hospital for a length of time.

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J

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K

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L

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M

MEMBER – An eligible person enrolled with UnitedHealthcare Community Plan in the Medicaid program.

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N

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O

ODJFS – Ohio Department of Job and Family Services

OUT-OF-NETWORK – Doctors, specialists, hospitals, pharmacies and other providers who do not have an arrangement with UnitedHealthcare Community Plan to provide health care services to members.

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P

PRESCRIPTION – A doctor's written instructions for medication or treatment.

PRIMARY CARE PROVIDER (PCP) – A doctor you choose to be your primary care provider who has his/her own private practice. Your PCP will coordinate all of your health care.

PRIOR AUTHORIZATION – Process that your doctor uses to get approval for services that need to be approved before they can be done.

PROVIDER OR PRACTITIONER – A person or facility that offers health care (doctor, pharmacy, dentist, clinic, hospital, etc.).

PROVIDER DIRECTORY – A list of providers who participate with UnitedHealthcare Community Plan to help take care of your healthcare needs.

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Q

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R

REFERRAL – When you and your PCP agree you need to see another doctor and your PCP sends you to a network specialist.

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S

SELF-REFERRED SERVICES – Services for which you do not need to see your PCP for a referral.

SPECIALIST – Any doctor who has special training for a specific condition or illness.

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T

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U

URGENT CARE – When you are sick but it is not an emergency, and you need treatment or medical advice within a 48-hour time period.

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V

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W

WIC – Supplemental Food Program for Women, Infants and Children which provides nutrition counseling, nutrition education, and nutritious foods to pregnant and postpartum women, infants and children up to the age of 2. Children deemed nutritionally deficent are covered up to age 5 if they are low income and are determined to be at nutritional risk.

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X

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Y

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Z

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