Children's Health Insurance Program (CHIP) Glossary
A
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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.
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Appeal
A request for your managed care organization to review a denial or a grievance again.
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ASC/SPU
Ambulatory surgical center/short procedure unit.
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Authorization
An O.K. or approval for a service.
B
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Benefits
Services, procedures and medications that CHIP will cover for you.
C
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Clinical Care Management
One-on-one help by a nurse providing education and coordination of CHIP benefits, tailored to your needs.
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Complaint
A grievance that you communicate to your health insurer or plan.
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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.
D
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Disenrollment
To stop your membership in CHIP.
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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.
E
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Emergency
When you reasonably believe that your health is in serious danger.
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Emergency Medical Condition
An illness, injury, symptom, or condition so serious that a reasonable person would seek care right away to avoid harm.
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Emergency Medical Transportation
Ground or air ambulance services for an emergency medical condition.
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Emergency Room Care
Emergency services you get in an emergency room.
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Emergency Services
Evaluation of an emergency medical condition and treatment to keep the condition from getting worse.
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Excluded Services
Health care services that your health insurance or plan doesn’t pay for or cover.
G
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Grievance
A complaint to your health insurer or plan.
H
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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.
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Health Insurance
A contract that requires your health insurer to pay your covered health care costs in exchange for a premium.
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Home Health Agency
A company hired by CHIP to provide care for you in your home.
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Home Health Care
Health care services a person receives in a home.
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Hospice Services
Services to provide comfort and support for persons in the last stages of a terminal illness and their families.
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Hospital Outpatient Care
Care in a hospital that usually doesn’t require an overnight stay.
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Hospitalization
Care in a hospital that requires admission as an inpatient and usually requires an overnight stay.
I
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ID Card
Identification card – a card that says you are a CHIP member. You should have this card with you at all times.
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Informed Consent
You agree to all medical treatments.
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Inpatient
When you are admitted into a hospital for a length of time.
M
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Medical Necessity
Your health care provider decides if a treatment, admission, procedure, medical supply, equipment, service or supply is medically necessary.
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Medically Necessary
Health care services or supplies needed to prevent, diagnose, or treat an illness, injury, condition, disease or its symptoms and that meet accepted standards of medicine.
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Member
A person who is eligible for CHIP.
N
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Network
The facilities, providers, and suppliers your health insurer or plan has contracted with to provide health care services.
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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.
O
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Outpatient
When you have a procedure done that does not require a hospital stay overnight.
P
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Participating Provider
A Provider who has a contract with your health insurer or plan to provide covered services to you.
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Physician Services
Health-care services a licensed medical physician (M.D. -Medical Doctor or D.O. -Doctor of Osteopathic Medicine) provides or coordinates.
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Plan
A benefit, like Medicaid, which provides and pays for your health-care services.
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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 insurance or plan will cover the cost.
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Premium
The amount that must be paid for your health insurance or plan.
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Prescription Drug Coverage
Health insurance or plan that helps pay for prescription drugs and medications.
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Prescription Drugs
Drugs and medications that by law require a prescription.
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Primary Care Physician
A physician (M.D. -Medical Doctor or D.O. -Doctor of Osteopathic Medicine) who directly provides or coordinates a range of health-care services for a patient.
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Primary Care Provider
A physician (M.D. -Medical Doctor or D.O. -Doctor of Osteopathic Medicine), nurse practitioner, clinical nurse specialist, or physician assistant, as allowed under state law, who provides, coordinates, or helps a patient access a range of health-care services.
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Prior Authorization
The process for any service that needs an O.K. from CHIP before it can take place.
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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.
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Provider Directory
A list of providers who participate with CHIP to help take care of your healthcare needs.
R
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Referral
When you and your primary care provider agree you need to see another doctor, your primary care provider will send you to a CHIP specialist.
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Rehabilitation Services and Devices
Health-care services such as physical or occupational therapy that help a person keep, get back or improve skills and functioning for daily living that have been lost or impaired because a person was sick, hurt or disabled.
S
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Self-Referred Services
Services for which you do not need to see your primary care provider for a referral.
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Skilled Nursing Care
Services from licensed nurses in your own home or in a nursing home.
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Special Needs Unit (SNU)
A voluntary service offered by CHIP that can give you extra help in understanding and using your benefits if you have a disability or other special need.
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Specialist
A physician specialist focuses on a specific area of medicine or a group of patients to diagnose, manage, prevent or treat certain types of symptoms and conditions.
T
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TANF
Temporary Assistance for Needy Families.
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Treatment
The care that you may receive from doctors and facilities.
U
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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.
W
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WIC
Women, Infants and Children program, a supplemental nutrition program that provides nutritious food, education support and health care referrals for women, infants and children.
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