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Children's Health Insurance Program (CHIP) Glossary

A

  • 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

    A request for your managed care organization to review a denial or a grievance again.

  • ASC/SPU

    Ambulatory surgical center/short procedure unit.

  • Authorization

     An O.K. or approval for a service.

B

  • Benefits

    Services, procedures and medications that CHIP will cover for you.

C

  • Clinical Care Management

    One-on-one help by a nurse providing education and coordination of CHIP benefits, tailored to your needs.

  • 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.

D

  • Disenrollment

    To stop your membership in CHIP.

  • 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

  • Emergency

    When you reasonably believe that your health is in serious danger.

  • 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 insurance or plan doesn’t pay for or cover.

G

  • Grievance

    A complaint to your health insurer or plan.

H

  • 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.

  • Home Health Agency

    A company hired by CHIP to provide care for you in your home.

  • 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.

  • Hospital Outpatient Care

    Care in a hospital that usually doesn’t require an overnight stay.

  • Hospitalization

    Care in a hospital that requires admission as an inpatient and usually requires an overnight stay.

I

  • ID Card

    Identification card – a card that says you are a CHIP member. You should have this card with you at all times.

  • Informed Consent

    You agree to all medical treatments.

  • Inpatient

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

M

  • Medical Necessity

    Your health care provider decides if a treatment, admission, procedure, medical supply, equipment, service or supply is medically necessary.

  • 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.

  • Member

    A person who is eligible for CHIP.

N

  • Network

    The facilities, providers, and suppliers your health insurer or plan has contracted with to provide health care services.

  • 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

  • Outpatient

    When you have a procedure done that does not require a hospital stay overnight.

P

  • Participating Provider

    A Provider who has a contract with your health insurer or plan to provide covered services to you.

  • 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, which provides and pays for your 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 insurance or plan will cover the cost.

  • Premium

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

  • Prescription Drug Coverage

    Health insurance or plan that helps pay for prescription drugs and medications.

  • Prescription Drugs

    Drugs and medications that by law require a prescription.

  • 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.

  • 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.

  • Prior Authorization

    The process for any service that needs an O.K. from CHIP before it can take place.

  • 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.

  • Provider Directory

    A list of providers who participate with CHIP to help take care of your healthcare needs.

R

  • 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.

  • 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

  • Self-Referred Services

    Services for which you do not need to see your primary care provider for a referral.

  • Skilled Nursing Care

    Services from licensed nurses in your own home or in a nursing home.

  • 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.

  • 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

  • TANF

    Temporary Assistance for Needy Families.

  • Treatment

     The care that you may receive from doctors and facilities.

U

  • 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

  • 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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Looking for the federal government’s Medicaid website? Look here at Medicaid.gov.

UnitedHealthcare Dual Complete Plans

Plans are insured through UnitedHealthcare Insurance Company or one of its affiliated companies, a Medicare Advantage organization with a Medicare contract and a contract with the State Medicaid Program. Enrollment in the plan depends on the plan’s contract renewal with Medicare. This plan is available to anyone who has both Medical Assistance from the State and Medicare. This information is not a complete description of benefits. Call 1-800-905-8671 TTY 711 for more information. Limitations, co-payments, and restrictions may apply. Benefits, premiums and/or co-payments/co-insurance may change on January 1 of each year.

Nurseline Disclaimer

This service should not be used for emergency or urgent care needs. In an emergency, call 911 or go to the nearest emergency room. The information provided through this service is for informational purposes only. The nurses cannot diagnose problems or recommend treatment and are not a substitute for your doctor's care. Your health information is kept confidential in accordance with the law. The service is not an insurance program and may be discontinued at any time.

UnitedHealthcare Connected™ for MyCare Ohio (Medicare-Medicaid Plan)

UnitedHealthcare Connected for MyCare Ohio (Medicare-Medicaid Plan) is a health plan that contracts with both Medicare and Ohio Medicaid to provide benefits of both programs to enrollees. If you have any problem reading or understanding this or any other UnitedHealthcare Connected for MyCare Ohio (Medicare-Medicaid Plan) information, please contact our Member Services at 1-844-445-8328 (TTY 711) from 7 a.m. to 8 p.m. Monday through Friday (voice mail available 24 hours a day/7 days a week) for help at no cost to you.

Si tiene problemas para leer o comprender esta o cualquier otra documentación de UnitedHealthcare® Connected™ de MyCare Ohio (plan Medicare-Medicaid), comuníquese con nuestro Departamento de Servicio al Cliente para obtener información adicional sin costo para usted al 1-844-445-8328 (TTY 711) de lunes a viernes de 7 a.m. a 8 p.m. (correo de voz disponible las 24 horas del día, los 7 días de la semana).

UnitedHealthcare Connected™ (Medicare-Medicaid Plan)

UnitedHealthcare Connected (Medicare-Medicaid Plan) is a health plan that contracts with both Medicare and Texas Medicaid to provide benefits of both programs to enrollees.

UnitedHealthcare Connected Benefit Disclaimer

This is not a complete list. The benefit information is a brief summary, not a complete description of benefits. For more information contact the plan or read the Member Handbook. Limitations, copays and restrictions may apply. For more information, call UnitedHealthcare Connected Member Services or read the UnitedHealthcare Connected Member Handbook. Benefits and/or copayments may change on January 1 of each year.

UnitedHealthcare Senior Care Options (HMO SNP) Plan

UnitedHealthcare SCO is a Coordinated Care plan with a Medicare contract and a contract with the Commonwealth of Massachusetts Medicaid program. Enrollment in the plan depends on the plan’s contract renewal with Medicare. This plan is a voluntary program that is available to anyone 65 and older who qualifies for MassHealth Standard and Original Medicare. If you have MassHealth Standard, but you do not qualify for Original Medicare, you may still be eligible to enroll in our MassHealth Senior Care Option plan and receive all of your MassHealth benefits through our SCO program.

Availability of Non-English Disclaimer

ATTENTION: If you speak [insert language], language assistance services, free of charge, are available to you. Call 1-800-905-8671 TTY 711.

ATENCIÓN: Si habla [ingrese el idioma], hay servicios de asistencia lingüística disponibles para usted y que no tienen cargo. Llame al 1-800-905-8671 TTY 711.

Star Ratings Disclaimer

Medicare evaluates plans based on a 5-Star rating system.

Formularies

The formulary, pharmacy network and provider network may change at any time. You will receive notice when necessary.

NCQA

UnitedHealthcare Connected has a Model of Care approved by the National Committee for Quality Assurance (NCQA) to operate as a Special Needs Plan (SNP) until 2017 based on a review of UnitedHealthcare Connected’s Model of Care.

Important Provider Information

The Choice is Yours

We will provide you with information to help you make informed choices, such as physicians' and health care professionals' credentials. This information, however, is not an endorsement of a particular physician or health care professional's suitability for your needs.

The providers available through this application may not necessarily reflect the full extent of UnitedHealthcare's network of contracted providers. There may be providers or certain specialties that are not included in this application that are part of our network. If you don't find the provider you are searching for, you may contact the provider directly to verify participation status with UnitedHealthcare's network, or contact Customer Care at the toll-free number shown on your UnitedHealthcare ID card. We also recommend that, prior to seeing any physician, including any specialists, you call the physician's office to verify their participation status and availability.

Some network providers may have been added or removed from our network after this directory was updated. We do not guarantee that each provider is still accepting new members.

Out-of-network/non- contracted providers are under no obligation to treat UnitedHealthcare plan members, except in emergency situations. Please call our customer service number or see your Evidence of Coverage for more information, including the cost- sharing that applies to out-of-network services.

American Disabilities Act Notice

In accordance with the requirements of the federal Americans with Disabilities Act of 1990 and Section 504 of the Rehabilitation Act of 1973 ("ADA"), UnitedHealthcare Insurance Company provides full and equal access to covered services and does not discriminate against qualified individuals with disabilities on the basis of disability in its services, programs, or activities.

Referrals

Network providers help you and your covered family members get the care needed. Access to specialists may be coordinated by your primary care physician.

Paper Directory Requests

Paper copies of the network provider directory are available at no cost to members by calling the customer service number on the back of your ID card. Non-members may download and print search results from the online directory.

Inaccurate Information

To report incorrect information, email provider_directory_invalid_issues@uhc.com. This email box is for members to report potential inaccuracies for demographic (address, phone, etc.) information in the online or paper directories. Reporting issues via this mail box will result in an outreach to the provider’s office to verify all directory demographic data, which can take approximately 30 days. Individuals can also report potential inaccuracies via phone. UHC Members should call the number on the back of their ID card, and non-UHC members can call 888-638-6613 TTY 711.

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Last Updated: 09.03.2019 at 03:02 PM CDT

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