Adverse benefit determination - Any decision to deny a service authorization request or to approve it for an amount that is less than requested.
Appeal - A way for you to challenge an adverse benefit determination (such as a denial or reduction of benefits) made by UnitedHealthcare Community Plan if you think we made a mistake. You can ask us to change a coverage decision by filing an appeal.
Activities of daily living - The things people do on a normal day, such as eating, using the toilet, getting dressed, bathing, or brushing the teeth.
Balance billing - A situation when a provider (such as a doctor or hospital) bills a person more than UnitedHealthcare Community Plan’s cost-sharing amount for services. We do not allow providers to “balance bill” you. Call Member Services if you get any bills that you do not understand.
Brand name drug - A prescription drug that is made and sold by the company that originally made the drug. Brand name drugs have the same ingredients as the generic versions of the drugs. Generic drugs are made and sold by other drug companies.
Care Coordinator - One main person from UnitedHealthcare Community Plan who works with you and with your care providers to make sure you get the care you need.
Care coordination - A person-centered individualized process that assists you in gaining access to needed services. The Care Coordinator will work with you, your family members, if appropriate, your providers and anyone else involved in your care to help you get the services and supports that you need.
Care plan - A plan for what health and support services you will get and how you will get them.
Care team - A care team may include doctors, nurses, counselors, or other health professionals who are there to help you get the care you need. Your care team will also help you make a care plan.
Centers for Medicare & Medicaid Services (CMS) - The federal agency in charge of Medicare and Medicaid programs.
Complaint - A written or spoken statement saying that you have a problem or concern about your covered services or care. This includes any concerns about the quality of your care, our network providers, or our network pharmacies. The formal name for “making a complaint” is “filing a grievance.”
Coverage decision - A decision about what benefits we cover. This includes decisions about covered drugs and services or the amount we will pay for your health services.
Covered drugs - The term we use to mean all of the prescription drugs covered by UnitedHealthcare Community Plan.
Covered services - The general term we use to mean all of the health care, long-term services and supports, supplies, prescription and over-the-counter drugs, equipment, and other services covered by UnitedHealthcare Community Plan.
Durable medical equipment - Certain items your doctor orders for you to use at home. Examples are walkers, wheelchairs, or hospital beds.
Emergency medical condition - An emergency means your life could be threatened or you could be hurt permanently (disabled) if you don’t get care quickly. If you are pregnant, it could mean harm to the health of you or your unborn baby.
Emergency medical transportation - Your condition is such that you are unable to go to the hospital by any other means but by calling 911 for an ambulance.
Emergency room care - A hospital room staffed and equipped for the treatment of people that require immediate medical care and/or services.
Excluded services - Services that are not covered under the Medicaid benefit.
Fair hearing - See State Fair Hearing. The process where you appeal to the State on a decision made by us that you believe is wrong.
Fee-for-service - The general term used to describe Medicaid services covered by the Department of Medical Assistance Services (DMAS).
Generic drug - A prescription drug that is approved by the federal government to use in place of a brand name drug. A generic drug has the same ingredients as a brand name drug. It is usually cheaper and works just as well as the brand name drug.
Grievance - A complaint you make about us or one of our network providers or pharmacies. This includes a complaint about the quality of your care.
Habilitation services and devices - Services and devices that help you keep, learn, or improve skills and functioning for daily living.
Health insurance - Type of insurance coverage that pays for health, medical and surgical expenses incurred by you.
Health plan - An organization made up of doctors, hospitals, pharmacies, providers of long-term services, and other providers. It also has Care Coordinators to help you manage all your providers and services. They all work together to provide the care you need.
Health risk assessment - A review of a patient’s medical history and current condition. It is used to figure out the patient’s health and how it might change in the future.
Helpline - an Enrollment Broker that DMAS contracts with to perform choice counseling and enrollment activities.
Home health aide - A person who provides services that do not need the skills of a licensed nurse or therapist, such as help with personal care (like bathing, using the toilet, dressing, or carrying out the prescribed exercises). Home health aides do not have a nursing license or provide therapy.
Home health care - Health care services a person receives in the home including nursing care, home health aide services and other services.
Hospitalization - The act of placing a person in a hospital as a patient.
Hospital outpatient care - Care or treatment that does not require an overnight stay in a hospital.
List of Covered Drugs (Drug List) - A list of prescription drugs covered by UnitedHealthcare Community Plan. UnitedHealthcare Community Plan chooses the drugs on this list with the help of doctors and pharmacists. The Drug List tells you if there are any rules you need to follow to get your drugs. The Drug List is sometimes called a “formulary.”
Medically Necessary - This describes the needed services to prevent, diagnose, or treat your medical condition or to maintain your current health status. This includes care that keeps you from going into a hospital or nursing facility. It also means the services, supplies, or drugs meet accepted standards of medical practice or as necessary under current Virginia Medicaid coverage rules.
Medicaid (or Medical Assistance) - A program run by the federal and the state government that helps people with limited incomes and resources pay for long-term services and supports and medical costs. It covers extra services and drugs not covered by Medicare. Most health care costs are covered if you qualify for both Medicare and Medicaid.
Member Services - A department within UnitedHealthcare Community Plan responsible for answering your questions about your Membership, benefits, grievances, and appeals.
Model of care - A way of providing high-quality care. The model of care includes care coordination and a team of qualified providers working together with you to improve your health and quality of life.
Network - “Provider” is the general term we use for doctors, nurses, and other people who give you services and care. The term also includes hospitals, home health agencies, clinics, and other places that provide your health care services, medical equipment, and long-term services and supports. They are licensed or certified by Medicaid and by the state to provide health care services. We call them “network providers” when they agree to work with the UnitedHealthcare Community Plan and accept our payment and not charge our Members an extra amount. While you are a Member of UnitedHealthcare Community Plan, you must use network providers to get covered services. Network providers are also called “plan providers.”
Network pharmacy - A pharmacy (drug store) that has agreed to fill prescriptions for UnitedHealthcare Community Plan Members. We call them “network pharmacies” because they have agreed to work with UnitedHealthcare Community Plan. In most cases, your prescriptions are covered only if they are filled at one of our network pharmacies.
Non-participating provider - A provider or facility that is not employed, owned, or operated by UnitedHealthcare Community Plan and is not under contract to provide covered services to Members of UnitedHealthcare Community Plan.
Nursing facility - A medical care facility that provides care for people who cannot get their care at home but who do not need to be in the hospital. Specific criteria must be met to live in a nursing facility.
Out-of-network provider or Out-of-network facility - A provider or facility that is not employed, owned, or operated by UnitedHealthcare Community Plan and is not under contract to provide covered services to Members of UnitedHealthcare Community Plan.
Participating provider - Providers, hospitals, home health agencies, clinics, and other places that provide your health care services, medical equipment, and long-term services and supports that are contracted with UnitedHealthcare Community Plan. Participating providers are also “in-network providers” or “plan providers.”
Physician services - Care provided to you by an individual licensed under state law to practice medicine, surgery, or behavioral health.
Prescription drug coverage - Prescription drugs or medications covered (paid) by your UnitedHealthcare Community Plan. Some over-the -counter medications are covered.
Prescription drugs: A drug or medication that, by law, can be obtained only by means of a physician's prescription.
Primary Care Physician (PCP) - Your primary care physician is the doctor who takes care of all of your health needs. They are responsible to provide, arrange, and coordinate all aspects of your health care. Often they are the first person you should contact if you need health care. Your PCP is typically a family practitioner, internist, or pediatrician. Having a PCP helps make sure the right medical care is available when you need it.
Prosthetics and Orthotics - These are medical devices ordered by your doctor or other health care provider. Covered items include, but are not limited to, arm, back, and neck braces; artificial limbs; artificial eyes; and devices needed to replace an internal body part or function.
Provider - A person who is authorized to provide your health care or services. Many kinds of providers participate with UnitedHealthcare Community Plan, including doctors, nurses, behavioral health providers and specialists.
Referral - Your PCP can send you to other providers in UnitedHealthcare Community Plan’s network for needed care your PCP cannot provide. This is called a referral.
Rehabilitation services and devices - Treatment you get to help you recover from an illness, accident, injury, or major operation.
Service area - A geographic area where a UnitedHealthcare Community Plan is allowed to operate. It is also generally the area where you can get routine (non-emergency) services.
Service authorization - Approval needed before you can get certain services or drugs. Some network medical services are covered only if your doctor or other network provider gets an authorization from UnitedHealthcare Community Plan.
Specialist - A doctor who provides health care for a specific disease, disability, or part of the body.
Urgently needed care - Care you get for a non-life threatening sudden illness, injury, or condition that is not an emergency but needs care right away. You can get urgently needed care from out-of-network providers when network providers are unavailable or you cannot get to them.