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Glossary

The following glossary of health care terms is provided to help you understand the meaning of this specialized terminology. These are terms that describe the various products, contracted providers, organizations and specialized services that relate to health care. These are general definitions. Some plans or carriers may define these terms differently or in a special way for special purposes. Always consult your Evidence of Coverage booklet or similar document.
Click on the first letter of the term you're looking for.
A 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

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A

Acupuncture: An alternative health procedure based on ancient Chinese methods, gaining acceptance in Western hospitals, involving insertion of thin needles at specific pressure points in the body.

Adjudication: Determination of the amount of payment for a claim.

Administrative Costs: The costs assumed by an insurance company or managed care plan for administrative services such as claims processing, billing and overhead costs.

Administrative Services Only (ASO): An arrangement under which an insurance carrier or an independent organization will, for a fee, handle the administration of claims, benefits and other administrative functions for a self-insured group but does not assume any financial risk for the payment of benefits.

Agent: An individual licensed by the State who sells insurance or coverage and provides service to the policyholder on behalf of the insurer or managed care plan. Could be sole-proprietor, member of a large firm or employee of the carrier and is paid a fee/commission by the carrier.

Allergy Treatment: Treatment of allergy, which may involve allergy testing and physician's services.

Allowable Charge: The maximum fee that a third party will reimburse a provider for a given service. An allowable charge may not be the same amount as either a reasonable or customary charge.

Ambulatory Care or Services: Health services which are provided on an outpatient basis, in contrast to services provided in the home or to persons who are inpatients in a hospital.

Ambulatory Surgery: Surgical procedures performed that do not require an overnight hospital stay.

Ancillary Services: Hospital services other than room and board, and professional services. They may include X-ray, drug, laboratory or other services.

Appeal(s): An individual's dispute over the denial of a claim payment or the denial of provision of a health care service, or a coverage denial based on a contractual exclusion or limitation.

Authorization: The approval of care, for hospitalization, outpatient procedure, certain specialty, etc., by a managed care or insurance company for its member, subscriber, or insured.

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B

BC Life & Health Insurance Company: A for profit life and health insurance company, formerly known as WellPoint Life, affiliated with Blue Cross of California. The company provides life and disability in California.

Behavioral Health: A Blue Cross of California mental/nervous and drug/chemical dependency program established in 1990. It combines a network of contracted providers and utilization management functions to deliver managed mental health care.

Beneficiary: A person who is eligible to receive insurance benefits.

Benefit: Payments provided for covered services under the terms of the policy. The benefits may be paid to the insured, or on his behalf, to others.

Benefit Agreement: The written agreement between Blue Cross and a group or individual under which Blue Cross covers health care expenses, provides or administers health care benefits, or otherwise pays or arranges for the payment of benefits for health care services.

Benefit Consultant: An individual or organization hired by a group planholder to review, analyze, and make recommendations on benefit strategies, including benefit plan design, carrier selection, pricing, etc. An insurance professional who provides information, advice and counseling for their clients.

Benefit Period: The maximum length of time for which benefits will be paid.

Birthing Center: A facility that allows mothers to give birth in a home-like setting.

Blue Cross of California: A healthcare service plan licensed in California, subject to the jurisdiction of the California Department of Managed Health Care, which provides a continuum of health care coverage options.

BlueCard Program: A BCBSA program that links participating health care providers and the independent Blue Cross and Blue Shield Plans across the country and abroad with a single electronic process for professional, outpatient and inpatient claims processing and reimbursement. The program allows members obtaining health care services while out of town to receive the same benefits of their Blue Cross plan and access out-of-town providers' savings. In most cases, providers bill claims directly to their local Plans without requiring up-front payment from the member.

Board Certified: A term used to describe a physician who has passed an examination given by a medical specialty board and who has been certified as a specialist in that medical area.

Brand Name Drug(s): Those drugs that are marketed under a specific trade name by a pharmaceutical manufacturer. In most cases, these drugs are still under patent protection, meaning the manufacturer is the sole source for the product.

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C

Calendar Year Deductible: The dollar amount for covered services that must be paid during the calendar year (January 1 December 31) by members before any benefits are paid by Blue Cross of California.

Case Management: A utilization management program that assists the patient in determining the most appropriate and cost effective treatment plan. It is used for patients who have prolonged, expensive or chronic conditions, helps determine the treatment location (hospital, other institution or home) and authorizes payment for such care if it is not covered under the patient's benefit agreement. The purpose of case management is to provide optimum patient care in the most cost effective manner.

Centers of Expertise (COE) Network: The network of health care providers that have entered into contracts with Blue Cross and/or one or more of its affiliates. These providers have agreed to participate in a transplant program or other designated specialty program that is/are to be based upon the member's benefit agreements.

Certification: See Pre-Certification.

Chemotherapy: Treatment of malignant disease by chemical or biological antineoplastic agents.

Chiropractic (Care): An alternative medicine therapy administered by a provider such as a chiropractor, osteopath or physical therapist. The provider adjusts the spine and joints to treat pain and improve general health.

Claim: A request for payment for benefits received or services rendered. A billing record as generated and submitted by a provider or subscriber using paper or electronic media.

Coinsurance: An arrangement under which the member pays a fixed percentage of the cost of medical care after the deductible has been paid. For example, an insurance plan might pay 80% of the allowable charge, with the member responsible for the remaining 20%, which is then referred to as the coinsurance amount.

Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA): The federal law that requires employers with more than 20 employees to extend group health insurance coverage for up to 36 months after a qualifying event (e.g. termination of employment, reduction in hours, divorce). The law contains detail provisions relating, among other things, to an employer's obligation to provide notice of these rights and the circumstances under which such continuation may end. Some states, such as California, have similar laws applicable to employers with more than 20 employees.

Coinsurance: An arrangement under which the covered person pays a fixed percentage of the cost of medical care after the deductible has been paid. For example, an insurance plan might pay 80% of the allowable charge, with the insured individual responsible for the remaining 20%, which is then referred to as the coinsurance amount.

Coinsurance Maximum: The total amount of coinsurance that an individual pays each year before the carrier pays 100% of allowable charges for covered services. Coinsurance amounts differ with each contract.

Continuation: See COBRA.

Coordination of Benefits: The anti-duplication provision to limit benefits for multiple group health insurance in a particular case to 100% of the covered charges and to designate the order in which the multiple carriers are to pay benefits. Under a COB provision, one Plan is determined to be primary and its benefits are applied to the claim. The unpaid balance is usually paid by the secondary Plan to the limit of its liability.

Copayment or Copay: A type of member cost sharing that requires a flat amount per unit of service or unit of time. This is usually a percentage of the charges but may also be a dollar amount for specified services. The most common percentage copyament is 20%. A common copay is $5-$15 per visit.

Cost Containment: A set of programs to reduce use of unnecessary or inappropriate services and to encourage provision of necessary and appropriate services in a cost-effective manner.

Covered Medical Expense: Those expenses payable according to the terms of the member contract. The charges for these services are still subject to any cost sharing components or limits, such as deductibles, coinsurance, copayments and maximums, included in the contract

Covered Services: Hospital, medical and other health care expenses incurred by the covered person that entitle him/her to benefits under a contract. The term defines the type and amount of expense, which will be considered in the calculation of benefits.

Credentialing: An examination of a health care provider's credentials and other qualifications to determine if they should be granted clinical privileges at a health care facility or with a managed care organization.

Custodial Care: Care provided primarily to assist a patient in meeting the activities of daily living, but not care requiring skilled nursing services.

Customary and Reasonable (C&R): The amount customarily charged for the service by other physicians in the area (often defined as a specific percentile of all charges in the community), and the reasonable cost of services for a given patient after medical review of the case.

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D

Day Treatment Center: An outpatient psychiatric facility that is licensed to provide outpatient care and treatment of mental or nervous disorders or substance abuse under the supervision of physicians.

Deductible: An amount the covered person must pay before payments for covered services begin. The deductible is usually a fixed amount or a percentage determined by the individual's contract, and is calculated based on the lower hospital/provider actual charges or payment benefit. For example, an insurance plan might require the insured to pay the first $250 of covered expense during a calendar year.

Dental Care: Under a medical plan, dental care is dental treatment which due to the nature of the procedure or patient's medical condition, may be provided in a hospital setting.

Dependent: Person, (spouse or child), other than the subscriber who is covered under the subscriber's benefit certificate.

Diagnostic Tests: Tests and procedures ordered by a physician to determine if the patient has a certain condition or disease based upon specific signs or symptoms demonstrated by the patient. Such diagnostic tools include radiology, ultrasound, nuclear medicine, laboratory, pathology services or tests.

Disease Management Programs (Health Management Programs): Educational programs designed for individuals with chronic diseases designed to help maintain high quality of life and prevent future need for medical resources by using an integrated, comprehensive approach to health care coordinate with the individual's physician. Pharmaceutical care, continuous quality improvement, practice guidelines, and case management all play key roles in this effort.

Drug (prescription drug): A drug approved by the State of California Department of Health or the Food and Drug Administration and which by law may only be sold with a written prescription of a qualified healthcare provider.

Drug Formulary: A list of preferred pharmaceutical products that health plans, working with an expert panel of pharmacists and physicians, have developed to encourage the dispensing of quality, cost effective medications. Formularies can be classified as:
1. Open, in which doctors are encouraged to prescribe medications on the formulary but which allow non-formulary drugs to be covered without prior authorization;
2. Restricted, in which only medications on the formulary list are covered;
3. Managed, in which doctors are encouraged to prescribe medications on the formulary, but non-formulary drugs are covered with prior authorization.

Durable Medical Equipment: Mechanical devices, equipment and supplies that enable a person to maintain functional ability.

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E

Effective Date: The date on which the coverage or a change in coverage of a contract goes into effect at 12:01 a.m.

Emergency: In general, a sudden, serious, and unexpected acute illness, injury, or condition (including without limitation sudden and unexpected severe pain) which the member reasonably perceives could permanently endanger health if medical treatment is not received immediately. More detailed or slightly different definitions may apply based on applicable law.

Emergency Care: Care for patients with severe or life threatening conditions that require immediate medical attention.

Employee Assistance Program (EAP): A worksite-based program that is designed to assist in the identification and resolution of productivity problems associated with personal concerns of employees. The program provides employees and their dependents with access to confidential, short-term counseling by qualified practitioners, in person or over the phone.

Enrollee: An individual who is enrolled and eligible for coverage under a health plan contract. Synonymous with member.

Exclusions: Specific conditions or circumstances that are not covered under the contract.

Experimental: Procedures that are not recognized under generally accepted medical standards as safe and effective for treating a particular condition.

Expiration Date: The date coverage expires.

Explanation of Benefits (EOB): A form sent to the covered person after a claim for payment has been processed by the carrier that explains the action taken on that claim. This explanation might include the amount that will be paid, the benefits available, reasons for denying payment, or the claims appeal process.

Employee Retirement Income Security Act (ERISA): A federal act, passed in 1974, that established new standards and reporting/disclosure requirements for employer-funded pension and health benefit programs.

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F

Formulary: See Drug Formulary.

Full-Time Employee: An employee who meets the eligibility requirements for full-time employees as outlined in the Benefit Agreement.

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G

Gatekeeper: Term given to a primary care provider who coordinates all medical care for a patient and determines whether services such as tests or referral to a specialist are necessary.

Generic Prescription Drug (generic drug): Safe, effective and equivalent to brand name medications that may cost considerably less than the brand name medications. Generic drugs must meet the same high standards of quality as brand name drugs and are formulated to have the same effect in the body as the brand name version. Generic drugs often become available when a brand name drug's patent expires.

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H

Health Benefit Plan: A health insurance product offered by a health plan company that is defined by the benefit contract and represents a set of covered services and a provider network.

Health Care Financing Administration (HCFA): Federal government agency that administers Medicare and Medicaid.

Health Insurance Portability and Accountability Act (HIPAA): A federal health benefits law passed in 1996, effective July 1, 1997, which among other things, restricts pre-existing condition exclusion periods to ensure portability of health-care coverage between plans, group and individual; requires guaranteed issue and renewal of insurance coverage; prohibits plans from charging individuals higher premiums, co-payments, and/or deductibles based on health status.

Health Maintenance Organization (HMO): An organization that provides a wide range of comprehensive health care services for a specified group at a fixed periodic payment; a prepaid health care plan under which people may enroll by paying a set annual fee. Members then receive all the medical services they need through a group of contracting doctors and hospitals, often with no additional copayments or fees. Members are generally limited to using providers designated by the HMO.

Hearing Services: Testing and services related to hearing.

HMO: See Health Maintenance Organization.

Home Health Care: Health services rendered to an individual as needed in the home. Such services are provided to aged, disabled, sick or convalescent individuals who do not need institutional care.

Home Infusion Therapy: The administration of intravenous drug therapy in the home. Home infusion therapy includes the following services: solutions and pharmaceutical additives; pharmacy compounding and dispensing services; durable medical equipment; ancillary medical supplies; and nursing services.

Hospice: A facility or service that provides care for terminally ill patients and support to their families, either directly or on a consulting basis with the patient's physician. Emphasis is on symptom control and support before and after death.

Hospital: An institution whose primary function is to provide inpatient services, diagnostic and therapeutic, for a variety of medical conditions, both surgical and non-surgical. In addition, most hospitals provide some outpatient services, particularly emergency care.

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I

ID Card/Identification Card: A card issued by a carrier to a covered person, which allows the individual to identify himself or his covered dependents to a provider for health care services. The card is subsequently used by the provider to determine benefit levels and to prepare billing statement.

Immunizations: Specific types of injections to prevent infectious diseases and viral infections.

In-Network: Refers to the use of providers who participate in the carrier's provider network. Many benefit plans encourage covered persons to use participating (in-network) providers to reduce the individual's out of pocket expense.

Indemnity: (1) Benefits paid in a predetermined amount in the event of a covered loss. (2) A traditional insurance plan that reimburses for medical services provided to patients based on bills submitted after the services are rendered. Also known as fee-for-service.

Infertility: Term used to describe the inability to conceive or an inability to carry a pregnancy to a live birth. Also includes the presence of a condition recognized by a physician as the cause of infertility.

Infusion Therapy: The administration of intravenous drug therapy. Infusion therapy includes the following services: solutions and pharmaceutical additives; pharmacy compounding and dispensing services; durable medical equipment; ancillary medical supplies; and nursing services.

Inpatient: Service provided while the patient is admitted to the hospital for at least a 24-hour period.

Investigative Procedures or Medications: Those that have progressed to limited use on humans, but which are not widely accepted as proven and effective within the organized medical community.

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L

Lifetime Maximum: Maximum amount the plan will pay toward a member's coverage in a lifetime. The amount varies depending on the type of coverage the member carries.

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M

Managed Care: Any form of health plan that initiates selective contracting to channel patients to a limited number of providers and that requires utilization review to control unnecessary use of health services.

Maternity Care: The care of women before and during childbirth as well as the care of newborn babies.

Medical Equipment: See Durable Medical Equipment.

Medically Necessary: Procedures, supplies equipment or services that are determined to be:
1. Appropriate and necessary for the diagnosis and treatment of the medical condition;
2. Provided for the diagnosis or direct care and treatment of the medical condition;
3. Within standards of good medical practice within the organized medical community;
4. Not primarily for the member's convenience, or for the convenience of the physician or another provider; and
5. The most appropriate procedure, supply, equipment, or service which can be safely provided. The most appropriate procedure, supply, and equipment or service must satisfy the following requirements:
a. There must be valid scientific evidence demonstrating that
the expected health benefits from the procedure, supply, equipment or service are clinically significant and produce a greater likelihood of benefit, without a disproportionately greater risk of harm or complications, for the member and the particular medical condition being treated than other possible alternatives; and
b. Generally accepted forms of treatment that are less invasive have been tried and found to be ineffective or are otherwise unsuitable; and
c. For hospital stays, acute care as an inpatient is necessary due to the kind of services the member is receiving and the severity of the condition and safe and adequate care cannot be received by the member as an outpatient or in a less intensified medical setting.

Medicare: The federal government's hospital and medical insurance program for the aged, totally disabled, and those with end-stage renal disease. There are two parts A and B. Part A is the hospital portion and is mandatory for all eligibles. Those who elect part B coverage, pay an additional premium to the federal government.

Member: An individual or dependent who is enrolled in and covered by a health care plan. Also called enrollee or beneficiary.

Mental Health/Behavioral Health: Conditions that affect thinking and the ability to figure things out which affect perceptions, mood and behavior. Such disorders are recognized primarily by symptoms or signs that appear as distortions of normal thinking or distortions of the way things are perceived (seeing or hearing things that are not there). Disorders can also be recognized by moodiness, sudden or extreme changes in mood, depression, and highly agitated or unusual behavior.

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N

National Committee of Quality Assurance (NCQA): An independent, non-profit organization that accredits managed health care plans by measuring the quality of care and service provided by managed care plans such as HMOs. Its standards are intended to help assure HMO members have the opportunity to receive high quality health care and excellent service.

Negotiated Rate: The amount participating providers agree to accept as payment in full for covered services. It is usually lower than their normal charge. Negotiated rates are determined by Participating Provider Agreements.

Network: The doctors, clinics, hospitals and other medical providers that a carrier contracts with to provide health care to its covered persons. Individuals are generally limited to network providers for full coverage of their health costs.

Network Provider: See Provider Network.

Non-Participating Provider: A medical provider who has not contracted with a carrier or health plan to be a participating provider.

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O

Occupational Therapy: Treatment to restore a physically disabled person's ability to perform activities such as walking, eating, drinking, toiling and bathing.

Open Enrollment: For employers with a dual or multiple choice of health plans, the annual time period in which employees can select among the plans offered.

Out-Of-Network: The use of health care providers who have not contracted with the carrier to provide services. HMO members are generally not reimbursed if they go out-of-network except in emergency situations. Covered persons of preferred provider organizations and HMOs with point-of-service options may go out-of-network, but must pay additional costs including deductibles and co-insurance.

Out-of-Pocket Maximum: Refers to the maximum amount that a covered person will have to pay for expenses covered under the plan. It is a sum of deductible and coinsurance amounts.

Outpatient: A patient who is receiving ambulatory care at a hospital or other health facility without being admitted to the facility.

Outpatient Surgery: Surgical procedures performed that do not require an overnight stay in the hospital or ambulatory surgery facility. Such surgery can be performed in the hospital, a surgery center or physician office.

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P

Partial Day Treatment: A program offered by appropriately licensed psychiatric facilities that includes either a day or evening treatment program for mental health or substance abuse. Such care is an alternative to inpatient treatment.

Participating Hospital: A hospital that has entered into an agreement with Blue Cross to provide hospital services as a participating provider. The hospital, by entering into the agreement, is a participating hospital for all members and covered persons.

Participating Medical Group (PMG) and Individual Practice Association (IPA): A group of physicians who have an agreement with Blue Cross to furnish medical services to Blue Cross HMO members.

Participating Physician: A physician who has entered into an agreement with Blue Cross to provide medical services as a participating provider to Blue Cross members.

Participating Provider: A physician, hospital, pharmacy, laboratory or other appropriately licensed provider of health care services or supplies, that has entered into an agreement with a managed care entity to provide such services or supplies to a patient enrolled in a health benefit plan.

PCP: See Primary Care Physician.

Physical Therapy: Treatment involving physical movement to relieve pain, restore function and prevent disability following disease, injury or loss of limb.

Plan Benefit Maximum: Maximum amount the carrier will pay toward an individual's coverage. The amount varies depending on the type of coverage the individual carries.

Point-of-Service (POS): An option provided by some HMOs that allows covered persons to go outside the plan's provider network for care, but requires they pay higher cost-sharing than they would for network providers.

Pre-Authorization: A procedure used to review and assess the medical necessity and appropriateness of elective hospital admissions and non-emergency outpatient services before the services are provided.

Pre-Certification: Refers to certifying the medical necessity and level of care in advance. Pre-certification does not guarantee that contract benefits will be available.

Pre-Certification Review: Utilization management performed prior to a patient's admission, stay, or other service or course of treatment. Also known as Prior Authorization.

Pre-Existing Condition: A health condition or medical problem that was diagnosed or treated before enrollment in a new health plan or insurance policy. Some pre-existing conditions may be excluded from coverage.

Preferred Provider Organization (PPO): A delivery system where providers are under contract to a carrier to provide care at a discount or for a fixed fee, and the health plan provides incentives to patients to use the contracting providers. The PPO does not assume insurance risk, and it does not facilitate the sharing of risk by its covered persons.

Prescription: A written order or refill notice issued by a licensed medical professional for drugs which are only available through a pharmacy.

Preventive Care: Proactive health care designed to keep people from getting sick or hurt. It includes immunizations and screenings. A key part of preventive medicine is making sure patients know how to improve their health by altering their lifestyles. Refers to certifying the medical necessity and level of care in advance.

Primary Care Physician (PCP): A doctor designated by an HMO or other managed health care company to be the first physician a patient contacts for any medical problem. The doctor acts as the patient's regular physician and as a gatekeeper who determines if the patient needs to see a specialist or requires hospitalization.

Prior Authorization: The process of obtaining pre-approval of coverage for a health care service or medication.

Prosthetic Devices: A device that replaces all or a portion of a part of the human body. These devices are necessary because a part of the body is permanently damaged, is absent or is malfunctioning.

Provider: A licensed health care facility, program, agency or health professional that delivers health care services.

Provider Network: That set of providers with which a carrier has contracted to provide services to the Accountable Health Plan's covered persons. In the case of a "fee-for-service" or non-network Health Benefit Plan, the Provider Network will be deemed to be all licensed providers of covered services.

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R

Radiation Therapy: Treatment of disease by x-ray, radium, cobalt or high energy particle sources.

Reasonable and Customary: The amount customarily charged for the service by other physicians in the area (often defined as a specific percentile of all charges in the community) and the reasonable cost of services for a given patient after medical review of the case. Also known as Usual and Customary (U&C) or Customary and Reasonable (C&R).

Referral: A recommendation by a physician or insurer that an individual receive care from a different doctor or facility.

Respiratory Therapy: Treatment of illness or disease that is accomplished by introducing dry or moist gases into the lungs.

Retrospective Review: A review of claims and medical records for medical necessity and appropriateness after the episode of care is concluded and before and/or after the claim is submitted by the provider.

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S

Second Opinion: The voluntary option or mandatory requirement to visit another physician or surgeon regarding diagnosis, course of treatment or having specific types of elective surgery performed.

Service Area: The geographic area that an insurer, health plan or health care provider services.

Senior Secure: A Blue Cross HMO plan operating in a defined geographic area under a Medicare risk contract with the federal Health Care Financing Administration (HCFA). In addition to physician care, hospitalization and other benefits covered by Medicare, the benefits under this plan include prescriptions drugs, routine physical exams, hearing tests, immunizations, eye examinations, counseling and health education services.

Skilled Nursing Facility: An institution (or a distinct part of an institution) that is primarily engaged in providing skilled nursing care and related services for patients who require medical care, nursing care or rehabilitation services.

Speech Therapy: Treatment or the correction of a speech impairment that resulted from birth, or from disease, injury or prior medical treatment.

Subscriber: The individual in whose name a contract is issued or the employee covered under an employer's group health contract.

Substance Abuse/Chemical Dependency: Conditions that include, but are not limited to (1) psychoactive substance induced mental disorders; (2) psychoactive substance use dependence; and (3) psychoactive substance use abuse. Chemical dependency does not include addition to or dependency on, tobacco or food substances (or dependency on items not ingested).

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U

Urgent Care: The services received for a sudden, serious, or unexpected illness, injury or condition, other than one which is life threatening, that requires immediate care for the relief of severe pain or diagnosis and treatment of such condition.

Utilization Management: (1) A process that evaluates health care on the basis of appropriateness, necessity and quality. For hospital review, it can include pre-admission certification, concurrent review with discharge planning and retrospective review. (2) One of the six categories of Standards of Quality used by NCQA, which examines the consistency and the reasonableness of the determinations of necessary services. Also looks at how well the plan responds to member and physician appeals. Utilization Management at WellPoint is comprised of the three following components: (a) Pre- Hospital Review For medical, surgical, obstetrical, mental health and substance abuse admission requests, the WellPoint companies evaluate whether hospitalization is necessary; the proposed length of stay ifs appropriate; another form of treatment is available and appropriate; and/or if diversion to an alternate care facility is possible. (b) Continued Stay Review During a hospital stay, the WellPoint companies continually monitor the patient's progress through the attending physician to ensure adherence to the treatment plan. The WellPoint companies review requests for (and authorize, when appropriate) extended lengths of stay. (c) Alternate Medical Care In conjunction with Pre-Hospital Review and Continued stay Review, the WellPoint companies identify patients for whom early discharge to home health care is appropriate. The program then controls home health care utilization through pre-authorization and ongoing evaluation and monitoring; authorizes services and specific dollar amounts by modality; works with the hospital discharge planner to develop an appropriate treatment plan and coordinates the patient's benefits.

Utilization Review: A review process designed to evaluate the appropriateness of health care services.

Usual, Customary and Reasonable: A "usual" charge is the amount that is most consistently charged by an individual physician for a given service. A "customary" charge is the amount that falls within a specified range of usual charges for a given service billed by most physicians with similar training and experience within a given geographic area. A "reasonable" charge is a charge that meets the Usual and Customary criteria, or is otherwise reasonable in light of the complexity of treatment of the particular case. Under a UCR Program, the payment is the lowest of the actual billed charge, the physician's usual charge or the area customary charge for any given covered service.

Urgent Care: An unexpected illness or injury that is not life threatening but requires outpatient medical care that cannot be postponed. An urgent situation requires prompt medical attention to avoid complications and unnecessary suffering, such as a high fever. Examples include skin rashes or ear infections.

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W

Well Baby/Well Child Care: Routine care, testing, checkups and immunizations for a generally healthy child from birth through the age of six.

Wellness Program: A health management program that incorporates the components of disease prevention, medical self-care, and health promotion. It utilizes proven health behavior techniques that focus on preventive illness and disability, which respond positively to lifestyle related interventions. Programs are designed to integrate with existing health care benefits; e.g., flex benefits, HMO, PPO; support the reduction in the demand for health care resources; and address the issues of dependent coverage and services for high-risk employees.

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