A UnitedHealthcare Community Plan decision to deny or limit
authorizations, services or payment
B
Beneficiary
A person determined eligible by the State of Michigan for the Medical
assistance program.
Benefits
Health care services provided for by Michigan Medicaid.
C
Certificate of Coverage (COC)
The contract or Member Agreement between UnitedHealthcare Community
Plan and Members, including all amendments, addenda, appendices and riders.
Co-payment
The amount a Member may be required to pay directly to a
Participating Provider or a Non-Participating Provider for certain
Covered Services as set forth in Article IX of the COC.
Cosmetic Surgery
Those procedures which improve physical appearance, but which do not
correct or materially improve a physiological function, and are not
Medically Necessary.
Covered Services
The Medically Necessary services, equipment and supplies set forth in
Section 9.2 of the COC, which are subject to all of the terms and
conditions of the COC and those services that UnitedHealthcare
Community Plan is required to provide.
D
Department
The Michigan Department of Community Health or its successor agency
which is duly authorized to regulate health maintenance organizations
and administer the Medicaid Program in the State of Michigan.
E
Emergency Services
Those services necessary to treat an emergency medical condition.
Emergency medical condition means a medical condition manifesting
itself by acute symptoms of sufficient severity (including severe
pain) such that a prudent lay person, with an average knowledge of
health and medicine, could reasonably expect the absence of immediate
medical attention to result in: (i) serious jeopardy to the health of
the individual or, in the case of a pregnant woman, the health of the
woman or her unborn child; (ii) serious impairment to bodily
functions; or (iii) serious dysfunction of any bodily organ or part.
F
Family Planning Services
Any medically approved means, including diagnostic evaluation, drugs,
supplies, devices, and related counseling, for the purpose of
voluntarily preventing or delaying pregnancy or for the detection or
treatment of sexually transmitted diseases.
Family Practice and General Practice Doctors
Doctors trained to treat adults and children.
G
Grievance
A complaint submitted on behalf of a member.
H
Health Professional
A health care provider, who is appropriately licensed, certified or
otherwise qualified to deliver health services pursuant to Michigan law.
HMO
Health Maintenance Organization. A health plan where a PCP manages
all your health care needs.
I
Internal Medicine Doctors
Doctors trained to treat adults.
M
Medicaid Agreement
The contract between the State of Michigan and UnitedHealthcare
Community Plan under which UnitedHealthcare Community Plan agrees to
arrange for the delivery of Covered Services for Members.
Medicaid Program
The Department's program for Medical Assistance under Section 105 of
Public Act 280 of 1939, as amended, MCL 400.105, and Title XIX of the
Federal Social Security Act, 42. U.S.C. 1396 et seq., as amended.
Medical Director
A Physician designated by UnitedHealthcare Community Plan to
supervise and manage the medical aspects of UnitedHealthcare Community
Plan programs and services.
Medically Necessary
The services, equipment or supplies necessary for the diagnosis, care
or treatment of a member's physical or mental condition according to
accepted medical practices and standards.
Member
A Medicaid Program recipient enrolled with UnitedHealthcare Community Plan.
Member Agreement
The COC, the Member's Application, the Member Handbook, and the
UnitedHealthcare Community Plan ID Card issued by UnitedHealthcare
Community Plan to the Member.
N
Non-Covered Services
Those medical and health care services, equipment and supplies which
are not covered by your plan.
Non-Participating Provider
A Health Professional, Hospital, healthcare entity or health care
professional that has not contracted with UnitedHealthcare Community
Plan to provide Covered Services to Members.
Nurse Practitioner
A registered nurse who has advanced training and certification.
O
OB/GYN
Doctors trained to treat women.
OFIR
The Office of Financial and Insurance Regulation or its successor
agency which is duly authorized to regulate health maintenance
organizations in the State of Michigan.
P
Participating Provider
A Health Professional, Hospital or other entity that contracts with
UnitedHealthcare Community Plan to provide Covered Services to Members.
PCP
Primary Care Provider (Your personal doctor).
Pediatricians
Doctors trained to treat children and teens.
Physician's Assistant
A health Professional who assists doctors.
R
Referral
When your Primary Care Provider sends you to a Specialist for a
covered service.
S
Service Area
The areas in which UnitedHealthcare Community Plan has been
authorized by OFIR and MDCH to provide services to Members.
U
UnitedHealthcare Community Plan Provider or Specialist
Doctors, hospitals, pharmacies or other medical service providers you
must use for your health care.
Urgent Care
Covered services that are not Emergency Services, but are Medically
Necessary and immediately required as a result of an unforeseen
illness, injury, or condition.
Utilization Management (UM) Decision
UnitedHealthcare Community Plan decisions made against set criteria.
