Causing harm to a person on purpose. This includes yelling, ignoring
a person's need, hurting or inappropriate touching.
Adverse Benefit Determination
An adverse benefit determination is the denial or limited
authorization of a requested service, including determinations based
on the type or level of service, requirements for medical necessity,
appropriateness, setting, or effectiveness of a covered benefit. An
adverse benefit determination includes:
The reduction, suspension, or termination of a previously
authorized service;
The denial, in whole or in part, of
payment for a service;
The failure to provide services in a
timely manner as defined in the appointment standards;
The
failure of the health plan to act within the timeframes provided in
42 C.F.R. § 438.408(b)(1) and (2) regarding the standard resolution
of grievances and appeals.
For a resident of a rural area with only one Managed Care
Organization, the denial of a member’s request to exercise his or her
right, under § 42 C.F. R. 438.52(b)(2)(ii) to obtain services outside
the network:
The denial of a member's request to dispute a financial
liability, including cost sharing, copayments, premiums,
deductibles, coinsurance, and other member financial liabilities;
and
determinations by skilled nursing facilities and nursing
facilities to transfer or discharge residents and adverse
determinations made by a State with regard to the preadmission
screening and annual resident review requirements of Section
1919(e)(7) of the Act, if applicable.
Appeal
A request to be performed for review by the by UnitedHealthcare for
an Adverse Benefit Determination. An appeal is when you tell us you
believe our Adverse Benefit Determination was made in error. The
Adverse Benefit Determination may include, but is not limited to, for
cause termination by the Contractor, or delay or non- payment for
covered services.
C
Complaint
An Expression of dissatisfaction received orally or in writing that
is of a less serious or formal nature that is resolved within one (1)
business day of receipt. A Complaint includes, but is not limited to
inquiries, matters, misunderstandings, or misinformation that can be
promptly resolved by clearing up the misunderstanding, or providing
accurate information.
Coordinated Care Organization
A company with healthcare providers and services.
Copayment
Copayments (copays) are a dollar amount that you pay to the doctor at
your visit. You do not have copayments if you are a member of
UnitedHealthcare Community Plan who is enrolled in the MS CAN program.
E
Emergency
A sudden and unexpected change in physical or mental health which, if
not treated right away, could result in 1) loss of life or limb, 2)
impairment to bodily function, or 3) permanent damage to a body part.
G
Grievance
is an expression of dissatisfaction about any matter other than an
Adverse Benefit Determination. Grievances may include, but are not
limited to:
Transportation.
Access to Service/Providers.
Provider Care and Treatment.
Coordinated Care
Organization Customer Service.
Payment and Reimbursement
Issues.
Administrative Issues.
Examples of grievances include but are not limited to:
You are unhappy with the quality of care or services you are
getting.
The doctor you want to see is not a UnitedHealthcare
Community Plan doctor.
Grievance includes a member’s right to dispute an extension of time
proposed by the Contractor, PIHP or PAHP to make an authorization decision.
H
Health Information
Facts about your health care. This may come from UnitedHealthcare or
a provider. It includes information about your physical and mental
health, as well as payments for health care.
I
Immunization
A shot that protects from a disease. Children should get a variety at
specific ages. Shots are often given during regular doctor visits.
In-Network
Doctors, specialists, hospitals, pharmacies and other providers who
have an arrangement with UnitedHealthcare to provide health care
services to Mississippi members.
L
Living Will
A document that tells what you want done with your health care. The
doctor uses this if you are not able to express what you want. It
lists specific treatments you do or do not want, and whether or not to
make special efforts to save your life.
M
Medically Necessary
Services that are required to maintain your health and by not
receiving those services, could affect your condition or quality of care.
Member
An eligible person enrolled in the UnitedHealthcare through MississippiCAN.
O
Out-of-Network
Doctors, specialists, hospitals, pharmacies and other providers who
do not have an arrangement with UnitedHealthcare to provide health
care services to Mississippi members.
P
Prescription
A doctor's written instructions for medication or treatment.
Primary Care Provider (PCP)
The doctor who treats you for all normal health care needs. Your PCP
may refer you to a specialist or admit you to a hospital. PCPs are
usually family practitioners, internists, pediatricians, and sometimes
nurse practitioners and physician's assistants, and can include
Obstetricians and certified nurse midwives for pregnant members.
Prior Authorization
Approval for services not normally covered by UnitedHealthcare that
your doctor must receive before providing those services.
Provider
A person or facility that provides health care services and treatment
such as a doctor, pharmacy, dentist, clinic or hospital.
R
Referral
Process when your primary care provider requests additional care for
you from a specialist.
S
Second Medical Opinion
A review of a medical condition that is done by another doctor.
Specialist
Any doctor who has special training for a specific condition or illness.
