Harming someone on purpose (this includes yelling, ignoring a
person's needs and inappropriate touching).
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
An appeal is a dispute made by a member, his or her representative or
a provider with the member's permission, challenging an action by the
health plan to deny or limit authorization of a service, including the
type or level of service or reduce, suspend, or terminate payment for
a previously authorized service; or any failure to authorize services
in a timely manner or decide a grievance or appeal within the required
time frames.
Authorization
An O.K. or approval for a service.
B
Benefits
Services, procedures and medications that UnitedHealthcare Community
Plan will cover for you.
C
Clinical Care Management
One-on-one help by a nurse providing education and coordination of
UnitedHealthcare Community Plan benefits, tailored to your needs.
D
Disenrollment
To stop your membership in UnitedHealthcare Community Plan.
DME
Durable Medical Equipment includes things such as wheelchairs,
walkers, diabetic glucose meter, IV poles that have to be used for a
length of time. It can also be equipment that must be thrown away such
as bandages, catheters and needles. DME must be requested by your doctor.
E
Emergency
A sudden and, at the time, unexpected change in a person's physical
or mental condition which, if a procedure or treatment is not
performed right away, could be expected to result in 1) the loss of
life or limb, 2) significant impairment to a bodily function, 3)
permanent damage to a body part or health of unborn child.
F
Fraud
An untruthful act (example: if someone other than you uses your
member ID card and pretends to be you).
G
Grievance
A grievance is an expression of dissatisfaction about the health
plan, or a practitioner or any matter other than an action taken by
the plan. Grievances can include issues with the quality of care or
services provided, aspects of interpersonal relationships such as
rudeness of a provider or employee, or failure to respect a member's rights.
H
Health Information
Facts about your health and care. This information may come from
UnitedHealthcare Community Plan or a provider. It includes information
about your physical and mental health, as well as payments for care.
I
ID Card
An identifcation card that says you are a UnitedHealthcare Community
Plan member. You should have this card with you at all times.
Immunization
A medicine (usually a shot) that protects, or "immunizes" a
member from a disease. Children should receive different shots at
different ages. These shots are often given during regular doctor visits.
In-Network
Doctors, specialists, hospitals, pharmacies and other providers who
have an arrangement with UnitedHealthcare Community Plan to provide
health care services to members.
Informed Consent
That all medical treatments have been explained to you; you
understand and agree to them.
Inpatient
When you are admitted into a hospital for a length of time.
M
Member
An eligible person enrolled with UnitedHealthcare Community Plan in
the Medicaid program.
O
ODJFS
Ohio Department of Job and Family Services
OhioRISE
OhioRISE is a specialized Medicaid health plan for youth with complex
behavioral health needs. This program provides behavioral healthcare
services to eligible youth. Children and youth who are eligible are
under the age of 21 and demonstrate the need for additional behavioral
health care as identified through the Ohio Children’s Initiative Child
and Adolescent Needs and Strengths (CANS) assessment or a recent
inpatient admission for mental health or substance use disorder
services.
OhioRISE expands access to in-home and community-based services to
ensure eligible children and youth and their families have the tools
and supports they need to grow and thrive.
Out-of-Network
Doctors, specialists, hospitals, pharmacies and other providers who
do not have an arrangement with UnitedHealthcare Community Plan to
provide health care services to members.
P
Prescription
A doctor's written instructions for medication or treatment.
Primary Care Provider (PCP)
A doctor you choose to be your primary care provider who has his/her
own private practice. Your PCP will coordinate all of your health care.
Prior Authorization
Process that your doctor uses to get approval for services that need
to be approved before they can be done. Your doctor must call
Utilization Management (UM) at 1-800-366-7304 before you obtain a service
or procedure that is listed as requiring an okay.
Provider Directory
A list of providers who participate with UnitedHealthcare Community
Plan to help take care of your healthcare needs.
Provider or Practitioner
A person or facility that offers health care (doctor, pharmacy,
dentist, clinic, hospital, etc.).
R
Referral
When you and your PCP agree you need to see another doctor and your
PCP sends you to a network specialist.
S
Self-Referred Services
Services for which you do not need to see your PCP for a referral.
Specialist
Any doctor who has special training for a specific condition or illness.
U
Urgent Care
An alternative to hospital emergency department care for use in
non-emergencies. Used when health conditions are urgent, but are not
health- or life-threatening.
W
WIC
Supplemental Food Program for Women, Infants and Children which
provides nutrition counseling, nutrition education, and nutritious
foods to pregnant and postpartum women, infants and children up to the
age of 2. Children deemed nutritionally deficient are covered up to
age 5 if they are low income and are determined to be at nutritional risk.
