If you appeal a denied service, and the service is denied again, you can request an administrative hearing. You can share information on your case to an administrative law judge who makes a decision on whether the services should be approved or not.
Adverse Benefit Determination
An adverse benefit determination means any of the following:
The denial or limited authorization of a requested service;
The reduction, suspension, or termination of a previously authorized service;
The failure to provide services or act in a timely manner;
The denial of request for “good cause” designation;
The failure of the Contractor to act within the timeframes for resolution and notification of appeals and grievances;
The denial of an Enrollee's request to dispute a financial liability;
In a rural area, with only one managed care organization, denial of enrollee’s request to receive services outside our network.
Appeal
The review of an adverse benefit determination.
Application
A formal request for benefits made to the agency in writing and signed by the applicant or someone acting on behalf of the applicant. Application may be received by mail, phone, fax, in person, or electronically.
B
Behavioral Health Services Only (BHSO)
The BHSO plan only covers mental health and substance use disorder (alcohol and drug treatment) services. Members may receive their physical health services another way, such as Medicare, private health insurance, or Indian Health Centers.
C
Certificate of Coverage
A description of your health care coverage and benefits. Your member handbook serves as your certificate of coverage.
Countable Resource
A resource that is countable when determining resource eligibility.
D
Decertification
Loss of eligibility to participate as a Medicaid provider, or for a license to operate a Medical facility licensed by DHH.
Department of Social and Health Services (DSHS)
DSHS is the Washington State agency responsible for providing a broad array of health care and social services, including but not limited to: Aging and Long-Term Support Administration, Developmental Disabilities Administration, and Behavioral Health Administration.
Dependent
An individual who is the financial responsibility of a member of the income unit. Example: This is someone who could be counted as a tax dependent, if income tax is filed.
Drug Formulary
A list of approved prescription drugs developed by the Washington Health Care Authority. The drug formulary is also called the Preferred Drug List (PDL).
E
Emergency
The emergent and acute onset of a symptom or symptoms, including severe pain, that would lead a prudent layperson acting reasonably to believe that a health condition exists that requires immediate medical attention, if failure to provide medical attention would result in serious impairment to bodily functions or serious dysfunction of a bodily organ or part, or would place the person’s health in serious jeopardy.
F
Fraud
An intentional deception or misrepresentation made by a person (individual or entity) with the knowledge that the deception could result in some unauthorized benefit to him- or herself or some other person. It includes any act that constitutes Fraud under applicable federal or state law.
G
Good Cause
An acceptable reason to defer the requirement to cooperate for certain eligibility factors.
Grievance
Your statement of dissatisfaction with any part of your care. A grievance can be filed over the phone or in writing, and must be filed directly with your plan.
H
Health Care Authority (HCA)
The Washington state agency responsible for administering Washington Apple Health (Medicaid), Apple Health Expansion and other state health programs.
I
Income
A gain or recurrent benefit measured in money.
Inpatient
A patient who is admitted for an overnight or longer stay at a health care facility and is receiving covered services.
L
Legal Guardian
A person who has been granted custody of a minor by court order.
M
Maternity Benefits Program
Apple Health (Medicaid) benefits include maternity benefits, maternity support services, and maternity case management. Apple Health (Medicaid) and Apple Health Expansion members who become pregnant should notify Washington Health Care Authority (HCA) and UnitedHealthcare Community Plan, to apply for Apple Health for Pregnant Individual coverages.. Eligibility for the program is determined by HCA.
Medicaid
A state health insurance program for people with low income who meet certain eligibility requirements. Programs can vary from state to state. For information on Washington’s Apple Health (Medicaid) programs, visit https://www.hca.wa.gov/apple-health
Medicare
A federal health insurance program for people who are 65 or older, people with disabilities, or those with end-stage kidney disease. Medicare eligibility is not based on income, and basic coverage is the same in each state.
Member
An eligible person enrolled in Apple Health (Medicaid) or Apple Health Expansion with UnitedHealthcare Health Plan. Member can also be referred to as an “enrollee”.
O
Outpatient
Medical care or treatment that does not require an overnight in a hospital or medical facility.
P
Primary Care Provider (PCP)
Your PCP is the doctor you see for most of your care provider. Your PCP can be a family or general practitioner, internist, pediatrician, naturopathic physician or other provider approved by UnitedHealthcare Community Plan.
Provider
A health care professional (such as a doctor, nurse, internist, etc.) or facility (such as a hospital, clinic, etc.).
R
Recertification
Periodic review of your family’s income and eligibility.
S
Service Area
The geographic area served by United Healthcare Community for Apple Health (Medicaid), and Apple Health Expansion.
Specialist
A provider of specialized medicine, such as a cardiologist or a neurosurgeon.
Spouse
An individual who is legally married to another or who presents to the community as a husband or wife in a non-legal relationship.
T
Third Party
An individual, institution, corporation or agency that is responsible for all or part of the medical assistance furnished under the Medicaid State Plan.
W
Washington Apple Health (Medicaid)
Apple Health (Medicaid) provides comprehensive free or low-cost health care to adults, families, individuals with disabilities, children under 19, children in foster care and pregnant individuals who meet income and eligibility requirements.
Apple Health Expansion provides comprehensive free or low-cost health care to adults 19 and older who meet income requirements and do not qualify for other Apple Health programs based on immigration status.
Washington Healthplanfinder
Washington Healthplanfinder is the website to find, compare and enroll in a health plan that fits your needs and budget. For more information about Apple Health or to enroll, please visit: wahealthplanfinder.org or call 1-855-WAFINDER (1-855-923-4633) TTY/TTD 1-855-627-9604.
Washington Resident
A person physically residing and maintaining a residence in the state of Washington. You must be a Washington resident to be eligible for Washington Apple Health. To be considered a Washington resident, members who are temporarily out of Washington for any reason:
May be required to prove their intent to return to Washington State; and
May not be out of Washington State for more than three consecutive calendar months.
Dependent children who are attending school out of state may be considered residents if they are out of state during the school year, as long as their primary residence is in Washington State and they return to Washington State during breaks. Dependent children attending school out of state may be required to provide proof that they pay out-of-state tuition, vote in Washington, and file income taxes using a Washington address.
Your residence may be a home you own or are purchasing or renting, a shelter or other physical location where you are staying in lieu of a home, or another person's home.
