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Definitions
Glossary of health insurance terminology and words.
- Acute care
- is care received in an inpatient hospital setting.
- Annual out-of-pocket maximum
- is the limitation on the amount of money you will have to spend for specified covered health services in a calendar year. This maximum amount is shown on your Summary of Benefits.
- Calendar year
- marks the time beginning January 1 and ending December 31.
- Certificate of Creditable Coverage
- provides proof of prior medical coverage. You may need to furnish this certificate to another insurance carrier to obtain medical coverage in the future.
- Certified nurse midwife
- is a person who is licensed or certified to supervise the conduct of labor and childbirth; advise the parent as to the progress of the childbirth; and furnish prenatal, intrapartum, and postpartum care.
- Coinsurance
- is the percentage of cost that you may need to pay for a covered service. The Plan pays the rest of the cost of the service. Coinsurance amounts are listed on your Summary of Benefits.
- Condition
- is an impaired state of health, due to a specific illness or injury that requires skilled professional treatment or services.
- Copayment
- is the fixed dollar amount you pay for a covered service at the time the care is provided. Copayment amounts are listed on your Summary of Benefits.
- Cosmetic treatment
- is defined as medical or surgical treatment primarily for the purpose of improving appearance or self esteem.
- Custodial care services
- are services or supplies that do not require the technical skills of a licensed nurse at all times, assist solely in activities of daily living activities or personal grooming and are not likely to improve your condition.
- Deductible
- is the amount of money that an individual must pay out-of-pocket for medical services before the health plan pay its portion. Deductibles are usually per person, or per family, per calendar year. For example, an individual may have a $200 deductible whereas a family may have a $400 deductible.
- Dependent
- means a person for whom you or your legal spouse provided, during the most recent calendar year, more that 50% of the person's support. In the case of a student, amounts received as scholarships for study will not be considered in determining source of support. If no one provided more than 50% of the person's support, the person will be treated as the dependent of who ever provided the most support. A child will also be considered a dependent if you or your spouse are required to provide medical care to a child under a qualified medical child support order, as defined by federal law.
- Durable medical equipment (DME)
- is equipment which is primarily and customarily used to serve a medical purpose, and generally is not useful to a person in the absence of illness or injury. It can withstand repeated use and is generally considered to be safe and effective for the purpose intended. DME may include items such as oxygen, wheelchairs, and other medically necessary equipment required for the treatment of an illness or injury.
- An emergency medical condition
- is a medical condition that manifests itself by symptoms of sufficient severity that a prudent layperson possessing an average knowledge of health and medicine would reasonably expect that failure to receive immediate attention would place the health of a person (or a fetus, in the case of a pregnant woman) in serious jeopardy.
- An employer group
- refers to the organization whose employees are covered by the Plan.
- Experimental, investigational or for research purposes,
- means services determined by Providence Health Plan or our authorizing agent to not be medically necessary or accepted medical practice in the service area. In determining whether services are experimental, investigational, or for research purposes, the Plan will consider whether services are, in general: used in the medical community in the state of Oregon; under continued scientific testing and research; show a demonstrable benefit for a particular illness; proven to be safe and efficacious and; approved for use by appropriate government agencies. The Plan includes a determination on a case by case basis of whether the requested service will result in greater benefits than other generally available services, and will not approve such a request if the service poses a significant risk to the health or safety of the patient. The Plan retains documentation of the criteria used to define a service deemed to be experimental, investigational or for research purposes and will make this available for review upon request.
- A family practice physician
- is a licensed personal physician/provider trained to diagnose and provide health care to patients of all ages. These providers are trained to provide routine gynecological care (including the annual gynecological exam) and some also provide obstetric care.
- A general practice physician
- is a licensed personal physician/provider trained to diagnose and provide health care services, including routine gynecological care and the annual gynecological exam, to patients of all ages.
- A gynecologist
- is a licensed physician specializing in the diagnosis and treatment of the diseases of women's reproductive systems. You may choose to have a Plan gynecologist provide your annual gynecological examination. Some gynecologists have been approved to act as personal physician/ providers and will be listed as such in the Participating Provider Directory.
- A member identification card
- is issued to each member enrolled in Providence Health Plan. The card identifies you as a Plan member and includes important information about your coverage. Always present your card when you seek medical care or benefits.
- Infertility
- is defined as the inability to become pregnant after a year of unprotected intercourse. Or, the inability to carry pregnancy to term as evidenced by three consecutive spontaneous abortions (miscarriages).
- An internist
- is a licensed primary care provider who is trained to diagnose and provide health care services to adults and teens, including routine gynecological care and the annual gynecological exam for women.
- Medically necessary
- refers to treatment which, as determined by the Plan, is required to treat or care for symptoms of an illness or injury or to diagnose an illness or condition that is harmful to life or health. Medically necessary services or supplies must be: appropriate as to place or level of care in amount, duration, and frequency for the treatment of the condition; not be provided primarily for convenience; appropriate and in keeping with widely-accepted standards of practice in the community; and likely to stabilize or improve a member's medical condition. The fact that services are provided, prescribed or approved by a physician or provider does not in and of itself mean that the services are medically necessary.
- Members
- are the eligible individuals covered by Providence Health Plan.
- A nurse practitioner
- is a licensed nurse who has a Master's Degree in nursing and advanced training which allows him or her to provide primary care. Some nurse practitioners have been approved to act as personal physicians/providers and will be listed in our Participating Provider Directory.
- An obstetrician
- is a provider specializing in the medical care related to pregnancy and the birth of children. Some obstetricians have been approved to act as personal physicians/providers and will be listed in our Participating Provider Directory.
- An Out-of-Area Dependent
- is an eligible family dependent of a subscriber, who does not reside in the Plan's service area and who is properly enrolled in the Plan as an Out-of-Area Dependent. A dependent child who is an eligible family dependent and who resides out of the service area for the purpose of attending school is eligible to be enrolled as an Out-of Area Dependent. The subscriber's spouse is eligible to be enrolled as an Out-of Area Dependent.
- A pediatrician
- is a personal physician/provider trained to diagnose and provide health care services to infants, children, and adolescents.
- A physician assistant
- provides medical services under the direction and supervision of a licensed physician. Some physician assistants have been approved to act as personal physicians/providers and will be listed in our Participating Provider Directory
- Plan
- means Providence Health Plan.
- A participating provider or Plan provider
- is any credentialed physician, provider, hospital, or facility which has an Agreement with Providence Health Plan to provide care to Plan members.
- Prior authorized services
- are services which require you and/or your provider to seek Plan confirmation before seeking or receiving care. Final determination will be based on the covered benefits and eligibility on the date of service.
- A personal physician or provider
- is a participating provider specializing in family practice, general practice, internal medicine or pediatrics; a nurse practitioner; a certified nurse midwife; or a physician assistant, when providing services under the supervision of a physician; who agrees to be responsible for the member's continuing medical care by serving as case manager. Adult female members may also select a provider specializing in obstetrics or gynecology; a nurse practitioner; a certified nurse midwife; or a physician assistant specializing in women's health care as their personal physician or provider. (Note: Not all these providers are personal physician/providers - see Participating Provider Directory for a listing of designated personal physician/providers.)
- A qualified practitioner
- means a physician, women's health care provider, nurse practitioner, clinical social worker, physician assistant, psychologist, dentist, or other practitioner who is professionally licensed by the appropriate state agency to diagnose or treat a bodily injury or illness and who provides covered services within the scope of that license.
- Riders (endorsements or supplemental benefits)
- are any benefits purchased by your employer in addition to Providence Health Plan's basic health care coverage. Examples are: vision, alternative care, chiropractor prescription drug riders. Not all members have these riders. Check your Summary of Benefits and handbook inserts to determine if your coverage includes rider benefits. You also may view your Summary of Benefits online if you've registered on our Web site.
- The Providence Health Plan service area
- is a defined geographical area.
- A skilled nursing facility (SNF)
- is a convalescent or chronic disease facility which is accredited by the Joint Commission on Accreditation of Hospitals or certified as an "SNF" by the Secretary of Health & Human Services according to Title XVIII of the Social Security Act as amended, section (j).
- A specialist
- is a nurse, physician or other health care professional who has advanced education and training in one clinical area of practice.
- A subscriber
- is the employee of the Group whose employment or membership in the Group establishes eligibility for his or her dependents under the Providence Health Plan policy.
- The Summary of Benefits
- is a description of your benefits and copayments. If you are a commercial PHP member, you can view your Summary of Benefits online once you have registered on our Web site.
- Usual, customary, and reasonable charges (UCR)
- are charges that the Plan determines fall within a range of those most frequently charged for services and supplies. The amount determined is based on charges in the community where the services and supplies were furnished, by those who provide them.
- A women's health care provider
- is an obstetrician, gynecologist, physician assistant specializing in women's health, advanced registered nurse practitioner specializing in women's health or a certified nurse midwife practicing within the applicable lawful scope of practice.
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