This is a doctor responsible for your basic care. They may also provide referrals for specialized care.
Exclusive Provider Organization: A type of health plan that falls somewhere between an HMO and a PPO in terms of cost and flexibility. With an EPO, members have only in-network coverage (except for emergencies), but they do not need to select a PCP or get referrals to see specialists.
Health Maintenance Organization: A type of health insurance plan that limits coverage to in-network care, usually from doctors, hospitals and other healthcare providers that have agreed to set rates.
Preferred Provider Organization: A type of health insurance plan that provides coverage through a network of selected medical providers. PPOs are popular because they offer a balance of lower costs and greater flexibility than other types of health insurance plans.
Also known as a “living will”, this legal document notifies your doctor what kind of care you want/don’t want.
The limit to which your health plan will pay. This amount is in addition to your plan’s required copays and deductibles.
Care a person receives in a clinic, ER, hospital or surgery center without an overnight stay. Also known as “outpatient”.
Occurs when a healthcare provider bills a patient for the difference between the provider’s charge and the amount the insurance plan agrees to pay. This typically happens when a patient receives care from an out-of-network provider, and the provider’s charges exceed what the insurance covers. The patient is then responsible for paying the remaining balance.
This is the person you elect to receive your assets should you die.
Care Coordinators help you and your health care providers optimize your health care benefits to meet your health-related needs. Their goal is to educate, coordinate and facilitate your care needs related to your chronic condition and reduce your risk for serious complications. This program does not replace your provider’s care. It is designed to work with your provider, reinforcing your provider’s recommendations so you can stay healthier between provider visits.
The EHP Medical Management Department offers Case Management Programs that provides members with telephone access to a Case Manager for assistance with complex medical care needs, complex behavioral health needs, network access issues, and referrals to community services. Members can self-refer or be referred by their physician or family for evaluation.
A request to be paid by a health plan for health services provided.
This is the percentage of health care costs you pay after meeting your deductible—but before reaching your out-of-pocket maximum
A copayment or copay is a fixed payment for a covered service—like doctor visits, prescription drugs and other health care services—that you pay when you receive the service.
You’re responsible for paying for 100 percent of your care until you reach this amount, called the deductible. After that, your plan will pay a percentage of the cost if you stay in network.
A person who is covered by another’s plan. It can include a spouse or, child
Term that is used to decide who can receive coverage. Requirements can include, time of employment or job status
• An appropriate medical screening examination that is within the capability of the emergency department of a Hospital or of an Independent Freestanding Emergency Department, as applicable, including Ancillary Services routinely available to the emergency department to evaluate such Emergency;
• Within the capabilities of the staff and facilities available at the Hospital or the Independent Freestanding Emergency Department, as applicable, such further medical examination and treatment that are Covered Charges and are required to stabilize the Member if performed by an Out-of-Network provider or facility (regardless of the department of the Hospital in which such further examination or treatment is furnished).
• Services provided by an Out-of-Network provider or facility after the Member is stabilized and as part of outpatient observation or an inpatient or outpatient stay related to the Emergency visit, until:
1. The provider or facility determines the Member is able to travel using nonmedical transportation or non-emergency medical transportation;
2. The Out-of-Network provider offering these services supplies the Member with a written notice that satisfies notice and consent criteria in accordance with applicable federal law, and the Member gives informed consent to continued treatment by the Out-of-Network provider.
The above limitations do not apply to unforeseen or urgent medical needs that arise at the time the service is provided regardless of whether notice and consent criteria has been satisfied.
A statement received by the patient from the TPA after services have been rendered that explains how the bill was paid.
A formulary is a list of generic, brand-name and specialty drugs identified as providing the greatest overall effectiveness and value.
A health coach is a professional who cultivates a collaborative relationship with members to guide, encourage, and educate them in achieving their personal health and wellness goals. They facilitate lifestyle and behavior modifications in areas such as nutrition, physical activity, stress management, and overall well-being, empowering individuals to unlock their own potential in their wellness journey.
A participating provider who has agreed to accept the Allowed Amount as payment in full for covered services rendered after applicable co-payment/co-insurance. The member is not liable for any amount charged over the Allowed Amount.
In a given year, this is the most you'll pay for health care. . It includes money you've paid for deductibles, coinsurance and copayment—but it doesn't include your premiums.
This type of care is used to help you stay healthy, identify risks and stop illness. Preventive care includes child and adult screenings for a wide range of services, including immunizations and yearly exams.
The process of verifying member eligibility and benefit coverage under the EHP. Prior Authorization also includes the process of determining whether or not a patient has met the clinical appropriateness criteria outlined by EHP for medical, prescription drug, and behavioral health/substance abuse services. Approval for a service prior to the service being rendered. Prior authorization, precertification, predetermination and prior approval are often used interchangeably.
You may be able to enroll or change your coverage outside annual enrollment if you have a qualifying life event—like marriage, divorce, spouse job loss, birth or adoption of a child, death of a dependent, loss of other benefits coverage, etc.
Physician practices with expertise in a specific medical specialty or sub-specialty.
A professional firm that performs administrative functions (e.g., claim processing membership) for a self-funded plan or a group plan.
Care received for medical conditions that are unforeseen and require attention within 24 hours. Examples of urgent care include, but are not limited to:
1. Minor cuts/lacerations
2. Minor burns
3. Minor trauma
4. Seemingly minor illnesses that include a high fever
5. Sprains
A scheduled or on-demand video appointment that allows patients to connect with their healthcare provider using a smartphone, tablet, or computer, without needing to visit a clinic in person. It offers a convenient, secure way to receive care for non-emergency conditions, follow-ups, or second opinions from the comfort of home or work.
A dedicated resource who supports caregivers in achieving their well-being goals by offering guidance and access to wellness programs such as Healthy Choice. They also assist with program eligibility, activity tracking devices, and navigating health plan benefits to help participants maintain or improve their incentive status.