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.
D
Deductible
The annual deductible is the total amount of money you must pay for some services that require copays over the eligibility year. You must pay the annual deductible before UnitedHealthcare will cover services that have copays.
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
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
Specialist
Any doctor who has special training for a specific condition or illness.
