A request for a fair hearing concerning a proposed agency action, a completed agency action, or failure of the agency to make a timely 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.
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 the Oklahoma Health Care Authority.
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 the health plan.
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
The willful intent to obtain ineligible benefits or payments.
G
Good Cause
An acceptable reason to defer the requirement to cooperate for certain eligibility factors.
H
Hearing
A hearing is when you ask your health program to review your case after your plan denied your appeal.
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
The Oklahoma Medicaid program includes all Medicaid benefits, including maternity benefits, maternity support services, and maternity case management, and is made available to Oklahoma Medicaid members who become pregnant, notify Oklahoma Medicaid and UnitedHealthcare Community Plan, and apply for benefits. Eligibility for the program is determined by Oklahoma Medicaid.
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 Oklahoma Medicaid programs visit https://oklahoma.gov/ohca.html
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 the UnitedHealthcare Health Plan.
O
Oklahoma Medicaid
Oklahoma managed care Medicaid program provides comprehensive free or low-cost health care to adults, families, people with disabilities, children under 19, children in foster care and pregnant women who meet income requirements.
Outpatient
A nonhospitalized patient receiving covered services away from a hospital, such as in a physician's office or the patient’s own home, or in a hospital outpatient or hospital emergency department or surgical center.
P
Primary Care Provider (PCP)
Your personal health care provider. Your primary care provider can be a family or general practitioner, internist, pediatrician, or other provider approved by UnitedHealthcare Community Plan. To receive benefits, your primary care provider must provide or coordinate your care. If you need to see a specialist, your primary care provider will refer you.
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. During recertification, you must submit current income and residency documentation to verify your eligibility and/or level of premium subsidy. You must recertify for Medicaid every 12 months.
S
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
The Oklahoma Health Care Authority (OHCA)
The state agency responsible for administering Oklahoma Medicaid.
Third Party
An individual, institution, corporation or agency that is responsible for all or part of the medical costs for Medicaid.
