The charge amounts that exceed our maximum allowed fees. This applies when a member is receiving services at a non-network provider, with or without a referral.
The maximum cost sharing amounts you will have to pay for covered services, excluding prescription drugs, received in a calendar year.
A patent-protected product manufactured by a pharmaceutical company that has the exclusive marketing rights to sell the prescription drug.
A defined percentage of the charges a member must pay for certain covered services.
The amount a member must pay for inpatient hospitalization in addition to the deductible.
A specified dollar amount a member must pay for certain covered services.
The dollar amount a member is responsible for paying when covered services are received from a healthcare provider. Cost-sharing amounts include co-insurance, co-payments, deductibles, above usual and customary and hospital confinement fee amounts.
Medically necessary medical treatment and other healthcare services for which benefits will be provided, unless limited or excluded by the Certificate of Coverage.
The amount a member must pay for certain covered services each calendar year of coverage before the Plan will begin to pay benefits.
The identification code representing a disease or condition a patient has. This is the reason for the visit or procedure. This code is required on all claims for services received and is determined by the provider.
A list of prescription medications and drugs approved by the Plan for use by members.
Medical treatment required unexpectedly and immediately because of an accidental injury or emergency illness. An emergency shall exist when a member's symptoms are of sufficient severity to lead a prudent layperson to reasonably conclude that immediate medical attention is necessary. It does not include elective medical treatment for an illness or injury for which the need for care could reasonably have been foreseen.
Charges, services or supplies not covered by the plan.
Drugs whose patents have expired and are usually manufactured by several pharmaceutical companies. Health Tradition uses A-rated generic drugs, which contain the same active ingredient as the brand name product, are manufactured under the same Food and Drug Administration (FDA) standards and are considered equivalent in all respects to the brand name product.
Institutional healthcare providers or individual healthcare providers (practitioners) providing healthcare services to members.
The healthcare professional (for example, a physician, physician assistant or nurse healthcare provider) who provides primary care medical services and usually serves as your initial contact with the healthcare system. Primary care areas include family medicine, pediatrics, internal medicine, OB/GYN and the Center for Women's Health.
A specific group of healthcare providers that have an agreement with the Plan to provide services to the member.
Services provided when you are admitted to the hospital for at least 24 hours. Inpatient services include room and board as well as nursing, diagnostic, therapeutic, medical or surgical services.
A subscriber or dependent that is participating under the benefit plan.
An identification card issued in the subscriber's name identifying the membership number of the subscriber. This card also includes the prescription filing information, contact numbers and mailing address of the health plan.
Providers who do not have an agreement with the Plan to provide services to the member.
Healthcare services provided to you when you do not require a 24-hour stay in the hospital. Outpatient services may be provided in a healthcare provider's office, hospital, diagnostic center or surgical facility.
The process of receiving written approval from the Plan for certain services or products in advance of the service or product being provided. Prior authorization does not guarantee payment of benefits.
A numeric or alpha-numeric description of the services and procedures a patient receives. This code is required on all claims for services received and is determined by the provider using national code sets.
A written form from an in-network healthcare provider requesting authorization for a specific scope of services to be provided by an out-of-network healthcare provider. The Plan must approve referrals to out-of-network healthcare providers before those services are received.
A condition requiring medically necessary care to treat an unforeseen illness or injury which is necessary to prevent serious deterioration of a member's health, and which cannot be reasonably delayed until the next available appointment with a member's individual healthcare provider.