Glosario de UnitedHealthcare Community Plan

A

  • Action or Denial

    A UnitedHealthcare Community Plan decision to deny or limit authorizations, services or payment

B

  • Beneficiary

    A person determined eligible by the State of Michigan for the Medical assistance program.

  • Beneficios

    Health care services provided for by Michigan Medicaid.

C

  • Certificado de cobertura (COC)

    The contract or Member Agreement between UnitedHealthcare Community Plan and Members, including all amendments, addenda, appendices and riders.

  • Co-payment

    The amount a Member may be required to pay directly to a Participating Provider or a Non-Participating Provider for certain Covered Services as set forth in Article IX of the COC.

  • Cirugía estética

    Those procedures which improve physical appearance, but which do not correct or materially improve a physiological function, and are not Medically Necessary.

  • Servicios cubiertos

    The Medically Necessary services, equipment and supplies set forth in Section 9.2 of the COC, which are subject to all of the terms and conditions of the COC and those services that UnitedHealthcare Community Plan is required to provide.

D

  • Department

    The Michigan Department of Community Health or its successor agency which is duly authorized to regulate health maintenance organizations and administer the Medicaid Program in the State of Michigan.

E

  • Servicios de emergencia

    Those services necessary to treat an emergency medical condition.  La afección médica de emergencia implica una afección médica que se manifiesta por síntomas agudos de suficiente gravedad (que incluye un dolor agudo) por los que una persona prudente, con un conocimiento medio sobre la salud y la medicina, podría prever razonablemente que si no recibe atención médica de forma inmediata esto le podrá traer consecuencias como: (i) poner en grave peligro la salud de la persona o, en el caso de una embarazada, la salud de la mujer o de su feto; (ii) ocasionar impedimentos graves de las funciones corporales; o (iii) ocasionar disfunciones graves de cualquier órgano o parte del cuerpo.

F

  • Servicios de planificación familiar

    Any medically approved means, including diagnostic evaluation, drugs, supplies, devices, and related counseling, for the purpose of voluntarily preventing or delaying pregnancy or for the detection or treatment of sexually transmitted diseases.

  • Family Practice and General Practice Doctors

    Doctors trained to treat adults and children.

G

  • Reclamo

    A complaint submitted on behalf of a member.

H

  • Profesional de la salud

    A health care provider, who is appropriately licensed, certified or otherwise qualified to deliver health services pursuant to Michigan law.

  • HMO

    Health Maintenance Organization. A health plan where a PCP manages all your health care needs.

I

  • Internal Medicine Doctors

    Doctors trained to treat adults.

M

  • Medicaid Agreement

    The contract between the State of Michigan and UnitedHealthcare Community Plan under which UnitedHealthcare Community Plan agrees to arrange for the delivery of Covered Services for Members.

  • Programa Medicaid

    The Department's program for Medical Assistance under Section 105 of Public Act 280 of 1939, as amended, MCL 400.105, and Title XIX of the Federal Social Security Act, 42. U.S.C. 1396 et seq., as amended.

  • Medical Director

    A Physician designated by UnitedHealthcare Community Plan to supervise and manage the medical aspects of UnitedHealthcare Community Plan programs and services.

  • Clínicamente necesarios

    The services, equipment or supplies necessary for the diagnosis, care or treatment of a member's physical or mental condition according to accepted medical practices and standards.

  • Miembro

    A Medicaid Program recipient enrolled with UnitedHealthcare Community Plan.

  • Member Agreement

    The COC, the Member's Application, the Member Handbook, and the UnitedHealthcare Community Plan ID Card issued by UnitedHealthcare Community Plan to the Member.

N

  • Non-Covered Services

    Those medical and health care services, equipment and supplies which are not Covered Services.

  • Proveedor no participante

    A Health Professional, Hospital, healthcare entity or health care professional that has not contracted with UnitedHealthcare Community Plan to provide Covered Services to Members.

  • Personal de enfermería practicante

    A registered nurse who has advanced training and certification.

O

  • Obstetricia/Ginecología

    Doctors trained to treat women.

  • OFIR

    The Office of Financial and Insurance Regulation or its successor agency which is duly authorized to regulate health maintenance organizations in the State of Michigan.

P

  • Proveedor participante

    A Health Professional, Hospital or other entity that contracts with UnitedHealthcare Community Plan to provide Covered Services to Members.

  • PCP

    Primary Care Provider (Your personal doctor).

  • Pediatricians

    Doctors trained to treat children and teens.

  • Physician's Assistant

    A health Professional who assists doctors.

R

  • Derivación

    When your Primary Care Provider sends you to a Specialist for a covered service.

S

  • Área de cobertura

    The areas in which UnitedHealthcare Community Plan has been authorized by OFIR and MDCH to provide services to Members.

U

  • UnitedHealthcare Community Plan Provider or Specialist

    Doctors, hospitals, pharmacies or other medical service providers you must use for your health care.

  • Atención urgente

    Covered services that are not Emergency Services, but are Medically Necessary and immediately required as a result of an unforeseen illness, injury, or condition.

  • Utilization Management (UM) Decision

    UnitedHealthcare Community Plan decisions made against set criteria.

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