Page 30 - Commercial Group Member Guidebook

Terms and Definitions

NEED A LITTLE HELP WITH THE INSURANCE TERMS AND OTHER TERMS IN THIS
GUIDEBOOK? LOOK THEM UP HERE. WE PROMISE TO MAKE IT QUICK.

Benefits: Services that are covered under your Participating facility: A hospital, urgent care center,
ConnectiCare plan. You’ll find them described in skilled nursing facility/sub-acute care facility,
detail in your Membership Agreement/Certificate of radiology center, lab, behavioral health facility or
Coverage. other facility that is part of our participating provider
network. Our Provider Directory is printed on an
Case manager: A registered nurse (R.N.) or social annual basis but may not always be up-to-date.
worker who works with members and their For the most current information, use Find a Doctor,
physicians to help coordinate care, and provide our Online Participating Provider Directory, at
education and support.
www.connecticare.com or call Member Services
for complete information.
Coinsurance: The percentage of the cost of benefits
that you are responsible for, after the deductible has Participating practitioner: A health professional,
been met. your PCP, Ob/Gyn, or specialist, who is part of the
ConnectiCare network. The Provider Directory is
Copayment: The flat fee you pay for certain benefits
like doctor visits and prescription drugs. The printed on an annual basis but may not always be
copayment is usually due at the time you receive up-to-date. For the most current information, use
the services. Find a Doctor, our Online Participating Provider
Directory, at www.connecticare.com or call
Deductible: The total amount you must pay for Member Services for complete information.
certain benefits under your plan, during the course
of the year, (whether it’s a calendar-year or contract- Pre-authorization: Prior approval to cover certain
year) before ConnectiCare will begin paying for health care services or prescription drugs (some
those benefits. examples of these are listed in this guidebook on
page 5). Your participating physician is responsible
Delegated program: An outside company that we for obtaining pre-authorization, but you should
may contract with to manage and/or administer always check to make sure it was granted.
certain categories of benefits provided through our
plans. These may include the administration of Prescription drug list: Similar to a drug formulary,
mental health benefits, vision care and dental plans. this is a list of prescription medications that are
covered by your ConnectiCare plan. The category or
Exclusions or Non-covered services: Services “tier” a drug is listed under determines how much the
and supplies that your ConnectiCare plan doesn’t copayment will be. Higher tiers correspond to higher
cover. Exclusions and non-covered services are copayments.
spelled out in your Membership Agreement/
Certificate of Coverage.
Primary Care Provider (PCP): This is your doctor —
Explanation of Benefits (EOB): This is a statement, a family practitioner, general practitioner, internist,
or Claim Summary, sent to you that lists services pediatrician or nurse practitioner you choose and
provided, amount billed and payment(s) made. who participates in our provider network and is listed
in our Directory of Participating Providers. Specialists
Maximum allowable amount: The amount of are not PCPs, so be sure you choose yours from the
a non-participating practitioner’s fees that categories described here.
ConnectiCare will use to determine how much it
will pay. (It’s your responsibility to pay the balance.)
The maximum allowable amount is usually based
on either a specified list of prevailing charges,
or Medicare’s relative value system, but it is
occasionally based on billed charges or a negotiated
amount. For prescriptions filled at the pharmacy, the
maximum allowable amount is the lesser of the
actual charge for the drug or the amount
ConnectiCare would have paid a participating
pharmacy for the drug.

28