Glossary of Terms
Appeal - Any procedures that deal with the review of adverse organization determinations regarding health care services a member believes he/she is entitled to receive including delay in providing, arranging for, or approving the health care services (such that a delay would adversely affect the health of the member) or any amounts that the member must pay for a covered service. These procedures include reconsiderations by the Medicare Advantage Organization, review by an independent review entity, hearings before Administrative Law Judges (of the Social Security Administration), review by the Medicare Appeals Council (MAC), and judicial review.
Basic Benefits - Health care services that are covered under Medicare Part A and Part B programs (except hospice services) and additional benefits. All members of Physicians Health Choice are eligible to receive all Basic Benefits.
Benefit Period - For both Physicians Health Choice and the Original Medicare, a benefit period is used to determine coverage for inpatient stays in hospitals and skilled nursing facilities. A benefit period begins with the first day you go to a Medicare covered inpatient hospital or skilled nursing facility (SNF). The benefit period ends when you have not been an inpatient at any hospital or SNF for 60 days in a row. If you go to they hospital or SNF after one benefit period has ended, a new benefit period begins. There is no limit to the number of benefits periods you can have. The type of care you actually receive during the stay determines whether you are considered to be an inpatient for SNF stays, but not for hospital stays. You are an inpatient in a SNF only if your care in the SNF meets certain skilled level of care standards. Specifically, in order to have been an inpatient while in a SNF, you must need daily skilled nursing or skilled rehabilitation care, or both.
Calendar Year - The period that begins on January 1 and ends twelve (12) consecutive months later on December 31.
Centers for Medicare & Medicaid Services (CMS) - The Federal agency that runs the Medicare program.
Coinsurance - Percentage of the cost of the covered service or supply for which you (the Member) are responsible for.
Copayment - Flat payment amount to be paid by the Member for covered health care services or supplies.
Covered Services - The general term we use in this handbook to refer to all health care services and supplies that are covered by Physicians Health Choice.
Custodial Services - Care which is provided solely for non-medically necessary personal needs which could be provided by persons without professional skills or training, such as assistance in walking, dressing, bathing, eating, cooking special diets, and taking medication. Custodial care is not covered by Physicians Health Choice nor the Original Medicare unless provided in conjunction with skilled nursing care and/or skilled rehabilitation services.
Customer Service – A department within Physicians Health Choice responsible for answering your questions about your membership, benefits, grievances, and appeals. A Physicians Health Choice Customer Representative is available to assist you when you call 1-866-550-4736 (TTY/TDD users may call 711) Monday through Friday between the hours of 8:00am and 5:00pm. You can also write to us at:
Physicians Health Choice
P.O. Box 690670
San Antonio, TX 78269
Disenroll or Disenrollment - The process of ending your membership in Physicians Health Choice. Disenrollment can be voluntary (your choice) or involuntary (not your choice).
Durable Medical Equipment (DME) – Equipment needed for medical reasons, which is sturdy enough to be used many times without wearing out. A person normally needs this kind of equipment only when ill or injured. It can be used in the home. Examples of DME include equipment that supplies a person with oxygen, wheelchairs, hospital beds and other items that are determined medically necessary, in accordance with Medicare law, regulations and guidelines.
Emergency Medical Condition – A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, with an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in 1) Serious jeopardy to the health of the individual (or, in the case of a pregnant woman, the health of the woman or her unborn child); 2) Serious impairment to bodily functions; or 3) Serious dysfunction of any bodily organ or part.
Emergency Care – Inpatient or outpatient covered services that are 1) furnished by a provider qualified to furnish emergency services; and 2) needed to evaluate or stabilize an Emergency Medical Condition.
Evidence of Coverage (EOC) and Disclosure Information – The document, which explains the covered services, defines our obligations, and explains your rights and responsibilities as a member of the Physicians Health Choice.
Exclusion – Items or services that Physicians Health Choice does not cover. You are responsible for paying for excluded items or services.
Experimental Procedures and Items – Items and procedures determined by Physicians Health Choice and Original Medicare not to be generally accepted by the medical community. When deciding if a service or item is experimental, Physicians Health Choice will follow CMS Medicare Carriers Manual and Coverage Issues Manual or will follow decisions already made by Medicare. With the exception of procedures and items under clinical trials, experimental procedures and items are not covered under the Evidence of Coverage.
Grievance – Any complaint or dispute other than one involving an Organization Determination expressing dissatisfaction with the manner in which Physicians Health Choice or delegated entity provides health care services, regardless of whether any action can be taken. The Member may make the complaint either orally or in writing to Physicians Health Choice, provider or facility. Examples of grievances may include: timeliness of getting an appointment, waiting times in physician offices; discourteous staff or provider, quality of care received.
Home Health Agency – A Medicare-certified agency that provides intermittent Skilled Nursing Care and other therapeutic services in your home when medically necessary, when you are confined to your home and when authorized by your Primary Care Physician.
Hospice – A Medicare-certified organization or agency that is primarily engaged in providing pain relief, symptom management and supportive services to terminally ill people and their families.
Hospital – A Medicare-certified institution licensed by the State, that provides inpatient, outpatient, emergency, diagnostic and therapeutic services. The term "Hospital" does not include a convalescent nursing home, rest facility or facility for the aged that primarily provides custodial care, including training in routines of daily living.
Independent Review Entity – An independent entity contracted by CMS to review denial of coverage determinations made by a Medicare Advantage Organization.
Lock-In – An arrangement under which Covered Services, with exception of the Emergency Services; Urgently Needed Services or Out-of-Area Renal Dialysis Services, must be provided or authorized by your contracted Primary Care Physician. (There are very limited exceptions to this rule where you can self refer to a contracted provider for Flu Shots and Mammography Screening services.) If you receive services from a Non-Contracted Provider without Prior Authorization, except for Emergency Services, Urgently Needed Services, or Out-of-Area Renal Dialysis Services, neither Physicians Health Choice nor Medicare will pay for that care.
Medicaid – A joint Federal and State medical assistance program. Some Medicare beneficiaries are also eligible for Medicaid. Medicaid, unlike Medicare, may cover long-term care, such as custodial nursing home care. Medicaid may cover all or part of your Medicare premiums and/or deductibles and coinsurance, if your income and resources are low enough. You should inquire about Medicaid and related programs - Qualified Medicare Beneficiary, Special Low Income Medicare Beneficiary, Qualified Disabled Working Individual, and SHIP which is a Health Insurance Information Program that provides free one on one counseling, education, and information to individuals with Medicare of all ages. The SHIP toll free number is 1-800-432-2080 (In-State Calls Only) and the local number is 1-505-476-4846.
Medical Director – A licensed physician who is an employee of Physicians Health Choice and is responsible for the overall quality of the medical care we provide.
Medically Necessary – Services or supplies that:
Medicare – The federal health insurance program for people 65 years of age or older, certain younger people with disabilities, and people with End Stage Renal Disease (generally those with permanent kidney failure who need dialysis).
Medicare Advantage Organization – A public or private organization licensed by the State as a risk-bearing entity that is under contract with Centers for Medicare and Medicaid Services (CMS) to provide covered services. Medicare Advantage Organizations can offer one or more Medicare Advantage Plans. Physicians Health Choice is a Medicare Advantage Organization (Medicare Advantage is the new name for Medicare + Choice).
Medicare Advantage Plan – A benefit package offered by a Medicare Advantage Organization that offers a specific set of health benefits at a uniform premium and uniform level of cost-sharing, if applicable, to all people with Medicare who live in the service area covered by the Plan. Medicare Advantage Organizations can offer one or more Medicare Advantage Plans. Physicians Health Choice is a Medicare Advantage Organization (Medicare Advantage is the new name for Medicare + Choice).
“Medigap” (Medicare Supplement Insurance) Policy – Many people who get their Medicare through Original Medicare buy “Medigap” or Medicare supplement insurance policies to fill “gaps” in Original Medicare coverage.
Member (member of Physicians Health Choice) – A person with Medicare who is eligible to get covered services, who has enrolled in Physicians Health Choice, and whose enrollment has been confirmed by the Centers for Medicare & Medicaid Services (CMS).
Network – A group of health care providers under contract with Physicians Health Choice, which is licensed and/or certified by Medicare with the purpose of delivering or furnishing health care services. Generally, members must receive routine services within their designated network in order to be covered by Physicians Health Choice exception for emergency medical conditions.
Non-Plan Medical Provider or Facility – A provider or facility that we have not arranged with to coordinate or provide covered services to members of Physicians Health Choice. Non-”Plan Provider” or facilities are not employed, owned, operated by, or under contract with Physicians Health Choice to deliver covered services to you without Prior Authorization. As explained on this Web site, most services you get from non-”Plan Provider” or facilities will not be covered by Physicians Health Choice nor Original Medicare.
Office Visit – A visit for Covered Services to your Primary Care Physician, Specialist, other Contracting Medical Providers.
Optional Supplemental Benefits – Non-Medicare covered benefits that can be purchased for an additional premium and are not included in the package of Basic Benefits. Physicians Health Choice does not currently offer Optional Supplemental Benefits.
Organization Determination – In general, a decision by Physicians Health Choice or a person acting on behalf of Physicians Health Choice to approve or deny a payment for a service or a request for service to which the member believes he/she is entitled.
Original Medicare – A plan that is available everywhere in the United States. Some people call it “traditional Medicare” or “fee-for-service” Medicare. Original Medicare is the way most people get their Medicare Part and Part B health care. It is the national pay-per-visit program that lets you go to any doctor, hospital or other health care provider who accepts Medicare. You must pay the deductible. Medicare pays for its share of the Medicare-approved amount, and you pay your share. Original Medicare has two parts: Part A (Hospital Insurance) and Part B (Medical Insurance).
Plan Premium – Medicare Advantage Organizations may charge a plan premium. Physicians Health Choice currently offer health plans requiring a monthly premium. Please refer to Our Health Plan Products section for a list of Physicians Health Choice plans and applicable monthly premiums. However, to qualify for the services outlined in this Evidence of Coverage, the member must continue to pay the monthly Medicare Part B Premium and, if applicable, Medicare Part A Premium.
Plan Provider – “Provider” is a general term used for doctors, other health care professionals, hospitals, and other health care facilities that are licensed or certified by Medicare or by the State to provide health care services. We call them ““Plan Provider”” when they are part of Physicians Health Choice. When we say that “Plan Provider” are “part of Physicians Health Choice”, this means that we arranged with them to coordinate or provide covered services to Physicians Health Choice members.
Prescription Drug Benefit Manager – This is a company that contracts with Medicare Advantage Organizations to manage pharmacy services.
Primary Care Physician (PCP) – A health care professional who is trained to provide basic health care needs. Your PCP is responsible for providing or authorizing Covered Services while you are a member of Physicians Health Choice.
Prior Authorization – Referral approval, in advance, to receive services. Some services are covered only if your doctor or other “Plan Provider” gets “Prior Authorization” from Physicians Health Choice before you receive certain health care services. These will be indicated in the Summary of Benefits.
Quality Improvement Organization (QIO) – Groups of practicing doctors and other health care experts who are paid by the Federal Government to check and improve the care given to Medicare recipients. They must review your complaints about the quality of care given by doctors in inpatient Hospitals, hospital outpatient departments, hospital emergency rooms, Skilled Nursing Facilities, Home Health Agencies, Private fee-for-service plans and ambulatory surgical centers. Upon request, the QIO also reviews hospital discharges for appropriateness and quality-of-care complaints. See the Appeals / Grievances Section on our Web site about making complaints (appeals or grievances) to the QIO.
Referral – Your Primary Care Physician’s approval for you to see a certain Specialist or to receive certain Covered Services.
Rehabilitation Services – These services include physical therapy, cardiac rehabilitation, speech and language therapy, and occupational therapy that are provided under the direction of a Physician Health Choice provider.
Service Area – A geographic area approved by Centers for Medicare and Medicaid Services (CMS) within which a Medicare Advantage eligible individual may enroll in a particular Medicare Advantage Plan offered by a Medicare Advantage Organization.
Skilled Nursing Care – Services that can only be performed by or under the supervision of licensed nursing personnel.
Skilled Nursing Facility – A facility (or distinct part of a facility) that provides inpatient Skilled Nursing Care, rehabilitation services or other related health services and is certified by Medicare. The term "Skilled Nursing Facility" does not include a convalescent nursing home, rest facility or facility for the aged which furnishes primarily Custodial Care, including training in routines of daily living.
Specialist – Any duly licensed physician, osteopath, psychologist or other practitioner (as defined by Medicare) who provides health care services for a specific disease or part of the body. Other examples include oncologists (care for cancer patients), cardiologists (care for the heart), and orthopedists (care for bones).
Time-Sensitive – A situation in which waiting for a standard decision on an authorization for a service could seriously jeopardize your life or health, or your ability to regain maximum function.
Urgently Needed Care - This is when you need medical attention right away for an unforeseen illness or injury, but your health is not in serious danger. This also includes covered services 1) when you are temporarily out of the service area, 2) in area when your Primary Care Physician is not available or 3) it is not reasonable to obtain services through your Primary Care Physician given the circumstances.
Utilization Review Committee - A committee used by Physicians Health Choice to promote the efficient use of resources and the quality of health care. Duties of the Utilization Review Committee include prospective, current and retrospective review of medical services.
