Definition of Terms - WellChoice

Allowed Amount
The maximum reimbusement allowed for covered services. It can reflect a fee schedule or customary charges determined by WellChoice, WellChoice's agreement with a provider, or by statute or regulation (may be subject to a deductible or coinsurance).

Ambulatory Care
All types of health services that are provided on an outpatient basis.

Benefit Contract
The legal agreement between members and WellChoice that establish the full range of benefits available to the member through their healthcare plan. Also referred to as certificate of coverage or evidence of coverage.

Benefits
Services available to a member as defined in the contract and the amount paid for them.

Co-insurance
A provision in a member's coverage that limits the amount of coverage by the plan to a certain percentage, usually 70% or 80%. Additional costs are paid by the member. The percentage paid by the member is referred to as coinsurance and is typically 30% or 20% of the charges.

Copayment
The portion of a claim or medical expense that a member must pay out of their own pocket to a provider or a facility for each service. It is usually a fixed amount that is paid at the time service is rendered.

Customary Charges
The fees most doctors charge for a certain procedure. These charges are determined based on a review of provider charges in a geographical area at a certain time period.

Deductible
The dollar amount that the member must pay for covered services each year before an indemnity plan or out-of-network option pays benefits.

Effective Date
The date on which a contract for coverage begins.

Eligibility
A determination of whether or not a person meets the requirements to participate in the plan.

Emergency
An emergency condition is a medical condition manifesting itself by acute symptoms of sufficient severity, including, but not limited to, severe pain, psychiatric disturbances and/or symptoms of substance abuse such that a prudent layperson possessing an average knowledge of medicine and health, could reasonably expect the absense of immediate medical attention to result in:

placing the health of the afflicted individual or in the case of a pregnant woman, the health of the woman or the unborn child, in serious jeopardy,
serious impairment to bodily functions, or
serious dysfunction of a bodily organ or part.

With respect to a pregnant woman who is having contractions, an emergency exists where there is inadequate time to make a safe transfer to another hospital before delivery or where the transfer may pose a threat to the health or safety of the woman or the unborn child.

Fee For Service
A financial method in which healthcare providers set their own fees for services rendered. Under this method, patients pay fees for each and every service at the time it is provided.

Fee Schedule
A list of amounts to be paid for specific services or procedures by participating providers as stated in the WellChoice participating provider contract.

Health Maintenance Organization (HMO)
A managed care health plan that provides services through a fixed network of health care providers who provide comprehensive health care coverage to enrolled members exclusively through the network, with some copayments. All care is provided through a network of providers (primary care physicians, specialists, ancillary service providers, and hospitals).

Identification Card
A card issued to the customer identifying him/her as a member of WellChoice.

Managed Care
A medical delivery system that manages healthcare and costs through a network of physicians, hospitals and other healthcare providers.

Medicare Carve Out Coverage
When a person covered under a group contract becomes Medicare-eligible, the benefits available under the group contract are reduced by the amounts payable by Medicare (unless the Medicare benefits are secondary according to TEFRA, DEFRA, COBRA or OBRA). This coverage is different from supplementary coverage.

Network
A defined group of doctors, hospitals and other healthcare providers typically linked through contractual arrangements, which supply a full range of primary and acute healthcare services.

Network Provider or Participating Provider
A doctor, hospital or other healthcare provider who has entered into an agreement with WellChoice to provide healthcare services to members for a negotiated rate of reimbursement.

New Jersey State Department of Banking and Insurance
The state regulatory agency that has the responsibility to review and oversee customer contracts, rates and many other aspects of the corporation's operations and activities.

Out-of-Network Services
For the HMO programs, this term refers to covered services that are not provided or authorized by the PCP. For the PPO programs, this term refers to care not rendered by a PPO network provider.

Precertification
A review of a proposed hospital or healthcare facility admission or of certain services or procedures prior to receiving them, in order to determine whether the proposed admission or services meets the medical necessity criteria for payment and to receive the maximum benefits available under a WellChoice healthcare plan.

Preferred Provider Organization (PPO)
A network of doctors, hospitals and other healthcare providers who provide healthcare services to plan members. Members have the flexibility to choose a network provider or to select any provider outside the network, each time they need healthcare. Members save money when they use in-network providers.

PCP (Primary Care Physician)
A network physician - a family practitioner, general practitioner, internist or pediatrician (for children) - who is responsible for managing and coordinating your healthcare.

Riders
Riders are extended coverage on a contract that can increase or decrease the scope of coverage.(i.e., a contract with no pharmacy benefits might pick up a drug rider to get prescription coverage.)