Helpful Terms (A-N)
Allowed Amount
The amount paid for a Covered Service. This may be called “eligible expense,” “payment allowance” or “negotiated rate.” If your provider charges more than the Allowed Amount, you may have to pay the difference. (See Balance Billing.)
Balance Billing
When an out-of-network provider bills you for the difference between their actual charge and the Allowed Amount paid to them by QualChoice. If the provider’s charge is $100 and the Allowed Amount is $70, the provider may bill you for the last $30. An in-network provider may not balance bill you for Covered Services.
Benefit Summary
An outline of your plan benefits and limits. Be sure to keep your Benefit Summary where you can easily find it.
Care Management
Planning, carrying out, coordinating and evaluating choices and care to meet a member’s health needs.
Coinsurance
A fixed portion of the Maximum Allowable Charge you must pay toward the cost of certain Covered Services. Those Covered Services that call for coinsurance are listed in your Benefit Summary. Coinsurance has an annual maximum limit.
Copayment
A fixed amount you pay for a Covered Service, most often at the time of service. The amount can differ by the type of Covered Service.
Cost Share
The share of costs that you pay out of your own pocket. Generally includes deductibles, coinsurance and copayments or similar charges. It doesn’t include premiums, balance billing amounts for out-of-network providers or the cost of non-covered services.
Covered Services
The services or goods your health plan covers.
Coverage Certificate
A legal document that describes the terms and conditions of your group health insurance plan.
Coverage Policy
A legal document that describes the terms and conditions of your individual/family health insurance plan.
Deductible
The amount you pay for healthcare services covered by your plan before the plan starts to pay. The deductible may not apply to all services.
Designated Personal Representative
A person authorized by the member to act on their behalf, in pursuing a claim or an appeal of a denied claim.
Drug Formulary
A list of generic and brand name drugs in your prescription drug plan.
Effective Date
The date your insurance coverage starts. You are not covered until the policy’s start date.
Emergency
A sickness, injury, symptom or health issue so serious that a normal person would seek care right away to avoid further harm. Please check your coverage policy or certificate for the full meaning.
Excluded Services
Healthcare services that your health insurance plan doesn’t cover.
Explanation of Benefits (EOB)
A written statement issued by QualChoice for any healthcare services that you have received and the resulting benefits and charges covered or not covered by your health plan.
Health Coach
An RN trained to help members in reaching short- and long-term goals for a healthier life. QualChoice health coaches can help members stop smoking, improve their diet or better handle ongoing health issues like high blood sugar or high blood pressure.
In-Network Provider
A doctor or other healthcare provider who contracts with your health plan to provide services at a lower rate.
Maximum Allowable Charge
The amount a health plan will pay for a Covered Service. It may be less than the real charges billed by the provider.
Network (or Provider Network)
The healthcare experts, facilities and suppliers that have agreed to provide healthcare services to your health plan at a lower rate. Provider networks can cover a large area or a wide range of healthcare services.
Nurse Care Manager
QualChoice nurse care managers are RNs who offer support to members with complex and long-term health issues.
Helpful Terms (O-U)
Out-of-Network Provider
A doctor or other healthcare provider who doesn’t have a contract with your health insurer to provide services. You’ll pay more to see an out-of-network provider.
Open Enrollment Period (OEP)
A period when members can add to or change their health benefits or sign up for coverage.
Out-of-Pocket Limit
The most you pay during a plan period (usually a year) before your health plan starts to pay 100% of the Allowed Amount. This limit never includes your premium, balance-billed charges or care that your health plan doesn’t cover.
Plan
Benefits your employer, union or other group sponsor provide to you to pay for your healthcare services.
Pharmacy Network
A group of pharmacies that has agreed to provide prescription drugs to plan members at certain discounts or rates.
Pre-authorization
A decision by your health plan that a service, care plan, prescription drug or healthcare device is medically necessary. Sometimes called prior authorization, prior approval or pre-certification. Your health plan may call for pre-authorization for certain services before you get them, except in an emergency. Pre-authorization isn’t a promise
your health insurance or plan will cover the cost.
Preventive Care
Programs or services that can help prevent disease. This may include yearly exams, shots and tests for some diseases. The tests are sometimes called screenings. QualChoice follows the direction of the U.S. Preventive Services Task Force in deciding on coverage for preventive services.
Primary Care Provider (PCP)
A doctor, nurse practitioner, clinical nurse specialist or physician assistant (as allowed under state law) who provides, coordinates or helps a patient use a range of healthcare services.
QCARE
The QualChoice health and wellness program offering support for complex health problems and long-term health issues. It also helps members set and reach health and well-being goals, leading to more effective and efficient care.
Qualifying Event
A change in your life that means you may enroll in health coverage or change plans outside an Open Enrollment Period. Some of these are: moving to a new state or changes in your family size (marriage, divorce or birth of a baby).
Rehabilitation Services
Healthcare services that help a person keep, get back or improve skills and functioning for daily living that have been lost or decreased because a person was sick, hurt or disabled. May include physical and occupational therapy, speech-language pathology and psychiatric services in inpatient and/or outpatient settings.
Skilled Nursing Care
Services from licensed nurses in your own home or in a nursing home.
Specialist
A doctor who focuses on a certain area of medicine or group of patients to diagnose, manage, prevent or treat certain types of symptoms and health problems.
Summary of Benefits and Coverage (SBC)
A summary of the price, benefits and other features of a health plan, provided by health insurers and group health plans as required by the Affordable Care Act.
Service Area
The area of the country or state in which a health plan is licensed by the state to do business. The QualChoice service area includes all 75 counties in Arkansas plus these counties outside of Arkansas: Shelby County (Tennessee), Bowie County (Texas) and Greene County (Missouri).
Special Enrollment Period
A time outside of an Open Enrollment Period (OEP) when you and your family may add to, change or sign up for health coverage because of a qualifying event, such as marriage, birth of a child or loss of other health coverage.
Urgent Care
Care for an illness, injury or health problem serious enough that a normal person would seek care right away, but not so serious as to call for emergency care.
Utilization Management
The review of the healthcare need, appropriateness and efficiency of healthcare services, procedures and clinics under a health benefits plan.
Please refer to your coverage policy or certificate or Benefit Summary for the specific details of your plan.