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Standard Member Material Terminology and Definitions
| Appeal |
| A way for you to challenge your plan’s action if you think your plan made a mistake. You can ask your plan to change a coverage decision by filing an appeal. |
| Co-payment |
| A payment paid by you in order to receive medical care and medicine. |
| Durable medical equipment |
| Certain items your doctor orders for you to use at home. Examples are walkers, wheelchairs, or hospital beds. |
| Emergency medical condition |
| An emergency means your life could be threatened or you could be hurt permanently (disabled) if you don’t get care quickly. If you are pregnant, it could mean harm to the health of you or your unborn baby. |
| Emergency medical transportation |
| Transportation that you can take if your health makes it impossible to go to the hospital by any other means but by calling 911 for an ambulance. |
| Emergency room care |
| Care provided in a hospital emergency room staffed and equipped for the treatment of people that require immediate medical care and/or services. |
| Emergency services |
| Services provided in a hospital emergency room by a provider trained to treat a medical or behavioral health emergency. |
| Excluded services |
| Services that are not covered under Medicaid or Nevada Check Up. |
| Grievance |
| A complaint you make about your plan or one of your network providers or pharmacies. This includes a complaint about the quality of your care. |
| Habilitation services and devices |
| Services and devices that help you keep, learn, or improve skills and functioning for daily living. |
| Health insurance |
| A type of insurance coverage that pays for your health, medical, and surgical expenses. |
| Home health care |
| Health care services a person receives in the home including nursing care, home health aide services, and other services. |
| Hospice services |
| A program of care and support to help people who have a terminal prognosis live comfortably. A terminal prognosis means that a person has a terminal illness and is expected to have six months or less to live. A Member who has a terminal prognosis has the right to elect hospice. A specially trained team of professionals and caregivers provide care for the whole person, including physical, emotional, social, and spiritual needs. |
| Hospitalization |
| The act of placing a person in a hospital as a patient. |
| Hospital outpatient care |
| Care or treatment that does not require an overnight stay in a hospital. |
| Medically Necessary |
| This describes services that are necessary to prevent, diagnose, or treat your medical condition or to maintain your current health status. This includes care that keeps you from going into a hospital or nursing home. It also means that the services, supplies, or drugs meet accepted standards of medical practice or are otherwise necessary under current Medicaid or Nevada Check Up coverage rules. |
| Network |
| A network is a group of doctors, health care professionals, hospitals, and health care facilities that your plan has contracted with to provide medical care to you and all Members. |
| Non-participating provider |
| A provider or facility that is not employed, owned, or operated by your plan and is not under contract to provide covered services to you or Members of your plan. |
| Physician services |
| Care provided to you by an individual licensed under state law to practice medicine, surgery, or behavioral health care. |
| Plan |
| Plan refers to a Managed Care Organization that creates a network of health care providers that deliver medical services to Medicaid or Nevada Check Up Members that have enrolled in that plan. |
| Preauthorization |
| A decision by your plan or the state that a health care service, treatment plan, prescription drug, or durable medical equipment is medically necessary. Sometimes called prior authorization, prior approval, or precertification. |
| Participating provider |
| Providers, hospitals, home health agencies, clinics, and other places that give you health care services, medical equipment, and long-term services and supports that are contracted with your health plan. Participating providers are also called “in-network providers” or “plan providers.” |
| Premium |
| A monthly payment a plan receives to provide you with health care coverage. |
| Prescription drug coverage |
| Prescription drugs or medications covered (paid) by your plan. Some over-the-counter medications are also covered. |
| Prescription drugs |
| A drug or medication that, by law, can be obtained only from a physician's prescription. |
| Primary care physician |
| Your primary care physician is the doctor or other provider you see first for most health problems. They make sure you get the care you need to stay healthy. They may also talk with other doctors and health care providers about your care and refer you to them. |
| Primary care provider (PCP) |
| Physicians who practice general medicine, family medicine, general internal medicine, general pediatrics, or osteopathic medicine. They are responsible to provide, arrange, and coordinate all aspects of your health care. Often, they are the first person you should contact if you need health care. Physicians who practice obstetrics and gynecology may function as PCPs for individuals who are pregnant. |
| Provider |
| A person who is authorized to give health care services. Examples of providers include doctors, nurses, behavioral health providers, nursing homes, and specialists. |
| Rehabilitation services and devices |
| Treatment you get to help you recover from an illness, accident, or major operation to restore you to the best possible functional level. |
| Skilled nursing care |
| Skilled nursing care is Medically Necessary care that can only be provided by or under the supervision of skilled or licensed medical personnel. |
| Specialist |
| A doctor who provides health care for a specific disease or part of the body. |
| Urgent care |
| Care when you need to see a doctor and your doctor is not able to see you or the office is closed, that is needed for a sudden illness, injury, or condition that is not an emergency but needs to be treated right away. |