Use the alphabetic list to be directed to a specific area of the Glossary.
A (return to top of page)
After Hours Care - services received in a Physician's office
at times other than regularly scheduled office hours, including days when the office
is normally closed (e.g., holidays or Sundays).
Alcoholism - a Condition classified as a mental disorder and
described in the International Classification of Diseases,ninth Revision, Clinical Modification (ICD-9-CM) or the most recent version, as
alcohol dependence, abuse or alcoholic psychosis.
Allowed Amount - For Network Providers, this means the lesser of the Negotiated Amount or Billed Charges, and for Non-Network Providers, this means the maximum amount determined as
payable and allowed by CCP for a Covered Service provided by a Provider based on certain factors, including, but not limited
to, the following:
- Center for Medicare and Medicaid
Services (CMS)'s Resource Based Value Scale (RBRVS)
- Input from Network Physicians
and wholesale prices (where applicable)
- Geographic considerations
- Other economic and statistical indicators
Application - all questionnaires and forms required by CCP to determine your
eligibility.
B (return to top of page)
Basic Health Care Services -
- Inpatient Hospital
services, meaning Medically Necessary Hospital services
including, but not limited to, room and board; general nursing care; special diets
when Medically Necessary; use of operating room and related facilities;
use of intensive care units and services; x-ray, laboratory and other diagnostic
tests; drugs, medications, biologicals, anesthesia and oxygen services; special
nursing when Medically Necessary; physical therapy, radiation therapy
and inhalation therapy; administration of whole blood and blood plasma; and short-term
rehabilitation services.
- Inpatient Physician
care services, meaning Medically Necessary health care services performed,
prescribed, or supervised by Physicians or other health professionals including diagnostic,
therapeutic, medical, surgical, preventive, referral and consultative health care
services.
- Outpatient medical services,
meaning preventive and Medically Necessary health care services provided
in a Physician's office, a non-hospital-based health care facility or at
a Hospital. Outpatient medical services shall include,
but are not limited to: diagnostic services; treatment services; laboratory services;
x-ray services; referral services; and physical therapy, radiation therapy and inhalation
therapy. Outpatient services shall also include preventive health
services which shall include, at least, a broad range of voluntary family planning
counseling services, well-child care from birth, periodic health evaluations for
adults, screening to determine the need for vision and hearing correction, and pediatric
and adult immunizations in accordance with accepted medical practice.
Benefit Period - the period of time specified in the Schedule of Benefits
during which Covered Services are rendered, and benefit maximums, Deductibles, Coinsurance Limits and Non-Network Coinsurance Limits
are accumulated. The first and/or last Benefit Periods may be less
than 12 months depending on the Effective Date and the date your coverage
terminates.
Billed Charges - the amount billed on the claim submitted by the Provider
for services and supplies provided to a Covered Person.
C (return to top of page)
Certificate - a document that contains the
coverage details
Certificate Holder - an eligible employee or participant of the Group who
has enrolled for coverage under the terms and conditions of the Group Contract.
Coinsurance - a percentage of the Allowed Amount for which
you are responsible after you have met your Deductible or paid your Copayment.
Coinsurance Limit - the maximum amount of Coinsurance that
a Covered Person will have to pay during a Benefit Period.
Condition - an injury, ailment, disease, illness or disorder.
Contract - the agreement between CCP and your Group referred to as the Group
Contract. The Contract includes the Group Application, individual Applications of the Certificate Holders, this Certificate, Schedules of Benefits and any
Riders or addenda.
Copayment - a dollar amount, if specified in the Schedule of Benefits, that
you are required to pay each time you receive certain Covered Services.
Covered Charges - the Billed Charges less non-covered items.
Covered Person - the Certificate Holder, and if family coverage
is in force, the Certificate Holder's Eligible Dependent(s) as defined
in the Eligibility section of this Certificate.
Covered Service - a Provider's service or supply as described in this Certificate
for which CCP will provide benefits.
Creditable Coverage - coverage of an individual under any of the following:
- a group health plan, including church and governmental
plans;
- health insurance coverage;
- Part A or Part B of Title XVIII of the Social
Security Act (Medicare);
- Title XIX of the Social Security Act, other
than coverage consisting solely of benefits under Section 1928 (Medicaid);
- the health plan for active military personnel,
including TRICARE;
- the Indian Health Service or other tribal organization
program;
- a state health benefits risk pool;
- the Federal Employees Health Benefits Program;
- a public health plan as defined in federal
regulations;
- a health benefit plan under section 5 (c) of
the Peace Corps Act; or
- any other plan that provides coverage for comprehensive
hospital, medical and surgical services.
Custodial Care - care that does not require the constant supervision of skilled
medical personnel to assist the patient in meeting his or her activities of daily living. Custodial Care is
care which can be taught to and administered by a lay person and includes but is not limited to:
- administration of medication which can be self-administered
or administered by a lay person; or
- help in walking, bathing, dressing, feeding
or the preparation of special diets.
Custodial Care does not include care provided for its therapeutic
value in the treatment of a Condition.
Custodian - a person who, by court order, has custody of a child.
D (return to top of page)
Deductible - an amount, usually stated in dollars, for which you are responsible
each Benefit Period before CCP will start to provide benefits.
Drug Abuse - a Condition classified as a mental disorder and
described in the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) or the most recent version, as
drug dependence abuse or drug psychosis.
E (return to top of page)
Effective Date - 12:01 a.m. on the date when your coverage begins, as determined
by your Group and CCP.
Emergency Care Services -
Emergency Medical Condition - a medical Condition manifesting
itself by acute symptoms of sufficient severity, including severe pain, such that
a prudent layperson who possesses an average knowledge of health and medicine could
reasonably expect the absence of immediate medical attention to result in:
- placing the health of the individual, or with
respect to a pregnant woman, the health of the woman or her unborn child, in serious
jeopardy;
- serious impairment to bodily functions; or
- serious dysfunction of any bodily organ or
part.
Excess Charges - the difference between Billed Charges and
the Allowed Amount.You may be responsible for Excess Charges when you receive services from a Non-Network Provider.
Experimental or Investigational Drug, Device, Medical Treatment or Procedure
- a drug, device, medical treatment or procedure is Experimental or Investigational:
- if the drug or device cannot be lawfully marketed
without approval of the U.S. Food and Drug Administration and approval for marketing
has not been given at the time the drug or device is furnished;
- if reliable evidence shows that the drug, device,
medical treatment or procedure is the subject of on-going phase I, II or III clinical
trials or is under study to determine maximum tolerated dose, toxicity, safety,
efficacy, or efficacy as compared with the standard means of treatment or diagnosis;
or
- if reliable evidence shows that the consensus
of opinion among experts regarding the drug, device, medical treatment or procedure
is that further studies or clinical trials are necessary to determine its maximum
tolerated dose, toxicity, safety, efficacy or efficacy as compared with the standard
means of treatment or diagnosis.
Reliable evidence means only published reports and articles in the authoritative
medical and scientific literature; the written protocol or protocols used by the treating facility or the protocol(s) of
another facility studying substantially the same drug, device, medical treatment or procedure; or the written informed consent
used by the treating facility or by another facility studying substantially the same drug, device, medical treatment
or procedure. Determination will be made by CCP at its sole discretion and will
be final and conclusive.
F (return to top of page)
Full-time Student - an Eligible Dependent who is enrolled at an accredited
institution of higher learning. It must be certified annually that the student meets the institution's requirements
for full-time status.
H (return to top of page)
Hospital- a duly licensed Institution which provides general
and specialized Inpatient medical care. The term "Hospital"
does not include a convalescent facility, nursing home or any Institution
or part thereof which is used principally as a convalescent facility, rest facility,
nursing facility or facility for the aged.
I (return to top of page)
Immediate Family - the Certificate Holder and the Certificate Holder's spouse, parents, stepparents, grandparents, nieces, nephews, aunts, uncles, cousins, brothers, sisters, children and stepchildren
by blood, marriage or adoption.
Incurred - rendered to you by a Provider. All services rendered by the Institutional
Provider during an Inpatient admission prior to termination of coverage
are considered to be Incurred on the date of admission.
Inpatient - a Covered Person who receives care as a registered bed patient
in a Hospital or Other Facility Provider where a room and board charge is made.
Institution (Institutional) - a Hospital or Other Facility Provider.
L (return to top of page)
Legal Guardian - an individual who is either the natural guardian of a child
or who was appointed a guardian of a child in a legal proceeding by a court having
the appropriate jurisdiction.
M (return to top of page)
Medical Care - professional services received from a Physician
or an Other Professional Provider to treat a Condition.
Medically Necessary (or Medical Necessity) - appropriate and necessary services as determined by
any Provider affiliated with CCP that are rendered to a Covered Person for any Condition requiring, according
to generally accepted principles of good medical practice, the diagnosis or direct care and treatment of an illness or injury and
are not provided only as a convenience.
Medicare - the program of health care for the aged and disabled established
by Title XVIII of the Social Security Act of 1965, as amended.
Medicare Approved - the status of a Provider that is certified by the United
States Department of Health and Human Services to receive payment under Medicare.
Mental Illness - a Condition classified as a mental disorder
in the International Classification of Diseases, Ninth Revision, Clinical Modification
(ICD-9-CM) or the most recent version, excluding Drug Abuse and Alcoholism and excluding Severe Mental Illness.
N (return to top of page)
Negotiated Amount - the amount the Provider has agreed with CCP to accept
as payment in full for Covered Services.
The Negotiated Amount for Providers does not include adjustments and/or
settlement due to prompt payment discounts, guaranteed discount corridor provisions,
maximum charge increase limitation violations, performance withhold adjustments
or any settlement, incentive, allowance or adjustment that does not accrue to a
specific claim.
The Negotiated Amount for Prescription Drugs does not
include any share of formulary reimbursement savings (rebates), volume based credits
or refunds or discount guarantees.
In certain circumstances, CCP may have an agreement or arrangement with a vendor
who purchases the services, supplies or products from the Provider instead of CCP contracting directly with
the Provider itself. In these circumstances, the Negotiated Amount
will be based upon the agreement or arrangement CCP has with the vendor and not
upon the vendor's actual negotiated price with the Provider, subject to the further
conditions and limitations set forth herein.
Network Provider - a Hospital, Other Facility Provider,
Physician or Other Professional Provider that is licensed
and operated as required by law and which has an agreement with CCP about payment for
Covered Services. (This includes professional staff members.)
Non-Covered Charges - Billed Charges for services and supplies
that are not Covered Services.
Non-Network Coinsurance - a percentage of the Allowed Amount
for Non-Network Providers for which you are responsible after you have met your Deductible or paid your Copayment,
if applicable.
Non-Network Coinsurance Limit - a specified dollar amount of Non-Network Coinsurance expense for which you are
responsible in each Benefit Period.
Non-Network Deductible - an amount, usually stated in dollars, for which
you are responsible each Benefit Period before CCP will start to provide benefits for services received from a Non-Network Provider.
Non-Network Provider - the status of a Provider that does not meet the definition
of a Network Provider.
O (return to top of page)
Office Visit - Office visits include medical visits or Outpatient
consultations in a Physician's office or patient's residence. A Physician's office can be defined as a medical/office building, Outpatient
department of a Hospital, freestanding clinic facility or a Hospital
based Outpatient clinic facility.
Open Enrollment Periods - those periods of time stated in the Group Contract
during which eligible employees of the Group may enroll.
Other Facility Provider - the following Institutions that are
licensed, when required, and where Covered Services are rendered that require compensation from their patients. Other than incidentally,
these facilities are not used as offices or clinics for the private practice of
a Physician or Other Professional Provider. CCP will
only provide benefits for services or supplies for which a charge is made. Only
the following Institutions that are defined below are considered to
be Other Facility Providers:
- Alcoholism Treatment Facility - a facility
that mainly provides detoxification and/or rehabilitation treatment for Alcoholism.
- Ambulatory Surgical Facility - a facility
with an organized staff of Physicians that has permanent facilities
and equipment for the primary purpose of performing surgical procedures strictly
on an Outpatient basis.Treatment must be provided by or under the
supervision of a Physician and also includes nursing services.
- Day/Night Psychiatric Facility - a facility
that is primarily engaged in providing diagnostic services and therapeutic services
for the Outpatient treatment of Mental Illness and Severe Mental Illness.These services are provided through either a day
or night treatment program.
- Dialysis Facility - a facility that
mainly provides dialysis treatment, maintenance or training to patients on an Outpatient or home care basis.
- Drug Abuse Treatment Facility - a facility
that mainly provides detoxification and/or rehabilitation treatment for Drug Abuse.
- Home Health Care Agency - a program
or organization authorized by law to provide health care services in the home. A
Home Health Care Agency is responsible for supervising the delivery of such services
under a plan prescribed and approved, in writing, by the attending Physician.
- Hospice Facility - a facility that provides
supportive care for terminally ill patients as specified in the Hospice Services
Section of this Certificate.
- Psychiatric Facility - a facility that
is primarily engaged in providing diagnostic services and therapeutic services for
the treatment of Mental Illness on an Outpatient basis.
- Psychiatric Hospital - a facility that
is primarily engaged in providing diagnostic services and therapeutic services for
the treatment of Mental Illness and Severe Mental Illness
on an Inpatient basis. Such services must be provided by or under
the supervision of an organized staff of Physicians. Continuous nursing
services must be provided under the supervision of a registered nurse.
- Skilled Nursing Facility - a facility
that primarily provides 24-hour Inpatient Skilled Care
and related services to patients requiring convalescent and rehabilitative care.
Such care must be provided by either a registered nurse, licensed practical nurse
or physical therapist performing under the supervision of a Physician.
Other Professional Provider - only the following persons or
entities which are licensed as required:
- advanced nurse practitioner (A.N.P.);
- doctor of chiropractic medicine;
- durable medical equipment or prosthetic appliance
vendor;
- licensed independent social workers (L.I.S.W.);
- licensed practical nurse (L.P.N.);
- licensed professional clinical counselor;
- licensed professional counselor;
- licensed vocational nurse (L.V.N.);
- mechanotherapist (licensed or certified prior
to November 3, 1975);
- registered nurse anesthetist; and
Outpatient - the status of a Covered Person who receives services or supplies
through a Hospital, Other Facility Provider, Physician
or Other Professional Provider while not confined as an Inpatient.
P (return to top of page)
Pharmacy - an Other Professional Provider that is a licensed
establishment where Prescription Drugs are dispensed by a pharmacist licensed under applicable state law.
Physician - a duly licensed doctor of medicine or osteopathy practicing within
the scope of such a license.
Prescription Drug (Federal Legend Drug) - any medication that by federal
or state law may not be dispensed without a Prescription Order.
Prescription Order - the request for medication by a Physician
appropriately licensed to make such a request in the ordinary course of professional practice.
Provider - means any Physician, dentist, Hospital,
pharmacist, Other Professional Provider or Other Facility Provider properly licensed, where required, to furnish health care services.
Psychologist - an Other Professional Provider who is a licensed
Psychologist having either a doctorate in psychology or a minimum of five years of clinical experience. In states where there is no licensure
law, the Psychologist must be certified by the appropriate professional body.
R (return to top of page)
Residential Treatment Facility –
- A facility that provides care on a 24 hour
a day, 7 days a week, live-in basis for the evaluation and treatment of residents
with psychiatric or chemical dependency disorders.
- The facility provides room and board as well
as providing an individual treatment plan for the chemical, psychological and social
needs of each of its residents.
- The facility meets all regional, state and
federal licensing requirements.
- The residential care treatment program is supervised
by a professional staff of qualified Physician(s), licensed nurses,
counselors and social workers.
- Residents do not require care in an acute or
more intensive medical setting.
Rider - a document that amends or supplements your coverage.
Routine Services - Services not considered Medically Necessary.
S (return to top of page)
Service Area - the geographic area served by CCP and that has been approved
by the appropriate regulatory agency. Contact CCP to determine the exact geographic area served. The Service Area
may change from time to time.
Severe Mental Illness - bipolar disorder, major depressive disorder, obsessive-compulsive
disorder, paranoid and other psychotic disorder, schizoaffective disorder, schizophrenia,
anxiety disorder, post traumatic stress disorder, depression in childhood and adolescence,
as these terms are defined in the most recent edition of the diagnostic and statistical
manual of mental disorders published by the American psychiatric association.
Skilled Care - care that requires the skill, knowledge or training of a Physician or a:
- licensed practical nurse; or
performing under the supervision of a Physician. In the absence of
such care, the Covered Person's health would be seriously impaired. Such care cannot be taught to or administered by a lay person.
Skilled Nursing Facility - a Skilled Nursing Facility that
has an agreement with CCP about payment for Covered Services or which is designated
by CCP as approved.
Specialist - a Physician or group of Physicians,
in other than family practice, general practice, internal medicine, pediatrics,
neonatology, obstetrics, gynecology or advanced practice nurses.
Surgery -
- the performance of generally accepted operative
and other invasive procedures;
- the correction of fractures and dislocations;
- usual and related preoperative and postoperative
care; or
- other procedures as reasonably approved by
CCP.
T (return to top of page)
Total Disability - a Covered Person's inability to perform all of the substantial
and material duties of his or her regular employment or occupation during the first year of disability. After the first year
of disability, Total Disability is defined as the complete inability of the employee
to engage in any employment or occupation, for wage or profit, for which the employee is qualified by reason of education, training or experience. A dependent
is considered totally disabled if they are unable to perform the normal activities of a person of like age and gender.
Transplant Center - a facility approved by CCP that is an integral part of
a Hospital and that:
- has consistent, fair and practical criteria
for selecting patients for transplants;
- has a written agreement with an organization
that is legally authorized to obtain donor organs; and
- complies with all federal and state laws and
regulations that apply to transplants covered under this Certificate.
U (return to top of page)
United States - all the states, the District of Columbia, the Virgin Islands,
Puerto Rico, American Samoa, Guam and the Northern Mariana Islands.
Urgent Care - any Condition, which is not an Emergency Medical Condition, that requires immediate attention.
Urgent Care Provider - an Other Professional Provider that
performs services for health problems that require immediate medical attention which
are not Emergency Medical Conditions.