Q: What is a copayment?
A: A fee that can be a fixed dollar amount or percentage charged to members or insured for covered services or covered expenses; usually paid to the provider at the time service is rendered.

Q: What is credentialing?
A: The process of reviewing potential health care providers' credentials to determine if they meet the standards of the Medical Group and UnitedHealthcare. Both UnitedHealthcare and the Medical Group consist of credential physicians.

Q: What is a deductible?
A: This is the amount of covered charges that the subscriber and/or the subscriber's eligible dependents must meet for the calendar or plan year for services before PacifiCare pays any benefits.

Q: What is fee-for-service?
A: Traditional method for paying providers based on the fee for each service, without any negotiated discounts.

Q: What is formulary?
A: The list of drugs chosen by a health plan to treat patients. Drugs outside the formulary are not used except in specified circumstances.

Q: What is limited fee schedule?
A: A comprehensive listing of fees used as a standard to reimburse physicians and other health care providers.

Q: What is Health Maintenance Organization (HMO)?
A: A form of prepaid health insurance that generally includes comprehensive health care benefits with a focus on wellness and preventive care.

Q: What is out-of-pocket costs?
A: The amount of payment made by the member for health care services (not including health care premiums).

Q: What is participating medical group/independent practice association?
A: An Independent Practice Association (IPA) or Medical Group of licensed doctors of medicine or osteopathy which has entered into a written agreement with PacifiCare to provide medical services to Members and their eligible dependents. A Medical Group employs physicians who typically all work at one physical location. An IPA contracts with independent contractor physicians who typically work at different office sites.

Q: What is a participating provider?
A: A hospital, physician, facility or other health care provider who has entered into a written agreement with PacifiCare to provided services, treatment an supplies for covered services.

Q: What are Point-of-Service (POS)?
A: A health care plan that offers members the flexibility to choose how to receive health care services. Services are covered either in-network or out-of-network. In-network provides coverage similar to standard HMO coverage, featuring comprehensive health care services with lower out-of-pocket costs. Out-of-network benefits typically have limited coverage and higher out-of-pocket costs.

Q: What is Preferred Provider Organization (PPO)?
A: Health care plan where members may choose to receive care from any provider but are encouraged to use the preferred network of contracted providers by offering lower copays.

Q: What is a premium?
A: A fee that is paid by the employer or individual member or on behalf of the member for health care coverage. This fee is usually paid monthly.

Q: What is preventive care?
A: Health care that places a high priority and emphasis on maintaining the health of members, featuring early detection of illness and disease through routine physicals, regular health screenings, immunizations, and well baby care, among others.

Q: What are Primary Care Physicians (PCP)?
A: The physician responsible for coordinating the member's health care. PCPs are typically Family/General Practitioners, Internists, Pediatricians, or Gynecologists (OB/GYNs).

Q: What is usual, customary and reasonable (UCR)?
A: The maximum reimbursement, which is based upon historical fee patterns and is sometimes referred to as U&C.