Member FAQs
Q: What is capitation?
A: A method of payment which UnitedHealthcare
compensates participating providers. This capitation payment
is made to those participating providers regardless of whether
or not a member accesses care.
Q: What is 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 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
UnitedHealthcare 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 are 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 UnitedHealthcare
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 participating provider?
A: A hospital, physician, facility or
other health care provider who has entered into a written agreement
with UnitedHealthcare to provided services, treatment an supplies
for covered services.
Q: What is 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 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 is 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: Can I change my Primary Care Physician?
A: Yes, you have that option once a month.
Simply call UnitedHealthcare Customer Service. If your request
is received on or before the 15th of the month, your change
will be effective the next month. After the 16th, your change
will take place the 1st of the second month.
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. |
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