Rocky Mountain Health Plans - Child Health Plan Plus (CHP+) - Glossary

Accidental injuries

Unintentional internal or external injuries, examples of accidental injuries are strains, animal bites, burns, contusions, and abrasions (cuts) that result in trauma to the body. Accidental injuries are different from illness-related conditions (being sick) and do not include disease or infection.

Acute care

Short-term medical treatment provided under the direction of a physician, usually in an acute care hospital for members having an acute illness or injury.

Admission

The period of time between the date a patient enters a facility as an inpatient and the date he or she is discharged as an inpatient.

Adverse decision

Includes any of the following: The denial or limited authorization of a requested service, including determinations based on the type or level of service, requirements for medical necessity, appropriateness, setting or effectiveness of a covered benefit. 

• The reduction, suspension or termination of a previously authorized service 
• The denial, in whole or in part, of payment for a service 
• The failure to provide services in a timely manner (as determined by the State) 
• The failure of RMHP to act within the timeframe required for the standard resolution of grievances and appeals 
• For a resident in a rural area with only one health plan, the denial of an enrollee’s request to exercise his or her right to obtain services outside the network 
• The denial of an enrollee's request to dispute financial liability, including cost sharing, copayments, premiums, deductibles, coinsurance, and other enrollee financial liabilities 

After-hours care

Office services requested after a provider's normal or published office hours or services requested on weekends and holidays.

Alcoholism and substance abuse

Conditions defined by usage that continue despite occupational, social, or physical problems. Abuse means an unusually excessive use of alcohol or other substances. These conditions may also be recognized by severe withdrawal symptoms if the use of alcohol or other substances is stopped.

Alcoholism and substance abuse

Conditions defined by usage that continue despite occupational, social, or physical problems. Abuse means an unusually excessive use of alcohol or other substances. These conditions may also be recognized by severe withdrawal symptoms if the use of alcohol or other substances is stopped.

Ambulance

A specially designed and equipped vehicle used only for transporting the sick and injured. It must have customary safety and lifesaving equipment such as first aid supplies and oxygen equipment. The vehicle must be operated by trained personnel and licensed as an ambulance.

Ancillary services

Services and supplies (in addition to room expenses) that hospitals and other facilities bill for. Such services include, but are not limited to, the following: 

• Use of an operating room, recovery room, emergency room, treatment rooms, and related equipment; intensive and coronary care units 
• Drugs/medication and medicines, biologics (medicines made from living organisms and their products) and pharmaceuticals 
• Medical supplies (dressings and supplies, sterile trays, casts, and splints used instead of a cast) 
• Durable medical equipment owned by the facility and used during a covered admission 
• Diagnostic and therapeutic services 
• Blood processing and transportation and blood handling costs and administration 
• Anesthesia — There are two different types of anesthesia:
  • General anesthesia, also known as total body anesthesia, causes the patient to become unconscious or put to sleep for a period of time 
  • Regional or local anesthesia causes loss of feeling or numbness in a specific area without causing loss of consciousness and is usually injected with a local anesthetic drug such as Lidocaine. Anesthesia must be administered by a provider or certified registered nurse anesthetist (CRNA). 

Appeal

A review by RMHP of an adverse decision, usually regarding a member's claim or pre-authorization request.

Audiology services

The testing for hearing disorders through identification and evaluation of hearing loss.

Authorization

Approval of benefits for a covered procedure or service. See also Pre-authorization.

Billed charges

The dollar amount a provider bills for services or supplies before any applicable in-network provider discounts or adjustments.

Calendar year

A period of a year that begins January 1st and ends on December 31st.

Care Management

The process that assists enrollees to access necessary covered services that are identified in the care plan. It also provides referral and coordination of other services to support your care plan.

Care manager/case manager

A professional (for example, nurse, doctor or social worker) who works with members, providers and RMHP to coordinate services deemed medically necessary for the member.

Chemical dependency

Dependence on either alcohol and/or other substances; for example, drugs. See also Substance abuse.

Chemotherapy

Medication therapy administered as treatment for malignant conditions and diseases of certain body systems.

Chiropractic services

A system of therapy in which disease is considered the result of abnormal function of the nervous system. This method of treatment usually involves manipulation of the spinal column and specific adjustment of body structures.

Chronic pain

Ongoing pain that lasts more than six months that is due to non-life threatening causes and has not responded to current available treatment methods. Chronic pain can continue for the remainder of a person's life.

Complaint

An expression of dissatisfaction with RMHP or the practices of an in-network provider, whether medical or non-medical in nature. This is sometimes also called a grievance.

Consultation

A visit between a provider and a patient to determine what medical examinations or procedures, if any, are appropriate and needed.

Copayment

A dollar amount you pay in order to receive a specific service, supply, or prescription medication. A copayment is a predetermined fixed amount paid at the time the service is rendered. The copayment amount is printed on each member's ID card. 

Cost sharing

The general term used for out-of-pocket expenses paid by a member. A copayment is a type of cost sharing.

Covered services

Services, supplies or treatments that are: 

• Medically necessary or otherwise specifically included as a benefit as shown in the CHP+ Member Handbook 
• Within the scope of the license of the provider performing the service 
• Rendered while coverage under this CHP+ Member Handbook is in force 
• Not experimental/investigational or otherwise excluded or limited by the CHP+ Member Handbook, or by any amendment made to the handbook or rider added to the handbook 
• Authorized in advance by RMHP if such pre-authorization is required

Dental services

Services performed for treatment of conditions related to the teeth or structures supporting the teeth.

Detoxification

Acute treatment for withdrawal from the physical effects of alcohol or another substance.

Diagnostic services

Tests or services ordered by a provider to determine the cause of illness.

Dialysis

The treatment of acute or chronic kidney ailment. During dialysis, impurities are removed from the body with dialysis equipment.

Discharge planning

The evaluation of a patient's medical needs and arrangement of appropriate care after discharge from a facility.

Durable medical equipment (DME)

Any equipment that can withstand repeated use, is made to serve a medical condition, is useless to a person who is not ill or injured and is appropriate for use in the home.

Emergency or Emergency medical condition

The sudden, and at the time, unexpected onset of a health condition that requires immediate medical attention where failure to provide medical attention would result in serious impairment to bodily functions or serious dysfunction of a bodily organ or part or would place the person's health in serious jeopardy.

Emergency services

Covered inpatient and outpatient services and are furnished by a Provider that is qualified to furnish these services under the term "emergency services" and that are needed to evaluate or stabilize an emergency medical condition.

Emergency transportation

See the definition of Ambulance.

Experimental or investigative procedures or services

a. Any drug/medication, biologic, device, diagnostic, product, equipment, procedure, treatment, service or supply used in or directly related to the diagnosis, evaluation or treatment of a disease, injury, illness or other health condition that RMHP determines, in its sole discretion, to be experimental or investigational. RMHP will deem any drug/medication, biologic, device, diagnostic, product, equipment, procedure, treatment, service or supply to be experimental or investigational if it determines that one or more of the following criteria apply when the service is rendered with respect to the use for which benefits are sought.

• The drug/medication, biologic, device, diagnostic, product, equipment, procedure, treatment, service or Is provided pursuant to informed consent documents that describe the drug/medication, biologic, device, diagnostic, product, equipment, procedure, treatment, service or supply as experimental or investigational, or otherwise indicate that the safety, toxicity or efficacy of the drug/medication, biologic, device, diagnostic, product, equipment, procedure, treatment, service or supply is under evaluation

b. Any service not deemed experimental or investigational based on the criteria in subsection (a) may still be deemed to be experimental or investigational by RMHP. In determining if a service is experimental or investigational, RMHP will consider the information described in subsection (c) and assess all of the following:

• Whether the scientific evidence is conclusory concerning the effect of the service on health outcomes
• Whether the evidence demonstrates that the service improves the net health outcomes of the total population for whom the service might be proposed as any established alternatives
• Whether the evidence demonstrates the service has been shown to improve the net health outcomes of the total population for whom the service might be proposed under the usual conditions of medical practice outside clinical investigatory settings

c. The information RMHP considers or evaluates to determine if a drug/medication, biologic, device, diagnostic, product, equipment, procedure, treatment, service or supply is experimental or investigational under subsections (a) and (b) may include one or more items from the following list, which is not all-inclusive:

• Randomized, controlled, clinical trials published in an authoritative, peer-reviewed United States medical or scientific journal
• Evaluations of national medical associations, consensus panels, and other technology evaluation bodies
• Documents issued by and/or filed with the FDA or other federal, state or local agency with the authority to approve, regulate or investigate the use of the drug/medication, biologic, device, diagnostic, product, equipment, procedure, treatment, service or supply
• Documents of an IRB or other similar body performing substantially the same function
• Consent documentation(s) used by the treating providers, other medical professionals or facilities, or by other treating providers, other medical professionals or facilities studying substantially the same drug/medication, biologic, device, diagnostic, product, equipment, procedure, treatment, service or supply
• The written protocol(s) used by the treating providers, other medical professionals or facilities or by other treating providers, other medical professionals or facilities studying substantially the same drug/medication, biologic, device, diagnostic, product, equipment, procedure, treatment, service or supply
• The opinions of consulting providers and other experts in the field

d. RMHP has the sole authority and discretion to identify and weigh all information and determine all questions pertaining to whether a drug/medication, biologic, device, diagnostic, product, equipment, procedure, treatment, service or supply is experimental or investigational.

Explanation of benefits

Also known as an EOB. An EOB is a printed form sent by an insurance company to a member after a claim has been filed and a decision has been made about the claim. The EOB includes such information as the date of service, name of provider, amount covered and patient balance.

Generic drug

The chemical equivalent of a brand name prescription medication. By law, brand name and generic medications must meet the same standards for safety, purity, strength and quality.

Grievance

An oral or written expression of dissatisfaction about any matter other than an adverse decision. Grievances may include the quality of care or services provided, the practices of an in-network provider, whether medical or non-medical in nature. A grievance also includes a member's right to dispute an extension of time proposed by RMHP to make an authorization decision. A grievance is sometimes also called a complaint.

Habilitative services and devices

Those services that will help a person retain, learn, or improve skills and functions for daily living.

Home health services

This is also called home health care. These are professional nursing services, certified nurse aide services, medical supplies, equipment and appliances suitable for use in the home, and physical therapy, occupational therapy, speech pathology, and audiology services provided by a certified home health agency to eligible members, who are under a plan of care, in their place of residence.

Hospice agency

An agency licensed by the Colorado Department of Public Health and Environment to provide hospice care in Colorado. A hospice is a centrally administered program of palliative (care that controls pain and relieves symptoms), supportive and interdisciplinary team services providing physical, psychological, spiritual, and sociological care for terminally ill individuals and their families, within a continuum of inpatient care, home health care and follow-up bereavement services available 24 hours a day, 7 days a week.

Hospice care

An alternative way of caring for terminally ill individuals that stresses palliative care. Hospice care focuses on the patient/family as the unit of care. Supportive services are offered to the family before and after the death of the patient. Hospice care addresses physical, social, psychological, and spiritual needs of the patient and the patient's family.

Hospital

A health institution offering facilities, beds, and continuous services 24 hours a day and that meets all licensing and certification requirements of local and state regulatory agencies.

Hospital outpatient care

Is when care is administered in a hospital facility without an overnight stay.

Hospitalization

Those Medically Necessary Covered Services for patients that are generally and typically provided by acute care general Hospitals. Hospital Services shall also include services rendered in the emergency room and/or the outpatient department of any Hospital. Except for a Medical Emergency or Written Referral, Hospital Services are Covered Services only when completed by Participating Providers.

ID Card

The card RMHP gives members with information such as the member’s name, and ID number, and copayment level. This is also known as the RMHP CHP+ member ID card.

Implantable birth control device

Device inserted underneath the skin that prevents pregnancy.

Inpatient medical rehabilitation

Care that includes a minimum of three hours of therapy, for example, speech therapy, respiratory therapy, occupational therapy, and/or physical therapy, and often some weekend therapy. Inpatient medical rehabilitation is generally provided in a rehabilitation section of a hospital or at a freestanding facility. Some skilled nursing facilities have rehabilitation beds.

IUD

Stands for intra-uterine device, a birth control device inserted into the uterus to prevent pregnancy.

Keratoconus

Cone-shaped protrusion of the cornea.

Laboratory and pathology services

Testing procedures required for the diagnosis or treatment of a condition. Generally, these services involve the analysis of a specimen of tissue or other material that has been removed from the body.

Long-term acute care facility

An institution that provides an array of long-term crucial care services to patients with serious illnesses or injuries. Long-term acute care is provided for patients with complex medical needs. These include patients with high risk pulmonary conditions who have ventilator or tracheotomy needs or who are medically unstable, patients with extensive wound care needs or postoperative surgery wound care needs, and patients with low-level, closed-head injuries. Long-term acute care facilities do not provide care for low-intensity patient needs.

Maternity services

Maternity services — Services required by a patient for the diagnosis and care of a pregnancy, complications of pregnancy, and for delivery. Delivery services include: 

• Normal vaginal delivery, 
• Cesarean section delivery, 
• Spontaneous termination of pregnancy before full term, and 
• Therapeutic or elective termination of pregnancy provided the termination is to save the life of the mother or the pregnancy is the result of rape or incest.

Maximum medical improvement

A determination at RMHP's sole discretion that no further medical care can reasonably be expected to measurably improve a patient’s condition. Maximum medical improvement shall be determined without regard to whether continued care is necessary to prevent deterioration of the condition or is otherwise life sustaining.

Medical care

Non-surgical health care services provided for the prevention, diagnosis, and treatment of illness, injury, and other general conditions.

Medical supplies

Items (except prescription medications) required for the treatment of an illness or injury.

Member

Any person who is enrolled for coverage with CHP+ with RMHP as his/her CHP+ health plan.

Mental health condition

Non-biologically based mental conditions that have a psychiatric diagnosis or that require specific psychotherapeutic treatment, regardless of the underlying condition (for example, depression secondary to diabetes or primary depression). RMHP defines mental health conditions based on the American Psychiatric Association's guidelines.

Nutrition assessment/counseling

Medical nutrition therapy provided by a qualified nutrition professional such as a registered dietitian without training in pediatric nutrition. Medical nutrition therapy includes nutrition assessment, support, and counseling to determine a treatment plan to increase nutritional intake to promote adequate growth, healing and improved health.

Occupational therapy

The use of educational and rehabilitative techniques to improve a patient's functional ability to live independently. Occupational therapy requires that a properly accredited occupational therapist (OT) or certified occupational therapy assistant (COTA) perform such therapy.

Organ transplants

A surgical process that involves the removal of an organ from one person and placement of the organ into another person. Transplant can also mean removal of body substances, such as stem cells or bone marrow, for the purpose of treatment and re-implanting the removed organ or tissue into the same person.

Orthotic

A support or brace for weak or ineffective joints or muscles.

Out-of-area services

Covered services provided to an RMHP CHP+ member when he or she is outside the service area.

Out-of-network provider or non-participating provider

An appropriately licensed health care provider that has not contracted with RMHP. Services provided by an out-of-network provider may not be covered unless a pre-authorization is obtained. A member may be financially responsible for services performed by an out-of-network provider unless stated otherwise in the CHP+ Member Handbook, or the services are approved (authorized) by RMHP.

Outpatient medical care

Non-surgical services provided in a provider's office, the outpatient department of a hospital or other facility, or the patient's home.

Overweight/obesity

Weight for height at greater than the 95th percentile or Body Mass Index (BMI) greater than the 95th percentile. Obesity in children has long-term consequences that become major health issues later in life. Treatment plans are standard pediatric weight management programs medically supervised by medical professional seldom using surgical or pharmacological interventions due to the long-term side effects of these treatments.

Palliative care

Care that controls pain and relieves symptoms, but does not cure.

Physical therapy

The use of physical agents to treat a disability resulting from disease or injury. Physical agents used include heat, cold, electrical currents, ultrasound, ultraviolet radiation, massage, and therapeutic exercise. A provider or registered physical therapist must perform physical therapy.

Physician

A doctor of medicine or osteopathy who is licensed to practice medicine under the laws of the state or jurisdiction where the services are provided.

Physician services

Services provided by an individual licensed under state law to practice medicine or osteopathy.

Plan

An individual or group plan that provides or pays the cost of medical care.

Pre-authorization

A process during which requests for procedures, services or certain prescription medications are reviewed prior to being rendered, for approval of benefits, length of stay, appropriate location, and medical necessity. For prescription medications, the designated RMHP pharmacy and therapeutics committee defines the medications and criteria for coverage, including the need for pre-authorization for certain medications.

Preventive care

Comprehensive care that emphasizes prevention, early detection and early treatment of conditions through routine physical exams, immunizations, and health education.

Primary Care Provider, Primary Care Physician or PCP (stands for Primary Care Provider)

It is the appropriately licensed and credentialed provider who has contracted with RMHP to supervise, coordinate, and provide initial and basic care to members, refer patients to other providers including specialists, and maintain continuity of patient care.

Provider

A person or facility that is recognized by RMHP as a health care provider and fits one or more of the following descriptions:

• Professional provider — A provider who is licensed or otherwise authorized by the state or jurisdiction where services are provided to perform designated health care services. For benefits to be payable, services of a provider must be within the scope of the authority granted by the license and covered by the handbook. Such services are subject to review by a medical authority appointed by RMHP. Other professional providers include, among others, certified nurse-midwives, dentists, optometrists, and certified registered nurse anesthetists. Services of such a provider must be among those covered by the handbook and are subject to review by a medical authority appointed by RMHP.
• Facility provider — An inpatient and outpatient facility provider, as defined below:
• Inpatient facility provider is a hospital, substance abuse treatment center, residential facility, hospice facility, skilled nursing facility or other facility that RMHP recognizes as a health care provider. These facility providers may be referred to collectively as a facility provider or separately as a substance abuse treatment center provider.
• Outpatient facility provider is a dialysis center, home health agency or other facility provider such as an ambulatory surgery center (but not a hospital, substance abuse treatment center or hospice facility, skilled nursing facility or residential treatment center) recognized by RMHP and licensed or certified to perform designated health care services by the state or jurisdiction where services are provided. Services of such a provider must be among those covered by this certificate and are subject to review by a medical authority appointed by RMHP.

Radiation therapy

X-ray, radon, cobalt, betatron, telocobalt, radioactive isotope, and similar treatments for malignant diseases and other medical conditions.

Reconstructive surgery

Surgery that restores or improves bodily function to the level experienced before the event that necessitated the surgery or in the case of a congenital defect, to a level considered normal. Reconstructive surgery may have a coincidental cosmetic effect.

RMHP participating provider

Also known as an in-network provider. This is a professional health care provider or facility (for example, a provider, hospital or home health agency) that contracts with RMHP to provide services to RMHP members. In-network providers agree to bill RMHP directly for services provided and to accept the payment amount (provided in accordance with the provisions of the contract) and a member's copayment as payment in full for covered services. RMHP pays the in-network provider directly. RMHP may add, change or delete specific providers at its discretion or recommend a specific provider for specialized care as medically necessary for the member.

RMHP service area

The geographic area where enrollment in RMHP CHP+ is available.

Routine care

Services for conditions not requiring immediate attention and that can usually be received in the PCP's office, or services that are usually done periodically within a specific time frame (for example, immunizations and physical exams).

Second opinion

A visit to another professional provider (following a first visit with a different provider) for review of the first provider's opinion of proposed surgery or treatment.

Skilled nursing care facility

An institution that provides skilled nursing care (for example, therapies and protective supervision) for patients with uncontrolled, unstable or chronic conditions. 

Skilled nursing care is provided under medical supervision to carry out non-surgical treatment of chronic diseases or convalescent stages of acute diseases or injuries. Skilled nursing facilities do not provide care for patients with high intensity medical needs, or for patients who are medically unstable.

Special care units

Special areas of a hospital with highly skilled personnel and special equipment to provide acute care, with constant treatment and observation.

Specialist

A professional, usually a provider, devoted to a specific disease, condition or body part (for example, an orthopedist is someone who specializes in the treatment of bones and muscles).

Speech therapy (also called speech pathology)

Services used for the diagnosis and treatment of speech and language disorders. A licensed and accredited speech/language pathologist must perform speech therapy.

Substance abuse treatment center

A detoxification and/or rehabilitation facility licensed by the state to treat alcoholism and/or drug abuse.

Surgery

Any variety of technical procedures for treatment or diagnosis of anatomical disease or injury, including but not limited to, cutting, microsurgery (use of scopes), laser procedures, grafting, suturing, castings, treatment of fractures and dislocations, electrical, chemical or medical destruction of tissue, endoscopic examinations, anesthetic epidural procedures, and other invasive procedures. Covered surgical services also include usual and related anesthesia and pre- and post-operative care, including recasting.

Urgent care

Care provided for individuals who require immediate medical attention but whose condition is not life threatening (non-emergency).

Utilization management

Is the evaluation of the appropriateness, medical need and efficiency of health care services procedures and facilities according to established criteria or guidelines and under the provisions of this plan's benefits.