UnitedHealthcare New Mexico Turquoise Care - Glossary

Abuse

Abuse happens when providers or members do things that do not follow good financial, business or medical standards. This can result in unnecessary costs and can result in payment for services or treatment that are not medically necessary. It can result in services that do not meet professionally recognized standards for health care. Costs that are not necessary because of bad management or practices.

Adult Care Home

A licensed residential care setting with seven or more beds for elderly or disabled people who need some additional supports. These homes offer supervision and personal care appropriate to the person’s age and disability.

Advance Directive

A written set of directions about how medical or mental health treatment decisions are to be made if you lose the ability to make them for yourself.

Adverse Benefit Determination

A decision your health plan can make to deny, reduce, stop or limit your health care services.

Appeal

If the health plan makes a decision you do not agree with, you can ask them to review it. This is called an “appeal.” Ask for an appeal when you do not agree with your health care service being denied, reduced, stopped or limited. When you ask your health plan for an appeal, you will get a new decision within 30 days. This decision is called a “resolution.” Appeals and grievances are different.

Behavioral Health Services

Behavioral health services may include behavior management, group, family and individual therapy and counseling, and emergency/crisis services.

Benefits

A set of health care services covered by your health plan.

Care Coordination

A service where a care coordinator or care manager helps organize your health goals and information to help you achieve safer and more effective care. These services may include, but are not limited to, identification of health service needs, determination of level of care, addressing additional support services and resources or monitoring treatment attendance.

Care Management

A service where a care manager can help you meet your health goals by coordinating your medical, social and behavioral health services and helping you find access to resources like transportation, healthy food and safe housing.

Care manager

A health professional who can help you meet your health goals by coordinating your medical, social and behavioral health services and helping you find access to sources like transportation, healthy food and safe housing.

Children's screening services

A medical examination to monitor how a child is developing. Screening services can help identify concerns and problems early. The screenings assess social/emotional behavior, vision and hearing, motor skills and coordination, cognitive abilities, language and speech.

Complaint

Dissatisfaction about your health plan, provider, care or services. Contact your health plan and tell them you have a “complaint” about your services. Complaints and appeals are different.

Copayment

 An amount you pay when you get certain health care services or a prescription.

County Department of Social Services (DSS)

The local (county) public agency that is responsible for determining eligibility for Medicaid.

Covered Services

Health care services that are provided by your health plan.

Durable Medical Equipment

Certain items (like a walker or a wheelchair) your doctor can order for you to use at home if you have an illness or an injury.

Early and Periodic Screening, Diagnostic and Treatment (EPSDT)

The Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit provides comprehensive and preventive health care services for children younger than age 21 who are enrolled in Medicaid.

A Medicaid benefit that provides comprehensive and preventive health care services for children under 21 who receive Medicaid. When children need medical care, services are not limited by United Healthcare Community Plan of New Mexico's coverage policies. Medicaid makes sure that members under age 21 can get the medical care they need, when they need it, including health care services to prevent future illnesses and medical conditions. 

Early Intervention

Services and support available to babies and young children with developmental delays and disabilities and their families. Services may include speech and physical therapy and other types of services.

Emergency Department Care

Care you receive in a hospital if you are experiencing an emergency medical condition.

Emergency Medical Condition

A situation in which your life could be threatened, or you could be hurt permanently if you do not get care right away.

Emergency Room (ER) or Emergency Department (ED)

Means a portion of the hospital where emergency diagnosis and treatment of illness or injury is provided.

Family Planning Services

You are covered for services that help you manage the timing of pregnancies. These include birth control products and procedures.

Formulary

A formulary (also called a Preferred Drug List) is a list of medicines that a health plan will cover.

Four Winds

United Healthcare Community Plan of NM provides program specifically for our Native American Population within Turquoise Care called “Four Winds”.

Fraud

When a person is dishonest on purpose. This means they know or should know that what they are doing could result in some benefit to them or another person that they are not supposed to get.

Grievance

A grievance is an issue or problem you have with your health plan, provider or health services. If you are unhappy with the care you are getting, you or someone acting for you can file a grievance with UnitedHealthcare. You can also file a grievance if you are not happy with UnitedHealthcare.

Habilitation Services and Devices

Health care services 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 and medical costs. Your Medicaid coverage is a type of insurance.

Health Plan

The Company providing you with health care services.

Home Health Care

Certain services you receive outside a hospital or a nursing home to help with daily activities of life, like home health aide services, skilled nursing or physical therapy services.

Hospice Services

Special services for patients and their families during the final stages of terminal illness and after death. Hospice services include certain physical, psychological, social and spiritual services that support terminally ill individuals and their families or caregivers.

Hospital Outpatient Care

Services you receive from a hospital or other medical setting that do not require hospitalization.

Hospital Services

You’re covered for hospital stays. You’re also covered for outpatient services. These are services you get in the hospital without spending the night.

Hospitalization

Admission to a hospital for treatment that lasts more than 24 hours.

In-network provider or participating provider

A provider that is in your health plan’s provider network.

Institution

A Health care facility or setting that may provide physical and/or behavioral supports. Some examples include, but are not limited to, Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF-IID), Skilled Nursing Facility (SNF) and Adult Care Home (ACH).

Laboratory services

Covered services include tests and X-rays that help find the cause of illness. 

Lead Testing

The doctor will need to do a blood test to make sure your child does not have too much lead. Your child should be checked at 12 months and 24 months of age or if they have never been checked. 

Legal Guardian or Legally Responsible Person

A person appointed by a court of law to make decisions for an individual who is unable to make decisions on their own behalf (most often a family member or friend unless there is no one available, in which case a public employee is appointed).

Local Management Entity/Managed Care Organization (LME-MCO)

The organization providing behavioral health services to beneficiaries in the NM Turquoise Care program.

LTSS

Care provided in the home, in community-based settings or in facilities to help individuals with certain health conditions or disabilities with day-to-day activities. LTSS includes services like home health and personal care services. LTSS is not covered for children receiving NM Turquoise Care.

Managed Care

A health care program where New Mexico contracts with health plans, called managed care organizations (MCOs), to arrange for integrated and coordinated physical, behavioral health and other health services for Medicaid and NM Turquoise Care beneficiaries.

Medicaid

Medicaid is a health coverage program. The program helps some families or individuals who have low income or serious medical problems. It is paid with federal, state and county dollars and covers many physical health, behavioral health.

Medically Necessary

Medical services, treatments or supplies that are needed to diagnose or treat an illness, injury, condition, disease or its symptoms and that meet accepted standards of medicine.

Medicines

Your plan covers prescription drugs for members of all ages. Also covered: insulin, needles and syringes, birth control, coated aspirin for arthritis, iron pills and chewable vitamins.

Member

A person enrolled in and covered by a health plan.

Network Provider

A group of doctors, hospitals, pharmacies and other health professionals who have a contract with your health plan to provide health care services for members.

Non-Covered Services

Those medical and health care services, equipment and supplies which are not covered by your plan.

Non-Emergency Medical Transportation (NEMT)

Transportation your plan can arrange to help you get to and from your appointments, including personal vehicles, taxis, vans, mini-buses, mountain area transports and public transportation.

Ongoing course of treatment

When a member, in the absence of continued services, reflected in a treatment or service plan or as otherwise clinically indicated, would suffer serious detriment to their health or be at risk of hospitalization or institutionalization.

Ongoing special condition

A condition that is serious enough to require treatment to avoid possible death or permanent harm. A chronic illness or condition that is life-threatening, degenerative, or disabling and requires treatment over an extended period. This definition also includes pregnancy in its second or third trimester, scheduled surgeries, organ transplants, scheduled inpatient care or being terminally ill.

Out-of-network provider or non-participating provider

A provider that is not in your health plan’s provider network.

Palliative care

Specialized care for a patient and family that begins at diagnosis and treatment of a serious or terminal illness. This type of care is focused on providing relief from symptoms and stress of the illness with the goal of improving quality of life for you and your family.

Personal Care Services

When your child’s doctor wants a caregiver to help your child with eating, bathing, dressing and toileting. 

Physician

A person who is qualified to practice medicine.

Physician Services

Health care services you receive from a physician, nurse practitioner or physician assistant.

Plan

Company providing you with health care services.

Postnatal

Pregnancy health care for a mother who has just given birth to a child.

Pre-authorization

Means approval necessary prior to the receipt of care. May also be referred to as prior authorization or precertification.

Preferred Drug List (PDL)

This is a list of drugs covered under your plan. You can find the complete list in your formulary, or online at myuhc.com/communityplan/nm.

Premium

The amount you pay for your health insurance every month. Most Medicaid and NM Turquoise Care beneficiaries do not have a premium.

Prenatal care

Pregnancy health care for expectant mothers, prior to the birth of a child.

Prescription Drug Coverage

Refers to how the health plan helps pay for its members’ prescription drugs and medications.

Prescription Drugs

A drug that, by law, requires a provider to order it before a beneficiary can receive it.

Primary Care

Services from a primary care provider that help you prevent illness (check-up, immunization) to manage a health condition you already have (like diabetes).

Primary Care Provider (PCP) or Primary Care Physician

The doctor or clinic where you get your primary care (immunizations, well-visits, sick visits). Your PCP should also be available after hours and on weekends to give you medical advice. They also refer you to specialists (cardiologists, behavioral health providers) if you need it. Your PCP should be your first call for care before going to the emergency room.

Primary care services

You are covered for all visits to your Primary Care Provider (PCP). Your PCP is the main doctor you will see for most of your health care. This includes checkups, treatment for colds and flu, health concerns and health screenings.

Private duty nursing

When your child’s doctor wants a nurse to provide care at home or at school. 

Provider

A health care professional or a facility that delivers health care services, like a doctor, hospital or pharmacy.

Provider Directory

The directory lists addresses and phone numbers of our in-network providers.

Referral

A documented order from your provider for you to see a specialist or receive certain medical services.

Rehabilitation Services and Devices

Health care services and equipment that help you recover from an illness, accident, injury or surgery. These services can include physical or speech therapy.

Service Limit

The maximum amount of a specific service that can be received.

Skilled Nursing Care

Health care services that require the skill of a licensed nurse.

Specialist services

A provider who is trained and practices in a specific area of medicine.

State Fair Hearing

When you do not agree with your health plan’s resolution, you can ask for the State of NM HSD to review it.

Substance use

A medical disorder that includes the misuse or addiction to alcohol and/or legal or illegal drugs.

Telehealth

Use of two-way real-time interactive audio and video to provide and support health care services when participants are in different physical locations.

Transition of care

Process of assisting you to move between health plans or to another Medicaid program. The term Transition of Care also applies to the assistance provided to you when your provider is not enrolled in the health plan.

Urgent Care

Care for a health condition that needs prompt medical attention but is not an emergency medical condition. You can get urgent care in a walk-in clinic for a non-life-threatening illness or injury.

Value added benefits

United Healthcare will provide extra services called “Value Added Benefits”. These are extra benefits are offered outside of regular Medicaid benefits.