B
balance
billing
The difference between the health care provider's fee and the Usual,
Customary and Reasonable (UCR) Charge. Occurs when the UCR amount
determined is less than the physician’s fee for a procedure.
This means the balance of unpaid charges may have to be paid even
if any applicable deductible has been met. Balance billing may be
avoided by choosing a network provider if enrolled in a network plan
(Prime Care Advantage, Prime Advantage Value, Prime Advantage Plus), or an MMO Traditional Provider when enrolled in
Prime Advantage Plus, Independent Choice, or the Out-of-Area Plan..
C
coinsurance
The percentage of the charge, if any, you pay for covered health care
services (not paid by the plan).
copay
The flat dollar amount you pay for covered health care services (not
paid by the plan).
covered
services
A service or supply given by a provider for which benefits will be
provided. A covered service may be subject to an annual deductible,
copayment or coinsurance. To be a covered service, services must be:
• Authorized by a physician;
• Medically necessary, except as otherwise specified in this
booklet;
• Consistent with the condition(s) for which you were admitted
when an inpatient; and,
• Within the scope of the license of the provider performing
the service.
D
deductible
Amount you pay before insurance coverage begins to pay. Restarts with
each plan year.
dependent
children
Dependent children may include:
.
Natural-born, adopted, and step children
. Legal guardianship
. Court-ordered
Note that medical,
dental, vision, and Dependent Group Life Insurance coverage for dependent
children ends when the child no longer meets dependency guidelines,
or on the child's twenty-third birthday (age limits may vary based
on program provisions).
diagnostic
services
Tests and procedures performed when you have specific symptoms to
detect or to monitor your disease or condition. Diagnostic services
include, but are not limited to, the following: X-ray and other radiology
services; laboratory and pathology services; cardiographic, encephalographic
and radioisotope tests.
disability
An illness or injury that makes it difficult or impossible to perform
your job duties.
E
effective
date
The date on which your coverage begins.
eligible
expenses
Expenses for covered services that are incurred by a covered person.
Eligible expenses do not include expenses in excess of the MHCS fee
schedule, UCR or the provider's reasonable charge.
emergency
care
Service and treatment provided in the outpatient emergency department
of a hospital or other provider. Emergency care is defined as follows:
•
An unexpected external injury, or
• A serious medical condition (caused by sickness or pregnancy)
that is sudden and
requires immediate care and treatment, or
• A serious medical condition requiring relief or elimination
of acute pain, other than
acute dental pain.
Explanation
of Benefits (EOB)
Detailed information of how your health claim was processed. Shows
the date of service, provider's name, billed amount, amount insurance
paid, and amount that is your responsibility to pay.
Evidence
of Insurability
Medical information that proves your health and insurability status.
May be required when you enroll in a plan after the initial eligibility
period.
F
family
status change
One of two types of qualifying status changes that allow eligible
employees to change benefit elections. Family status changes include:
marriage, divorce, childbirth, adoption of a child, death of a spouse/dependent,
or a dependent child reaching the age limit. Documentation of the
status change may be required.
fee
schedule
The reimbursement amounts as determined by OSU Managed Health Care
Systems (MHCS) for payment of covered services rendered by in-network
providers.
full
time equivalent (FTE)
FTE is the percentage of time an employee works, with 100% being
full-time.
I
incurred
date
The date on which a covered person receives the service or supply
for which the charge is made.
inpatient
A covered person admitted to a hospital or other facility for at least
one overnight stay as a registered inpatient.
M
maternity
services
Services for normal pregnancy, complications of pregnancy, miscarriage
and therapeutic abortions.
medical/prescription
drug identification card
The card on which you will be given your identification number and
that you must present to your medical or prescription drug provider
in order to verify your coverage.
medically
necessary
In order for covered services to be paid, the services must be medically
necessary. It is the criteria used by NGS and MHCS to determine the
medical necessity of medical services explained in this booklet. To
be medically necessary, covered services must also be provided at
the most appropriate level of care and in the most appropriate type
of health care facility. Only your medical condition (not the financial
status or family situation, the distance from a facility or any other
non-medical factor) is considered in determining which level of care
or type of health care facility is appropriate. To be medically necessary,
covered services must:
•
Be rendered in connection with an injury or sickness;
• Be consistent with the diagnosis and treatment of your condition;
• Be in accordance with the standards of good medical practice;
• Not be considered experimental or investigative; and
• Not be for your convenience or your physician's convenience.
Note: Any service failing to meet the medical necessity criteria will
be the covered employee's liability.
Managed
Health Care Systems (MHCS)
OSU Managed Health Care Systems, Inc.
MHCS
Fee Schedule
The reimbursement amounts as determined by MHCS for payment of covered
services rendered by in-network providers.
Medical
Mutual of Ohio (MMO) SuperMed Plus
Prime Care Advantage, Prime Advantage Value, and Prime Advantage Plus members must use MMO's SuperMed Plus network
when using providers outside Franklin County. You must use MHCS network providers
within Franklin County.
Medical
Mutual of Ohio (MMO) Traditional Provider
The university has contracted with MMO to allow those enrolled in
the Prime Advantage Plus, Independent Choice, or the Out-of-Area Plan to use providers who are
part of the MMO Traditional Provider Group. MMO Traditional Providers
agree to accept the allowed amount as payment in full. You will only
be responsible for any applicable out-of-pocket expenses. You may
receive more information about this program by contacting MMO or speaking
with your provider.
N
network
Refers to a list of health care providers who have a service contract
in effect with the health plan administrators.
network
physician or provider
A physician, provider or group that has a network service contract
in effect with MHCS to provide services under the Prime Care Advantage, Prime Advantage Value, or Prime Advantage Plus
network inside Franklin County; or the MMO SuperMed Plus network outside of Franklin County.
NGS
American
The Third Party Administrator (TPA) for claims administration of the
universitysponsored medical plans.
non-network physician/provider
A physician or provider who does not have a network service contract in effect with MHCS.
O
OHR
Office of Human Resources at The Ohio State University
open
enrollment
Each year, an open enrollment period is designated during which eligible Ohio State faculty and
staff may make enrollment and coverage changes to benefit plans.
out-of-pocket
limit
Maximum portion of allowable expenses that you pay in deductible,
copay, and coinsurance amounts during a plan year. The limit restarts
each plan year.
outpatient
A covered person who receives medical care or treatment without an
overnight stay.
P
physician
One of these professionals licensed under the applicable state
laws:
• Doctor of Medicine (MD)
• Doctor of Osteopathy (DO)
• Podiatrist (DPM)
• Dental Surgeon or Dentist (DDS)
• Chiropractor (DC)
• Doctor of Optometry (OD)
plan
year
January 1 through December 31. Annual deductibles, out-of-pocket limits,
and plan limitations restart each January 1. You will receive enrollment
information during open enrollment, with coverage changes effective
January 1.
precertification
An authorization process that must occur before services are rendered
for a particular service or item. See specific plan details for more
information.
predetermination
of expense/prior authorization
A recommended process for dental or medical work that is anticipated
to cost over $200. A cost estimate is performed to determine the dollar
amount paid by the plan and your payment responsibility for services
provided according to the contract. See specific plan details for
more information.
primary
care physician (PCP)
Doctors who are trained to provide a basic, comprehensive, routine
level of health care, and typically include family practice, general
practice, and internal medicine physicians and pediatricians.
prior
authorization
Notification to MHCS requesting coverage for specific medications
prescribed for certain uses. In most cases, the authorization is valid
for one year. If the prescription drug is not approved for coverage
under the plan, you will be responsible for paying the full cost of
the medication. A listing of medications that require prior authorization
is available in this booklet or from MHCS.
protected
health information
Information that is created or received by the Ohio State University
Employee Health Plans and relates to the past, present or future physical
or mental health of a covered person; the provision of health care
to a covered person; or the past, present or future payment for the
provision of health care to a covered person; and that identifies
the covered person or there is a reasonable basis to believe that
the information could be used to identify the covered person. It includes
information about living or deceased people. The following components
of a covered person’s information when received, created or
maintained by the OSU Plans are also considered PHI:
•
Names.
• Street address, city, county, precinct, zip code.
• Dates directly related to a covered person (including birth
dates, admission dates, discharge dates, date of death).
• Telephone numbers, fax numbers and electronic mail addresses.
• Social Security numbers.
• Medical record numbers.
• Account numbers.
• Certificate/license umbers.
• Vehicle identifiers, serial numbers and license plate numbers.
• Device identifiers and serial numbers.
• Web Universal Resource Locators (URLs).
• Biometric identifiers (including finger and voice prints).
• Full face photographic images or comparable images.
• Any other unique identifying number, characteristic or code.
Q
qualifying
status change
A qualifying status change is a specific event or change that allows
you to make changes to your benefit elections. Federal restrictions
prohibit you from dropping, adding, or changing health plan coverage
during the plan year unless a qualifying status change occurs. When
a qualifying status change occurs, notification must be received by
the Office of Human Resources within 31 days of the status change.
.
Family status changes may include marriage, divorce, childbirth,
adoption or legal guardianship of a child, death of a spouse/dependent,
a dependent child reaching the age limit or no longer meeting dependency
criteria, or loss of coverage. Documentation may be required.
.
Employment status changes that affect benefit eligibility may include
a change in the full-time equivalent of your appointment or a change
in your appointment type.
.
Other status changes include a benefit open enrollment at your spouse's
employer, a change in your spouse's employment, or a change in your
spouse's eligibility for benefits. Refer to specific program provisions.
TPA
Third Party Administrator that provides claims administration.
U
unemployment
compensation
Wage replacement if you experience a job loss.
Usual,
Customary and Reasonable Charge (UCR)
The method used to determine the maximum amount to be reimbursed for
covered services performed by non-network providers. The UCR maximum
amounts are established using historical data collected by the claim
administrator for providers' charges within specific geographic areas.
The data may be supplemented with information provided by independent
research firms who specialize in the collection of provider charge
data. The database used to establish UCR maximum amounts is updated
at least annually.
W
Workers'
Compensation
A benefit provided to you for injuries or occupational diseases sustained
at the workplace.
Life
Events
