Glossary of Terms Ancillary Services Health care services conducted by providers other than primary care physicians such as home health services, durable medical equipment, skilled nursing care. Authorization means a written approval by a Medical Director or his/her designee for a Member to receive certain Medically Necessary Covered Services before services are rendered. Section 16: Agreement means the Group Service Agreement, including but not limited to this Combined Evidence of Coverage and Disclosure Form, any and all applications and information submitted by the Group and Members in applying for Coverage, attachments, addenda, and any amendments that may be added in the future. The Agreement contains the exact terms and conditions of Coverage. It incorporates all of the contracts, promises, and agreements exchanged by the Group and VHP. It replaces any and all prior or concurrent negotiations, agreements, or communications, whether written or oral, between both parties with respect to the contents of the Agreement. Covered Services means the Medically Necessary health care services, supplies and products modified by the exclusions and limitations to which you are entitled as a Member under your Group Service Agreement and which are described in this Combined Evidence of Coverage and Disclosure Form.
SECTION 16: GLOSSARY OF TERMS
Benefit Plan means the Covered Services contained in this Combined Evidence of Coverage and Disclosure Form. Any date referenced in this Benefit Plan begins at 12:01 a.m., Pacific Standard Time. Benefit Year means a period of the twelve (12) months commencing with the effective or anniversary date of the Agreement. Capitation A method of payment in managed care in which a provider is paid a fixed amount per person enrolled in a plan. This fee is based on a defined set of benefits and is typically paid on a monthly basis regardless of the type of care delivered or the frequency with which a patient accesses services. CCS (California Children’s Services) The CCS program, administered by the state and counties, provides medical care for eligible low-income families with children who have serious medical problems. These include acute injury and illness, genetic diseases, chronic conditions or physical disabilities, congenital defects, and major injuries due to violence and accidents. CCS covers medical services including physician services, hospital care, laboratory work, Xrays, rehabilitation services, pharmaceuticals, durable medical equipment and case management. CHDP (Child Health Disability Prevention Program) administered by the state and counties, provides preventive health screening examinations to children with family incomes of less than 200% of the federal poverty level. Claim is a demand to the insurer by or on behalf of a Member for the payment of benefits under a policy. Coordination of Benefits (COB) applies when a Member is covered by two (2) or more insurance plans, COB: eliminates duplicate payments, specifies the order in which coverage will be paid (the primary plan, the secondary plan, etc.), and ensures that the benefits paid under both plans do not total over 100% of the charges. Co-payment is a fee, which a Member is required to pay in order to receive a particular Benefit. Co-payments paid for eyeglasses, Dental Services, or any other supplementary benefit(s) that are not covered under this Benefit Plan are not counted against the Co-payment Maximum. Co-payment Maximum is the maximum Member responsibility for Covered Services during a Benefit Year.
www.valleyhealthplan.org rev.2020
Section 16
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