Page 36 - EPO_Member_Kit

Basic HTML Version

Glossary of Terms
Affiliated Provider
– a doctor, hospital, group practice, nursing home, pharmacy, individual or
group of individuals who contract with Alliance to provide health care services.
Allowable Charge
– a reimbursement negotiated between Alliance and its providers for services
and supplies that are medically necessary as determined by Alliance and identified as covered
services. Allowable charges are subject to coinsurance, copays and deductibles.
Benefit Period
– the 12 month period in which your benefits and coverage is effective.
– the percentage of covered costs of negotiated charges that you are responsible for
paying when you receive covered services. For example, if your Group Health Insurance Policy
states that Alliance will pay 80 percent of allowable charges for covered services (after your
deductible and/or copays have been met) then the remaining 20 percent is your coinsurance.
Coinsurance percentages are listed in your Group Health Insurance Policy.
– a fee you will pay at the time you receive services. Typically copays are for doctor office
visits, prescription medications, emergency room or urgent care visits. A copay is a set dollar
amount. Copay amounts are listed in your Group Health Insurance Policy and Riders.
Covered Services
– those medically necessary health care services and benefits that are included
in your Group Health Insurance Policy and Riders.
– fixed amount that you must pay before your health benefits begin to cover medical
services. After the deductible is met, covered services are payable at the allowable charge, based
on the specific provisions of your Group Health Insurance Policy. Services must be a “covered”
benefit to be applied towards the deductible.
– an individual who receives health coverage through a spouse, parent or other family
member who is the Alliance Group Health Insurance Policy.
Drug Formulary
– the panel or list of medications chosen by Alliance that is used to treat patients.
All medications on the formulary are approved by the Food and Drug Administration. Medications
outside of the formulary are only used in rare, specific circumstances.
– care necessary to screen and stabilize a enrollee in cases where a person with no
medical training, acting reasonably, believes that an emergency medical condition exists.
– Alliance has a network of doctors available to service your health care needs. The
services you receive are considered in-plan when you receive them from the Alliance-affiliated
doctors list in your Provider Directory.
Medical Center
– made up of many doctors all under one roof. Most medical centers offer other
services, such as laboratory, X-ray and optical, within the same building.