Page 37 - EPO_Member_Kit

Basic HTML Version

– a term used to describe providers grouped together to serve enrollees. This group is
usually composed of doctors working in private offices. It may also included a hospital (or
hospitals) linked to those doctor affiliations.
Non-Affiliated Provider
– a medical partnership or individual doctor that does not have a contract
with Alliance.
– Alliance has a network of affiliated doctors available to service your health care
needs. Services are considered out-of-plan when you receive them from doctors that are not
affiliated with Alliance. Out-of-plan services are covered at a lesser coverage level for plans with
out-of-plan coverage.
Patients’ Bill of Rights
– federal or state signed
legislation that mandates health plans must offer
external appeal policies, quick appeals decisions,
greater access to specialists than was previously
available in many managed care plans and other
specific consumer protections. Alliance fully supports
state and federal legislation that advises you of your
health care rights and allows you to make health care
choices based on informed decisions.
Personal Care Physician (PCP)
– an affiliated doctor
who has agreed to coordinate the medical care of
Alliance enrollees. A PCP may practice in the area of
family practice, internal medicine or pediatrics. Not all
plans require an enrollee to select a PCP. Please refer to
your plan description for your plan specifics.
– a prior approval process where
Alliance’s utilization review service is conducted to
authorize services. Precertification is required for
admissions and certain procedures and treatments.
Prescription Medication
– a medication which has been approved by the Food and Drug
Administration and which can, under federal or state law, be dispensed only when prescribed by
your Alliance-affiliated doctor.
Preventive Care
– health care emphasizing priorities for prevention, early detection and early
treatment of conditions, generally including routine physical examination, immunization and
well-person care.
Urgent Care
– an urgent medical condition that is not life threatening but may require prompt
attention. Sprained ankles, most burns and minor wounds requiring stitches are typical examples
of urgent conditions. See a list of affiliated Urgent Care Centers in the step sheets.