Page 29 - PA_PPO_Member_Kit

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Skilled Nursing Care
– services from licensed nurses in your own home or in a nursing home.
Skilled care services are from technicians and therapists in your own home or in a nursing home.
Specialist
– a doctor specialist focuses on a specific area of medicine or a group of patients to
diagnose, manage, prevent or treat certain types of symptoms and conditions. A non-doctor specialist
is a provider who has more training in a specific area of health care.
Step Therapy
– a type of prior authorization for some prescription medications. With step therapy,
in most cases, members must first try using certain less expensive medications that have been
proven effective for most people with the same condition before the member can get a similar, more
expensive brand-name drug covered.
UCR (Usual, Customary and Reasonable)
– the amount paid for a medical service in a geographic
area based on what providers in the area usually charge for the same or similar medical service. The
UCR amount sometimes is used to determine the allowable amount.
Urgent Care
– care for an illness, an injury or a condition serious enough that a reasonable person
would seek care right away but not so severe to need emergency care.