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  1. 1. Provider/ Contracted with OPTUM or through a OPTUM vendor.
  2. 7. is a pain reliever also used to prevent withdrawal symptoms in people addicted to other drugs
  3. 8. Out/ A decision to purchase separately a service, which is typically a part of an indemnity or HMO plan.
  4. 9. used to describe services rendered/received at a facility such as a hospital or treatment center.
  5. 11. refers to any clinician, hospital, group practice, nursing home, pharmacy, or individual or group of individuals that provide a health care service.
  6. 13. Health/ also referred to as “psychiatric” this includes all conditions marked by sufficient disorganization of personality, mind, and/or emotion so as to seriously impair normal psychological functioning
  7. 17. refers to the criteria which must be met for a person to be able to be covered on a given benefit plan contract.
  8. 18. This benefit, aimed at initial/immediate care, usually allows only three to five visits per calendar year for services received by network clinicians. This benefit is always paid at 100% of the contracted rate with an authorization.
  9. 19. Year/ the period of time from January 1 of any year through December 31 of the same year, inclusive
  10. 20. the portion of covered health care costs for which the covered person has a financial responsibility, usually according to a fixed percentage.
  11. 21. an institutional provider of care such as a hospital or treatment center.
  12. 22. a specific service, procedure, condition, or circumstance that is not eligible for benefit coverage as defined in a given contract
  13. 24. a cost-sharing arrangement in which a plan member pays a specified charge for a specified service. The member is usually responsible for payment at the time the service is rendered
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  1. 2. used to describe services normally rendered/received in an individual clinician’s office
  2. 3. that provides overnight mental health services for members who do not require acute inpatient care but who do require 24-hour structure.
  3. 4. Coverage/ protection that provides payment of benefits for covered sickness or injury. This may include short and long term disability, dental, medical, vision care, and, sometimes, accidental death coverage as well as other benefits.
  4. 5. A covered service as defined by an employer group contract; the payment structure designed to cover a service; or the actual OPTUM HEALTH payment made on a claim.
  5. 6. a person responsible for payment of premiums or whose employment is the basis for eligibility for membership in an HMO, PPO, or other managed health care plan.
  6. 10. Network Provider/ A system of contracted physicians, hospitals and ancillary providers who has not contracted with the carrier or health plan to be a participating provider of health care.
  7. 12. treatment services are provided in a facility or a freestanding
  8. 14. A specific request to reverse a denial or adverse determination and potential restriction of benefit reimbursement.
  9. 15. Another term for certification – Approval of service
  10. 16. the five-digit code indicating the actual service performed
  11. 23. Advocate/ A clinical professional (e.g., nurse, doctor or social worker) who works with patients, health care providers, physicians and insurers to determine and coordinate a plan of medically necessary and appropriate health care. Also referred as care coordinator