Glossary

Glossary of Terms and Phrases

PLAN: Refers to any type of health insurance plan. This can be a standard insurance plan (known as indemnity or fee-for-service) or a managed care plan. In some cases, usually when your employer is a large company, a company has set up a health insurance plan of its own. These plans are called self-insured plans and fall under federal guidelines known as ERISA and are exempt from New York law. To find out if your plan is this type, check with your employer or union.

MCO: Managed Care Organization: A healthinsurance plan that uses primary care providers (PCP) and a specific list of health care providers (the plan’s network) whose services are covered under the plan.

HCP: Health Care Provider: Any licensed health care professional. This term applies not only to doctors but also to nurses, social workers, etc.

PCP: Primary Care Provider: The health care professional who coordinates your health care needs if you are enrolled in an MCO.

BENEFIT: A medical service, test or treatment, a medical device or a prescription drug.

GRIEVANCE: A formal complaint or disagreement you or your Health Care Provider make with your MCO.

UTILIZATION REVIEW (or “ UR”): The process used by plans to decide whether or not a benefit is “medically necessary.”

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