CALIFORNIA - Pacificare Health Systems

PART B
152
Section 1 – Health Care Terms
whose enrollment has been confirmed by
CMS and thus is entitled to receive Covered
Services.
Network
Providers, facilities and Hospitals contracted
by PacifiCare to deliver the Covered Services
provided for in this Evidence of Coverage and
Disclosure Information, Retiree Benefits
Summary and the Retiree Benefits Summary
Insert.
Network Hospital
A Hospital that has a contract with PacifiCare
to provide services and/or supplies to Secure
Horizons Group Retiree Medicare Advantage
Plan Members.
Non-Contracting Medical Provider or
Facility
Any professional person, organization,
health facility, Hospital, or other person or
institution licensed and/or certified by the
state or Medicare to deliver or furnish health
care services, and who is neither employed,
owned, operated by, nor under contract with
PacifiCare to deliver Covered Services to you.
Office visit
A visit for Covered Services to your Primary
Care Physician, Contracting Specialist,
Nurse Practitioner, Physician’s Assistant,
Psychologist, Coumadin Clinic, other
Contracting Medical Provider and with Prior
Authorization, a Non-Contracting Medical
Provider.
Outpatient Services
Ambulatory medical services received by a
Member when the Member is not admitted to a
Hospital or Skilled Nursing Facility.
PacifiCare
A state corporation that is organized and
licensed by the state as a risk-bearing entity
and is certified by CMS as meeting Medicare
Advantage requirements. PacifiCare is a
Medicare Advantage Organization that offers
Secure Horizons Medicare Advantage Plans.
Prescription Unit
The maximum amount (quantity) of drug
that may be dispensed per prescription for a
single Copayment or Coinsurance amount.
For most oral drugs, the Prescription Unit
represents a thirty (30)-day supply of the
drug. For drugs that could be habit-forming,
the Prescription Unit may be set at a smaller
quantity for your protection and safety.
Primary Care Physician (PCP)
The Contracting Medical Provider you
choose who is responsible for providing or
authorizing Covered Services while you are
a Member of the Secure Horizons Group
Retiree Medicare Advantage Plan. Primary
Care Physicians are generally Physicians
specializing in Internal Medicine, Family
Practice or General Practice.
Prior Authorization
A system whereby a Provider must receive
approval from PacifiCare or your Contracting
Medical Group/IPA before you, the Member,
receive certain Covered Services. All services
rendered by Non-Contracting Medical
Providers must have Prior Authorization
unless provided during an emergency or
while you are temporarily out of the Service
Area and need urgent care.
Provider
Any professional person, organization, health
facility, Hospital or other person or institution
licensed and/or certified by the state or
Medicare to deliver or furnish health care
services.
Quality Improvement Organization (QIO)
An independent contractor paid by CMS to review
Medical Necessity, appropriateness and quality of
medical care and services provided to Medicare
beneficiaries. QIO must review complaints about
the quality of care given by physicians in inpatient
Hospitals, outpatient Hospital facilities, Hospital
emergency rooms, Skilled Nursing Facilities,
Home Health Agencies, ambulatory surgical
centers and Private Fee-for-Service plans.