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Your member handbook tells you how your plan coverage works to get the medical care you need and avoid out-of-pocket costs.
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Here are some important facts to help you be an informed patient in all health care settings.
Don’t know what something means? Try searching through this list of health care terms.
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Treatment of disease by x-ray, radium, cobalt or high energy particle sources.
The amount customarily charged for the service by other physicians in the area (often defined as a specific percentile of all charges in the community), and the reasonable cost of services for a given patient after medical review of the case. Also called "Usual, Customary and Reasonable" (UCR).
A recommendation by a physician that an enrollee receive care from a specialty physician or facility.
For HMO members, referral care is the care you receive from a network provider other than your primary care doctor. Your primary care doctor must first give you a referral for this care or the plan may not pay for it. Note that women may visit their OB/GYN without a referral.
A termination of coverage with an effective date that is retroactive.
Treatment of illness or disease that is accomplished by introducing dry or moist gases into the lungs.
A review done after services are completed (usually as part of a claim or appeal), that ensures that the care given was medically necessary.
A provision added to a contract whereby the scope of its coverage is increased or decreased.
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