An injury to the body that happens unexpectedly and is caused by some kind of external, traumatic and unforeseen force or means. For example, if an individual is injured in a car accident or cuts their finger with a sharp knife in the kitchen. Accidental Injury does not include disease or infection, hernia or cerebral vascular accident. In addition, dental injury caused by chewing, biting or malocclusion is not considered an Accidental Injury.
A treatment that involves the use of needles inserted into and removed from the body. Also, the use of other devices, techniques and procedures are integrated into these treatments. A traditional form of Chinese medicine, acupuncture is used as a type of prevention, cure or correction of any disease, illness, injury, pain or other condition by controlling and regulating the flow and balance of energy in the body in order to restore and maintain health.
The period of time between the date a patient is admitted into a hospital or other facility as an inpatient, and the date he/she is discharged as an inpatient. The date of admission represents the date of service for the hospitalization and all related services.
Age Limitation (AG)
A coverage limit based on minimum or maximum age of the member in order to ensure safety and effectiveness of treatments and drug dosages.
The dependence or the abuse of alcohol.
A duly licensed transportation service, capable of providing Medically Necessary life support care in the event of a life-threatening situation or incident.
Ambulatory Surgical Facility
An appropriately licensed provider, with an organized staff of physicians that meets all of the following criteria:
Has permanent facilities and equipment for the primary purpose of performing surgical procedures on an outpatient basis
Gives treatment by or under the supervision of physicians and nursing services whenever the patient is in the facility
Does not have inpatient accommodations
Is not a facility used mainly as an office or clinic for the private practice of a physician or other professional provider
Annual Out-of-Pocket Maximum
A specified dollar amount of covered services received during a benefit period that is the Member's responsibility.
The form that an employee is required to complete when enrolling for Presbyterian Health Plan, Inc. coverage.
The doctor who is responsible for the patient's hospital treatment or who is charged with the patient's overall care and treatment program. Note that a consulting physician is not the Attending Physician. In addition, a physician employed by the hospital is not ordinarily the Attending Physician.
The process whereby Presbyterian Health Plan or Presbyterian's delegated provider contractor reviews and approves, in advance, the provision of certain Covered Services to Members before those services are performed. If a required Benefit Certification is not obtained for services rendered by an Out-of-Network provider, the Member may be responsible for the resulting charges. Benefit Certification is used in conjunction with the Referral in the management of healthcare needs; Benefit Certification does not replace, nor is it replaced by, a Referral. It is important to note that services rendered beyond the scope of the Referral or the Benefit Certification may not be covered.
An alternative birthing facility licensed under state law. The care and services are primarily given by a certified nurse midwife.
The period beginning January 1 and ending December 31.
A licensed registered nurse, certified by the American College of Nurse Midwives to perform maternity care within the scope of the license.
A person who is a Doctor of Chiropractic licensed by the appropriate governmental agency to practice chiropractic medicine. This kind of medicine focuses on the treatment and alignment of the musculoskeletal system (especially the spine).
Behaviors learned by family members or significant others in order to survive in difficult situations of great emotional pain and stress that is often caused when another family member is dependent upon the excessive use of alcohol or drugs.
The percentage paid for a covered service, after the deductible has been met. For example, if a CT scan is covered with a 20% coinsurance, and the scan costs $1,000, a patient will pay only $200 for the scan as long as the deductible has been met.
Any condition or birth defect that a baby is born with. and is significantly different than the average child. Examples of these types of physical problems include a cleft palate or certain heart defects.
Copayment (or Copay)
A fixed amount paid, like $30, for a healthcare service each time you receive that service. A copay is often a small percentage of the amount a patient would pay for that visit or service without insurance coverage.
Surgery that is performed to reshape or alter features of the body in order to improve appearance and self-esteem. Examples of this type of surgery include a face-lift or breast implants.
Services or supplies specified in this Summary Plan Description (SPD), as well as any supplements, endorsements, addenda or riders, for which benefits are given, subject to the terms, conditions, limitations and exclusions of this SPD.
This kind of care is given primarily to meet a patient's Monday-Friday activities and basic care needs. It is not given for its therapeutic value in the treatment of a disease, illness, Accidental Injury or condition. Custodial care includes—but is not limited to—help with the following activities: walking, bathing, dressing, eating, meal preparation, and supervision over self-administration of medication that doesn’t require the constant oversight of a nurse, a doctor or another trained medical personnel.
A Doctor of Dental Surgery (DDS) or Doctor of Medical Dentistry (DMD) who is licensed to practice prevention and treatment that relates to an individual’s mouth, teeth and jaws. These treatments can be related to diseases, accidental injuries, and any malformation related to the mouth, teeth and jaws.
Any member of a covered employee's family who meets the requirements of Section 3 of this Summary Plan Description and is actually enrolled in the Plan.
Procedures ordered by a physician or other professional provider to find a definite condition or disease.
Durable Medical Equipment
Equipment prescribed by a physician that is Medically Necessary for the treatment of an illness or Accidental Injury, or to prevent a patient becoming more sick. Examples of this kind of equipment include oxygen equipment, wheelchairs, hospital beds and crutches.
Any treatment, procedure, facility, equipment, drug, device or supply not accepted as standard medical practice within a particular state. In addition, if a federal or other governmental agency approval is required for use of any items and such approval was not granted at the time services were administered, the service is Experimental. To be considered standard medical practice and not Experimental or Investigational, treatment must meet all five of the following criteria:
A technology must have final approval from the appropriate regulatory government bodies (such as the FDA)
The scientific evidence as published in peer-reviewed literature must permit conclusions concerning the effect of the technology on health outcomes
The technology must improve the net health outcome
The technology must be as beneficial as any established alternatives
The improvement must be attainable outside the investigational settings
This type of health coverage includes the employee, the employee's spouse, and/or the employee's Dependent children.
Freestanding Dialysis Facility
A provider that offers dialysis treatment, maintenance or training to patients on an outpatient or home basis.
An oral or written complaint submitted by or on behalf of a covered person regarding the:
Availability, delivery or quality of healthcare services
Administrative practices of the healthcare insurer that affect the availability, delivery or quality of healthcare services
Claims payment, handling or reimbursement for healthcare services
Matters pertaining to any aspect of the health benefits plan
A physician or other healthcare practitioner or pharmacist, who is licensed, certified or otherwise authorized by the state to provide healthcare services that are consistent with the state law.
A wide range of services, supplies and procedures for the diagnosis, prevention, treatment, cure or relief of a health condition, illness, injury or disease. These services also include—to the extent offered by the health benefits plan—physical and behavioral health, such as support groups or individual therapy.
Home Health Agency
An appropriately licensed provider that both:
Brings skilled nursing and other services on an intermittent, visiting basis into the member's home in accordance with the licensing regulations for home health agencies in New Mexico or in the locality where the services are administered
Is responsible for supervising the delivery of these services under a plan prescribed and approved in writing by the Attending Physician
A duly licensed program or facility providing care and support to terminally ill patients and their families.
A duly licensed provider that is a short-term, acute, general hospital that meets all of the following criteria:
Is a duly licensed institution
For compensation from its patients, is primarily engaged in providing inpatient diagnostic and therapeutic services for the diagnosis, treatment, and care of injured and sick persons by or under the supervision of physicians
Has organized departments of medicine and major surgery
Gives 24-hour nursing service by or under the supervision of registered nurses
Is not, other than incidentally, a skilled nursing facility, nursing home, custodial care home, health resort, spa or sanitarium
Is not a place for rest, for the aged, for the treatment of mental illness, alcoholism, drug abuse or pulmonary tuberculosis, and ordinarily does not provide hospice or rehabilitation care, and is not a residential treatment facility.
Identification Card or ID Card
The card issued to the covered employee enrolled under this Plan.
Drugs that are prescribed and used to suppress, or inhibit, the human immune system. Some of the reasons for using immunosuppressive drugs include but are not limited to help:
Prevent transplant rejection
Treat certain diseases of the immune system (i.e. "auto-immune" diseases)
Relieve certain symptoms
Suppress the human immune response if needed
A network of doctors, hospitals and other healthcare professionals, facilities and suppliers that have agreed to be paid discounted amounts to help keep the costs down for you and the insurance company.
Independent Clinical Laboratory
A laboratory that performs clinical procedures under the supervision of a physician and that is not associated with a hospital, physician or other provider.
A patient who is being treated in a hospital/treatment facility and stays there for at least one full night.
An acupuncture practitioner who is licensed by the appropriate state authority. Certification alone does not meet the licensure requirement.
Licensed Practical Nurse (LPN)
A nurse who has graduated from a formal practical nursing education program and is licensed by the appropriate state authority.
Treatment that does not significantly enhance or increase the patient's function or productivity.
Any condition related to being pregnant. Maternity care includes these different areas: prenatal and postnatal care, and care for the complications of pregnancy (such as ectopic pregnancy), spontaneous abortion (miscarriage), elective abortion or cesarean section.
A government-funded program to provide health insurance to low-income Americans. This includes households with children, people with disabilities, and the elderly.
The wide range of professional services administered by a physician or another professional provider for the treatment of an illness or Accidental Injury.
Medical Drugs (MED)
Medications that are prescribed and administered by a healthcare professional who works in a medical office or facility. Often, a doctor may write a prescription and then these medications are picked up at a pharmacy. Some Medical Drugs may require Prior Authorization before they can be obtained. Patients can receive medical drugs in the following types of locations (but are not limited to): physician's offices, emergency rooms, urgent care facilities and outpatient surgery facilities.
An Accidental Injury or a condition that occurs suddenly and unexpectedly and is life threatening or could result in permanent damage if not treated immediately. To be eligible for possible emergency benefits, the Member must seek treatment within 48 hours of the Accidental Injury or onset of the condition.
A drug that is not on the Plan's formulary (or drug list). Drugs not on the formulary list require an exception due to allergy, adverse reactions or no response to all formulary drugs.
Medical Necessity or Medically Necessary
Healthcare services determined by a provider, in consultation with the healthcare insurer, to be appropriate or necessary. These guidelines are developed by a number of different official groups, which include the federal government, national or professional medical societies, boards and associations. In addition, any applicable clinical protocols or guidelines developed by the healthcare insurer are consistent with such federal, national and professional practice guidelines for the following areas: diagnosis or direct care and treatment of a physical or mental health condition, illness, injury or disease.
An insurance plan for people over 65 who have worked for ten or more years in Medicare-covered employment. Complete eligibility requirements are available from the Centers for Medicare and Medicaid Services.
The eligible employee or dependent who is enrolled under this Plan.
The contracted amount that Presbyterian Health Plan agrees to pay to PCPs and In-Network Providers for hospital, professional services and other charges, and for which PCPs and In-Network Providers agree to accept as payment for services rendered to Members.
A person registered to practice occupational therapy. This kind of therapist treats a variety of problems related to physical, mental or developmental issues caused by disease, trauma, congenital anomaly or prior therapeutic process. The approach of the treatment is focused on teaching skills and educating a patient of how to increase their basic Monday-Friday activities. This type of treatment often includes physical therapy.
A device customized and fitted by a licensed orthopedic technician to support or correct an existing problem related to the movement of an individual’s body. Examples include a back brace or a finger splint.
An external device intended to correct any defect of form or function of an individual’s body. Examples include orthotic cushions for your running shoes or a foam wedge insert for a sore heel.
Other Provider:a person or facility other than a hospital that is licensed in the state where services are provided or to administer covered services. Other providers include:
An institution or entity only listed as:
Ambulatory Surgical Facility
Durable Medical Equipment Supplier
Freestanding Dialysis Facility
Home Health Agency
Independent Clinical Laboratory
Urgent Care Facility
A person or practitioner only listed as:
Certified Nurse Midwife
Certified Registered Nurse Anesthetist
Licensed Practical Nurse
Licensed Lay Midwife
A duly licensed healthcare provider or medical facilities, that has no agreement with Presbyterian Health Plan for reimbursement of services to its Members.
A specified dollar amount of covered services received in a calendar year that is the Member's responsibility. For PCP-Coordinated Care, this amount includes only the copayments and coinsurance for PCP-Coordinated services.
The type of care that is received in one of the following locations: a hospital department, ambulatory surgical facility, urgent care facility or physician's office where the patient leaves the same day.
A licensed physical therapist. A physical therapist treats disease or Accidental Injury with a focus on improving an individual’s physical ability to move. Where there is no licensure law, the physical therapist must be certified by the appropriate professional body.
A duly licensed practitioner of the healing arts acting within the scope of his/her license.
A licensed Doctor of Podiatric Medicine (DPM). A podiatrist treats conditions related to the feet, such as bunions or injuries of the heel, foot or ankle.
Payments you make, often on a monthly basis, to participate in a specific plan. Premiums are like a sort of subscription, such as to a magazine or newspaper, that you pay on a monthly basis. It’s important to note that if you don’t pay your premiums in a timely manner, your insurance subscription will be canceled.
Presbyterian Health Plan
Presbyterian Health Plan, Inc., a corporation organized under the laws of the State of New Mexico.
The class of drugs that, by federal law, require a physician's prescription for purchase by a patient.
Primary Care Physician (PCP)
A duly licensed Doctor of Medicine or Osteopathy, formally selected by the Member to assume primary responsibility for his/her care.
Prior Authorization (PA)
A drug that requires prior approval before the Plan will cover it, and when the patient meets the established criteria. The doctor must submit a Prior Authorization Request Form. These requests can be submitted by fax, phone or regular mail.
Prosthesis, Prosthetic Device
An externally attached or surgically implanted artificial substitute for an absent body part. Examples of this type of device include an artificial eye or an artificial arm.
A duly licensed hospital, physician, or other provider performing within the scope of the appropriate licensure.
Quantity Limit (QL)
A coverage limit on the medication quantity covered for a defined days' supply (normally 30 or 90 days) based on safety, efficacy and/or the optimal dosage for treatment.
Reasonable Charge or Reasonable and Customary (R&C) Charge
The amount determined to be payable by Presbyterian Health Plan for services rendered to members by Out-of-Network Providers, based upon the following criteria:
Fees that a professional provider often charges for a given service
Fees which fall within the range of usual charges for a given service filed by most professional providers in the same locality who have similar training and experience
Fees which are usual and customary or which could not be considered excessive in particular case because of unusual circumstances
An order by a Member's Primary Care Physician (PCP) requesting and recommending that the Member receive services from another physician in accordance with the terms of this Summary Plan Description (SPD).
Registered Nurse (RN)
A nurse who has graduated from a formal program of nursing education school, associated degree or baccalaureate program. Also, a nurse must be licensed by appropriate state authority.
An appropriately licensed facility that provides rehabilitation care services on an inpatient basis. Rehabilitation care services consist of the combined use of medical, social, educational and vocational services to enable patients disabled by illness or Accidental Injury to achieve the highest possible ability to function in their Monday-Friday lives. Services are provided by or under the supervision of an organized staff of physicians. Continuous nursing services are supplied under the supervision of a registered nurse.
A person qualified for employment in the field of respiratory therapy. A respiratory therapist assists patients with breathing problems, such as asthma or sleep disorders.
A hospital room that includes two or more beds within a skilled nursing facility or other healthcare program.
Skilled Nursing Care
Services that can be provided only by someone with at least the qualifications of a licensed practical nurse or registered nurse.
Skilled Nursing Facility
An institution that is licensed under state law to provide skilled nursing care services.
Special Care Unit
A designated unit that provides an intensive level of care for critically ill patients. These units include all facilities, equipment and supportive devices needed for this type of care.
Is a time outside of the open enrollment period during which you and your family have a right to sign up for health coverage. You must enroll within 60 days of a qualifying life event to be eligible. Supporting documents will be required at the time of application. Examples of qualifying life events include:
Marriage or divorce
Having a baby, adopting a child, or placement a child for adoption or foster care
Moving your residence, gaining citizenship, leaving incarceration
Losing other health coverage due to losing job-based coverage, COBRA expiration, aging off a parent’s plan, losing eligibility for Medicaid or CHIP, and similar circumstances.
A Doctor of Medicine (MD) or Doctor of Osteopathy (DO) who specializes in a particular kind of job or area of study, such as cancer or heart disease. Note: a specialist is not a family practitioner, general practitioner, pediatrician or internist.
High cost medications that are mostly dispensed or filled by a specialty pharmacy. Specialty pharmaceuticals are self-administered, meaning they are administered by the patient or to the patient by a family member or caregiver. Most specialty medications require Prior Authorization and are mandated to be obtained through the specialty pharmacy vendor.
A therapist who assists patients in overcoming speech disorders. These therapists are certified by the American Speech and Hearing Association.
Step Therapy (ST)
A drug that requires a prescription history of specific drugs in the pharmacy claims or data system. Also, these specific drugs must be taken during a given time frame. After the specific drugs have been taken within the given time frame, online coverage of the newly prescribed drug occurs at the pharmacy. Step Edits make it easier to access drugs that would normally require a Prior Authorization.
Summary Plan Description (SPD)
Is the "Summary Plan Description" PDF booklet that gives details about specific health insurance plans.
Also called an operation , is often done in a hospital or ambulatory surgical facility. Surgery is a medical treatment in which a doctor may cut into a someone’s body to remove a damaged or diseased part, like to replace a hip or to remove a tumor. Surgery can include:
Specialized instrumentations, endoscopic examinations and other invasive procedures
Correction of fractures and dislocations
Usual and related preoperative care (care before the surgery) and postoperative care (care after the surgery).
Tax Equity and Fiscal Responsibility Act (TEFRA)
Federal law regarding the working aged.
Terminally Ill Patient
An individual suffering from a specific disease or illness with a life expectancy of six months or less as certified in writing by the Attending Physician.
Coverage for the employee and his/her spouse, or coverage for the employee and one or more dependent child(ren).
Healthcare services provided by an Urgent Care Facility in emergencies or after a physician's office hours.
Well Child Care
Routine pediatric care for children. This type of care includes a history, physical examination, developmental assessment, anticipatory guidance, and appropriate immunizations and laboratory tests in accordance with prevailing medical standards as published by the American Academy of Pediatrics.