Claim - A request by a covered person for payment of a benefit under the plan, including hospital, medical/surgical, and mental health/substance abuse services, prescription drugs, and other services and supplies.

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Copayment - A specified amount the covered person must pay at the time services are rendered for certain covered services, which may not be used as part of the deductible. All services received during a provider office visit (on the same site) are covered by the payment of a single copayment.

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Covered Service - A service or supply that is available under the plan, when medically necessary and obtained in full compliance with all plan rules-including the plan delivery system rules. A charge for a covered service shall be considered to have been incurred on the date the service or supply was provided.

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Deductible - A specified dollar amount of covered services that must be incurred by the covered person before the plan shall provide benefits for all or part of the remaining covered services during the plan year.

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Dependent - An individual who relies on an employee for support or obtains health coverage through a spouse, parent or grandparent who is the covered person.

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Drug Formulary - A listing of prescription medications which are approved for use and/or coverage by the plan and which will be dispensed through participating pharmacies to a covered person. The list is subject to periodic review and modification by the health plan.

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Eligibility Date - The defined date a covered person becomes eligible for benefits under an existing contract.

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Generic Drug - A chemically equivalent copy designed from a brand-name drug that has an expired patent. A generic is typically less expensive and sold under a common or "generic" name for that drug, not the name brand.

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Medically Necessary - A service or treatment which is appropriate and consistent with diagnosis, and which, in accordance with accepted standards of practice in the medical community of the area in which the health services are rendered, could not have been omitted without adversely affecting the member's condition or the quality of medical care rendered.

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Non-Participating Provider - Term used to describe a provider that has not contracted with the carrier or health plan to be a participating provider of health care.

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Participating Provider - Any provider who has an agreement with the carrier or the carrier's associated medical groups to provide covered services.

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Referral - The recommendation by a physician and/or health plan for a member to receive care from a different physician or facility.

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Service Area - The geographic area serviced by the health plan as approved by the state regulatory agencies and/or detailed in the certification of authority.

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