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Definitions
| Term | Definition |
|---|---|
| Administrative Law Hearing | The appeal process administered by the Government and as required by federal law is available to members after they exhaust the Contractor’s complaint and appeal system. |
| Appeal | A request from the insured for review of a decision. It is a formal request made by the insured, their authorized representative, or provider, acting on behalf of the insured with the insured’s consent, to reconsider a decision. |
| Authorized Representative | A person who receives written authorization from an affiliate to make health-related decisions on behalf of the affiliate, including enrollment and disenrollment decisions, filing complaints, grievances, and appeals, and choosing a primary care physician or medical group, among others. |
| Commonwealth Population | Individuals, regardless of age, who meet State eligibility standards established by the Puerto Rico Medicaid Program but do not qualify for Medicaid or CHIP. |
| Complaint | An expression of dissatisfaction about any issue that is not an Adverse Benefit Determination that is resolved at the point of contact. |
| Covered Services | Services and benefits included in Vital. |
| Emergency Services | Treatment of an emergency medical condition to keep it from getting worse. |
| Grievance | A formal claim made by the Enrollee in writing, by telephone or by visiting your Insurer or the Health Advocate Office, requesting a solution be granted when a service has been denied or allowed on a limited basis. A service; reduction, suspension or termination of a previously authorized service; total or partial denial of payment for a service; not having received services in a timely manner; when First Medical has not acted on a situation according to the established terms, refusal of First Medical to let the Enrollee exercise his/her right to receive services outside the network. |
| Grievance and Appeals System | The general system includes complaints, lawsuits, and appeals at the contractor level, as well as access to the Administrative Hearing process. |
| HIPAA (Health Insurance Portability and Accountability Act) | Health Insurance Portability and Accountability Act. The law includes regulations to establish secure electronic health records that will protect the privacy of a person’s medical information and prevent the misuse of this information. |
| High Cost High Needs Program | A specialized program of coordinated care for Enrollees with specific conditions that require additional management due to the cost or elevated needs associated with the condition. |
| Hospital | A facility that provides medical-surgical services to patients. |
| Medical Emergency | An emergency is an illness, an injury, a symptom, or a condition (including severe pain) that a reasonable person could expect and that, if not promptly addressed, could: • Endanger the person’s health. • Endanger the unborn baby of a pregnant woman. • Cause serious harm to bodily functions. • Cause serious harm to any organ or part of the body. In case of an emergency, go to the nearest hospital or call 911 immediately. If you have an emergency, you can go to any emergency room (in-network or out-of-network) to receive emergency care. When you arrive, please show your Vital Plan identification card. To receive emergency services, you do not need a referral from your primary care physician or a preauthorization for services from First Medical. You can also call First Medical’s Medical Advice Line at 1-844-347-7801. |
| Medically Necessary | Services related to (i) the prevention, diagnosis, and treatment of health deficiencies; (ii) the ability to achieve age-appropriate growth and development; or (iii) the ability to achieve, maintain, or regain functional capacity. In addition, medically necessary services must be: • Appropriate and consistent with the diagnosis of the treating provider and failure to receive them could adversely affect your medical condition; • Compatible with accepted standards of medical practice in the community; • Provided in a safe, appropriate and cost-effective environment, given the nature of the diagnosis and the severity of the symptoms; • They are not provided solely for your convenience or the convenience of the provider or hospital; and • They are not primarily for custodial care (for example, guardianship care) For a service to be medically necessary, there must be no other effective treatment or service, or facility available that is more conservatively or substantially less expensive. |
| Medicaid | Program that provides health insurance for people with low or no income and limited resources, according to federal regulations. |
| Primary Care Physician (PCP) | A licensed medical doctor (MD) who is a provider and who, within the scope of practice and in accordance with Puerto Rico Certification and licensure requirements, is responsible for providing all required primary care to Enrollees. The PCP is responsible for determining services required by Enrollees, provides continuity of care, and provides Referrals for Enrollees when Medically Necessary. A PCP may be a general practitioner, family physician, internal medicine physician, obstetrician/gynecologist, or pediatrician. |
| Patient | Person receiving Treatment for his mental and physical health. |
| Prescription | Original written order issued by a duly licensed health professional, ordering the dispensing of a product, or formula. |
| Preferred Provider Network | Health professionals duly licensed to practice medicine in Puerto Rico contracted by First Medical for the Enrollee to use as the first option. Enrollees can access these providers without Referral or co-payments if they belong to their Primary Medical Group. |
| Primary Medical Group | Health professionals grouped to contract with First Medical to provide health services under a Coordinated Care model. |
| Prior-Authorization | Permission First Medical grants in writing to you, at the request of the PCP, Specialist or sub-specialist, to obtain a specialized service. |
| Referral | Written authorization a PCP gives to an Enrollee to receive services from a Specialist, sub-specialist or facility outside the preferred network of the Primary Medical Group. |
| Second Opinion | Additional consultation the Enrollee makes to another physician with the same medical specialty to receive or confirm that the initially recommended medical procedure is the Treatment indicated for his condition. |
| Treatment | To provide, coordinate or manage health care and related services offered by health care providers. |