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Q: Where should
I start to purchase my insurance plan?
A: Please go to Contact Us on the home page and call PacifiCare's
toll free sales number.
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Q:
What is capitation?
A: A method of payment which PacifiCare compensates participating
providers. This capitation payment is made to those participating
providers regardless of whether or not a member accesses
care. |
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Q: What is a copayment?
A: A fee that can be a fixed dollar amount or percentage
charged to members or insured for covered services or
covered expenses; usually paid to the provider at the
time service is rendered. |
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Q:
What is credentialing?
A: The process of reviewing potential health care providers'
credentials to determine if they meet the standards of
the Medical Group and PacifiCare. Both PacifiCare and
the Medical Group consist of credential physicians. |
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Q: What is a deductible?
A: This is the amount of covered charges that the subscriber
and/or the subscriber's eligible dependents must meet
for the calendar or plan year for services before PacifiCare
pays any benefits. |
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Q: What is
fee-for-service?
A: Traditional method for paying providers based on
the fee for each service, without any negotiated discounts. |
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Q: What is formulary?
A: The list of drugs chosen by a health plan to treat
patients. Drugs outside the formulary are not used except
in specified circumstances. |
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Q:
What is limited fee schedule?
A: A comprehensive listing of fees used as a standard
to reimburse physicians and other health care providers. |
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Q: What is Health
Maintenance Organization (HMO)?
A: A form of prepaid health insurance that generally includes
comprehensive health care benefits with a focus on wellness
and preventive care. |
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Q:
What is out-of-pocket costs?
A: The amount of payment made by the member for health
care services (not including health care premiums). |
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Q: What is
participating medical group/independent practice association?
A: An Independent Practice Association (IPA) or Medical
Group of licensed doctors of medicine or osteopathy which
has entered into a written agreement with PacifiCare to
provide medical services to Members and their eligible
dependents. A Medical Group employs physicians who typically
all work at one physical location. An IPA contracts with
independent contractor physicians who typically work at
different office sites. |
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Q:
What is a participating provider?
A: A hospital, physician, facility or other health care
provider who has entered into a written agreement with
PacifiCare to provided services, treatment an supplies
for covered services. |
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Q: What are
Point-of-Service (POS)?
A: A health care plan that offers members the flexibility
to choose how to receive health care services. Services
are covered either in-network or out-of-network. In-network
provides coverage similar to standard HMO coverage, featuring
comprehensive health care services with lower out-of-pocket
costs. Out-of-network benefits typically have limited
coverage and higher out-of-pocket costs. |
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Q:
What is Preferred Provider Organization (PPO)?
A: Health care plan where members may choose to receive
care from any provider but are encouraged to use the preferred
network of contracted providers by offering lower copays. |
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Q: What is
a premium?
A: A fee that is paid by the employer or individual member
or on behalf of the member for health care coverage. This
fee is usually paid monthly. |
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Q:
What is preventive care?
A: Health care that places a high priority and emphasis
on maintaining the health of members, featuring early
detection of illness and disease through routine physicals,
regular health screenings, immunizations, and well baby
care, among others. |
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Q: What are
Primary Care Physicians (PCP)?
A: The physician responsible for coordinating the member's
health care. PCPs are typically Family/General Practitioners,
Internists, Pediatricians, or Gynecologists (OB/GYNs). |
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Q: What is
usual, customary and reasonable (UCR)?
A:
The maximum reimbursement, which is based upon
historical fee patterns and is sometimes referred to as
U&C.
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