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Member FAQs |
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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 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 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 are 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 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 is 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 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 is 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:
Can I change my Primary Care Physician?
A:
Yes, you have that option once a month. Simply call PacifiCare
Customer Service. If your request is received on or before
the 15th of the month, your change will be effective the
next month. After the 16th, your change will take place
the 1st of the second month.
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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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