Glossary of Terms
Acute is a word used for a serious and sudden condition that lasts a short time and is not chronic. Examples include a heart attack, pneumonia or appendicitis.
Advance Directive is a signed legal document that allows you to select a person to make your health care choices at a time when you can’t make them yourself. It expresses your decision about your end-of-life care ahead of time.
Americans with Disabilities Act (ADA) is a law that protects people with disabilities from not being treated fairly. The ADA law makes sure there are equal chances for people with disabilities in employment and state and local government services, including health care.
Anti-rejection medications are medications used to prevent your body from not accepting a new organ.
Authorize/Authorization is when a health plan approves treatment for covered health care services. Members may have to pay for non-approved treatment. Note: Emergency services and out-of-area urgent care services do not require prior authorization.
Benefits are the health care services, supplies, drugs and equipment that are medically necessary and covered by your medical plan.
California Children Services Program (CCS) is the public health program that assures the delivery of specialized diagnostic, treatment and therapy services to financially and medically eligible children under the age of 21 who have CCS eligible conditions.
California Department of Health Care Services (DHCS) is the state agency that is responsible for the Medi-Cal program.
California Department of Managed Health Care (DMHC) is the state agency responsible for regulating health care service plans.
Cancer Clinical Trial is a research study with cancer patients to find out if a new cancer treatment or drug is safe and treats a member’s type of cancer.
Case Management refers to doctors and nurses who make sure that you are getting the right health care services when you need them. This includes checkups, plans to make you better, getting you the right doctors, and coordinating care to meet your health care needs.
Certified Nurse Midwife is a registered nurse who has experience in labor and delivery, and at least one year of hands-on training in midwifery. A Certified Nurse Midwife has completed an advanced course of study and is certified by the American College of Nurse-Midwives.
Certified Nurse Practitioner is a registered nurse who has completed an advanced training program in a medical specialty.
Child Health and Disability Prevention (CHDP) is for people under the age of 21 with a disability. CHDP is a preventive program that delivers periodic health assessment and services. CHDP provides care coordination to assist families with medical appointment scheduling, transportation, and access to diagnostic and treatment services.
Chronic is a word used for a condition that is longterm and ongoing, and is not acute. Examples include diabetes, asthma, allergies and hypertension.
Clinic is a facility that members can select as a Primary Care Provider (PCP). It can be either a Federally Qualified Health Center (FQHC), Los Angeles County clinic, community clinic, rural health clinic, Native American Health Clinic, or other primary care facility.
Combined Evidence of Coverage and Disclosure Form is the L.A. Care Member Handbook which has information about benefits, services and terms for members.
Complain/Complaint is an oral or written expression of dissatisfaction, including any complaint dispute request for reconsideration or appeal. A complaint is also known as a grievance.
Consultation is the rendering of an opinion, advice, or prescribing treatment by telephone and includes rendering of a decision regarding hospitalization or transfer by telephone or other means of communication.
Diagnostic/Diagnosis is when a doctor identifies a condition, illness or disease.
Disability is a physical or mental condition that substantially limits a person’s ability in at least one major life activity.
Disenroll/Disenrollment is when a member leaves a health plan.
Disputed health care service is a health care service eligible for coverage and payment under a plan that has been denied, modified or delayed based on the plan’s decision that the service was not medically necessary.
Durable Medical Equipment is medical equipment used in the course of treatment or home care, including items such as crutches, knee-braces or wheelchairs.
Eligible/Eligibility means that a person meets certain requirements to receive benefits from programs such as Medi-Cal, California Children’s Services (CCS) and Child Health Disability Program (CHDP).
Enroll/Enrollment is when a member joins a health plan.
Emergency Services are covered anywhere in the United States, Mexico or Canada - 24 hours a day, seven (7) days a week. Emergency care is a service a member reasonably believes is necessary to stop or relieve serious illness or symptoms, injury or conditions requiring immediate diagnosis and treatment, including physical and psychiatric emergency conditions and active labor.
Emergency Services and Urgent Care means medical screening, examination, and evaluation by a physician or surgeon, or other licensed persons under the supervision of a physician and surgeon and includes a determination within the scope of that person's license if an emergency medical condition, psychiatric medical condition or active labor exists and, if it does, the care, treatment, and surgery necessary to relieve or eliminate the emergency medical condition.
Exclusions are any medical, surgical, hospital or other treatments for which the program offers no coverage.
Expedited Review is a complaint that must be resolved as quickly as possible if it involves an imminent or serious threat, including but not limited to, severe pain or the potential loss of life, limb or major bodily function. With an expedited review, the health plan will resolve the complaint as quickly as the medical condition requires and no later than within 72 hours.
Experimental or investigational in nature refers to new medical treatment that is still being tested but has not been proven to treat a condition.
Family planning services help people learn about and plan the number and spacing of children they want through the use of birth control.
Fee-For-Service Medi-Cal, also known as regular Medi-Cal, is the component of the Medi-Cal Program that is paid directly by the state for services.
Federally Qualified Health Center (FQHC) is a community-based health organization that provides comprehensive primary health, oral health, mental health, and substance abuse services.
Food and Drug Administration (FDA) is the U.S. government agency that enforces the laws on the manufacturing, testing, and use of drugs and medical devices.
Formulary is a list of approved drugs that is generally accepted in the medical community as safe and effective.
Grievance is sometimes called a complaint. A grievance is the process used when a member is not happy with his or her health care. Grievances are about services or care received or not received.
Health care services prevent and treat disease, and keep people healthy. Examples include, but are not limited to, some of the following:
- Doctor services (includes one-on-one visits with a doctor and referrals)
- Emergency services (includes ambulance and out-of-area coverage)
- Home health services
- Hospital inpatient and outpatient services
- Laboratory services
- Pharmacy services
- Preventive health services
- Radiology services
Health Maintenance Organization (HMO) is an organization that, through a coordinated system of health care, provides or assures the delivery of an agreed upon set of comprehensive health maintenance and treatment services for an enrolled group of persons through a predetermined, periodic fixed prepayment.
Health Plan means an individual or group plan that arranges for the provision, or pays the cost of, medical care.
Hospice is the care and services provided to people who have received a diagnosis for a terminal illness. These services are given in a home or facility to relieve pain and provide support.
Hospital provides inpatient and outpatient care from doctors or nurses.
Human Immunodeficiency Virus (HIV) is the virus that affects the immune system and causes the disease known as AIDS (acquired immunodeficiency disorder).
Independent Medical Review for Experimental and Investigational Therapies (IMR-EIT) is a process by which expert independent medical professionals are selected to review a denial by the health plan for a medical service, drug or equipment because it is experimental or investigational in nature.
Independent Physician Association (IPA) is a company that organizes a group of doctors, specialists and other providers of health services to see members.
Infertility is when a person is not able to conceive and produce children after having unprotected sex on a regular basis for more than 12 months.
Inpatient is when a person receives medical treatment in a hospital or other health care facility with an overnight stay.
Interpreter is a person who expresses a message spoken or signed in one language into a second language and who abides by a code of professional ethics.
Involuntary/Involuntarily is when something is done without choice.
Liable/Liability is the responsibility of a party or person according to law.
Life-threatening is a disease, illness or condition that may put a person’s life in danger if it is not treated.
Local Education Agency is the school district or county office of education that will receive and disburse grant funds.
Managed care is a health care system in which the health care provider, in return for a fixed fee per year from a health plan, manages the care of the individual, including decisions about whether a specialist is required.
Medi-Cal is a California health coverage program for low-income families. This program is funded by state and federal dollars.
Medi-Cal card, also known as the Benefits Identification Card (BIC), is the plastic card issued by the state to Medi-Cal recipients. The BIC is used by providers to verify Medi-Cal eligibility.
Mediation is a process by which a neutral person tries to help individuals resolve a dispute. The results of the mediation are not binding.
Medical group is a group of PCPs, specialists, and other health care providers who work together.
Medically necessary/Medical necessity refers to all covered services that are reasonable and necessary to protect life, prevent significant illness or significant disability, or to ease severe pain through the diagnosis or treatment of disease, illness or injury.
Member is a person who has joined a health plan.
Member Handbook, also called a Combined Evidence of Coverage/Disclosure Form, has information about the benefits, services and terms offered by the health plan.
Member Representative is a person or persons appointed by the member, via written statement, to represent them in the State of California as a health care proxy, trustee named in a durable power of attorney or court appointed guardian. Also known as Personal Representative(s), a Member Representative may be a spouse, relative, friend, advocate, your doctor, a practitioner or someone designated as a representative by the member under Durable Power of Attorney, or as an Executor/Administrator of Estate or as a legal/court appointed guardian.
Member Services Department is the health plan’s department that helps members with questions and concerns.
Mental or behavioral health services are given for the diagnosis or treatment of a mental or emotional illness.
Network is a team of health care providers contracted with a health plan to provide services. The health care providers may be contracted directly with the health plan or through a medical group.
Non-contracted provider is a doctor or provider who is not under contract with the health plan to provide services to members.
Non-formulary drug is a drug that is not listed on the health plan’s formulary and requires an authorization from the health plan in order to be covered.
Notice of Privacy Practices (NOPP) informs the member how medical information may be used and distributed by the health plans.
Nurse Advice Line is a 24-hour telephone line supported by registered nurses who are available to help people with health questions or concerns.
Occupational therapy is used to improve and maintain a patient’s daily living skills when the patient has a disability or injury.
Orthotic is used to support, align, correct or improve the function of movable body parts.
Outpatient is when a person receives medical treatment in a hospital or other health care facility without an overnight stay.
Out-of-area services are emergency care or urgent care services provided outside of the health plan’s service area that could not be delayed until the member returned to the service area.
Out-of-network providers are doctors and providers not under contract, either directly or indirectly, with the health plan.
Pediatric sub-acute services are the health care services needed by a person under 21 years of age who uses a medical technology that compensates for the loss of a vital bodily function.
Pharmacy is a place to get prescribed drugs.
Phenylketonuria (PKU) is a rare disease. PKU can cause mental retardation and other neurological problems if treatment is not started within the first few weeks of life.
Physical therapy uses exercise to improve and maintain a patient’s ability to function after an illness or injury.
Physician is a licensed medical doctor.
Prescription is a written order given by a licensed provider for drugs and equipment.
Preventive health care consists of health checkups or services given at certain times due to a person’s age, gender and medical history in order to keep that person well.
Primary care is a basic level of health care usually provided in ambulatory settings by general practitioners, family practitioners, internists, obstetricians, pediatricians and mid-level practitioners. This type of care emphasizes caring for the member’s general health needs as opposed to specialists focusing on specific needs.
Primary care provider (PCP) is a doctor or clinic that takes care of a member’s health care needs and works with the member to keep them healthy. The PCP will also make specialty referrals when medically necessary.
Prior authorization is a formal process requiring a health care provider to obtain advanced approval to provide specific services or procedures. Prior authorization is required for most services or care. However, for emergency or out-of-area urgent care services, prior authorization is not required.
Prosthesis is used to replace a missing part of the body.
Providers are contracted with a health plan to provide covered health care services.
- Skilled nursing facilities
- Sub-acute facilities
- Home health agencies
- X-ray facilities
- Durable medical equipment suppliers
Provider directory is a list of providers contracted with a health plan.
Provider network is a group of doctors, specialists, pharmacies, hospitals and other health care providers that are contracted by and work with the health plan.
Referrals are when a doctor sends a member to another doctor, such as a specialist or providers of services including lab, X-ray, physical therapy and others.
Service area means the ZIP codes in Los Angeles County that the health plan, to which a member is assigned, serves.
Skilled nursing facility is a facility licensed to provide medical services for non-acute conditions.
Specialist is a physician or other health professional who has advanced education and training in a clinical area of practice and is accredited, certified, or recognized by a board of physicians or peer group, or an organization offering qualifying examinations (board certified) as having special expertise in that clinical area of practice.
Specialty mental health services are rehabilitative services that include mental health services, medication support services, day treatment intensives, day rehabilitation, crisis intervention, crisis stabilization, adult residential treatment services, crisis residential services, and psychiatric health facility services such as:
- Psychiatric inpatient hospital services
- Targeted case management
- Psychiatric services
- Psychologist services
- Early, Periodic, Screening, Diagnosis and Treatment (EPSDT) supplemental specialty mental health services
Speech therapy is used to treat speech problems.
Standing referral is a referral by a doctor for more than one visit by a specialist.
Sub-acute care is a level of care needed by a patient who does not require hospital acute care, but who requires more intensive skilled nursing care than is provided to the majority of patients in a skilled nursing facility.
Triage or screening is the evaluation of a member's health by a doctor or nurse who is trained to screen for the purpose of determining the urgency of the member's need for care.
Triage or screening waiting time is the time waiting to speak by telephone with a doctor or nurse who is trained to screen a member who may need care.
TTY/TDD is a communication device for the deaf, speech impaired, or hard of hearing, using a telephone system.
Urgent care is any service required to prevent serious deterioration of health following the onset of an unforeseen condition or injury.
Women, Infants and Children Program (WIC) is a state nutrition program that helps pregnant women, new mothers and young children eat well and stay healthy.