Adverse Determination - A determination by a health care plan or by a utilization review program that a health care service is not medically necessary.

Co-payment - A cost-sharing arrangement in which a plan member pays a specified charge for a specified service, such as $10 for an office visit. The member is usually responsible for payment at the time the health care is rendered.

Drug Formulary - A listing of prescription medications approved for use and/or coverage by the plan and dispensed through participating pharmacies to a covered person.

Eligible Expenses - Reasonable and customary charges or the agreed upon fee for health services and supplies covered under a health plan.

Grievance Procedure - The process by which a health plan member or participating provider can air complaints and seek remedies.

Managed Care Organization (MCO) - A generic term applied to companies offering managed care health plans. They were formed as a way to keep medical costs down through preventative medicine, and patient education.

Pre-certification - Also known as pre-admission certification, pre-admission review and "pre-cert," this is the process of obtaining certification or authorization from the health plan for non-emergency hospital admissions (inpatient or outpatient). Failure to obtain pre-certification often results in a financial penalty to either you or your health care provider.

Primary Care Physician (PCP) - A physician specializing in internal medicine, pediatric medicine, or family/general practice. An obstetrician/gynecologist may be considered a primary care physician.

Utilization Review - An evaluation of the medical necessity, appropriateness and the efficiency of health care services on a prospective, concurrent or retrospective basis.

Note: This information was prepared as a public service by the Illinois State Bar Association and is a joint project with the Illinois Press Association. Its purpose is to inform citizens of their legal rights and obligations.