Glossary of Managed Care Terms
Adverse determination means a determination by a health care plan or by a utilization review program that a health care service is not medically necessary.
Co-payment means 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 means 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 means reasonable and customary charges or the agreed upon health services fee for health services and supplies covered under a health plan.
Grievance procedure means the process by which a health plan member or participating provider can air complaints and seek remedies.
Managed Care Organization (MCO) is 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, patient education and in other ways.
Pre-certification, also known as pre-admission certification, pre-admission review and "pre-cert," means 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) means a physician specializing in internal medicine, pediatric medicine or family/general practice. An obstetrician/gynecologist may be considered a primary care physician.
Utilization review means an evaluation of the medical necessity, appropriateness and the efficiency of the use 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.
© Illinois State Bar Association
If you have questions about the application of the law in a particular case, consult your lawyer. The law is constantly changing. Information on this site or any site to which we link does not constitute legal advice.