{"id":83,"date":"2018-09-05T20:43:19","date_gmt":"2018-09-06T00:43:19","guid":{"rendered":"http:\/\/localhost\/mi-salud\/?page_id=83"},"modified":"2022-12-09T12:54:00","modified_gmt":"2022-12-09T16:54:00","slug":"definitions","status":"publish","type":"page","link":"https:\/\/sssvital.com\/en\/definitions\/","title":{"rendered":"Definitions"},"content":{"rendered":"

Appeal:\u00a0<\/b>A request from the enrollee for the review of a decision. It is a formal request made by the enrollee, his authorized representative or provider, acting on behalf of the enrollee with the consent of the enrollee, to reconsider a decision in the case that the provider does not agree.<\/span><\/p>\n

Authorization:\u00a0\u00a0<\/b>A written document through which a person freely and voluntarily authorizes another person or provider to represent, him\/her for medical or treatment purposes or to initiate an action such as a grievance. It may also be used to end a previous authorization.<\/span><\/p>\n

Benefits:\u00a0<\/b>The health care services covered under Plan Vital.<\/span><\/p>\n

Beneficiary (Enrollee): A person who after being certified as eligible under the Medicaid program has completed the enrollment process with the plan and for whom the plan has issued the Member card that identifies the person as a Plan Vital Beneficiary.<\/span><\/p>\n

CHIP:\u00a0\u00a0<\/b>Children Health Insurance Program<\/span><\/i>, a federal program that provides medical services to low-income children age 21 and under, through Insurers qualified to offer coverage under this program.<\/span><\/p>\n

Commonwealth Population:<\/b>\u00a0Individuals, regardless of age, who meet State eligibility standards established by the Puerto Rico Medicaid Program but do not qualify for Medicaid or CHIP.<\/span><\/p>\n

Complaint:<\/b>\u00a0An expression of dissatisfaction about any issue that is not an Adverse Benefit Determination that is resolved at the point of contact.<\/span><\/p>\n

Coordinated Care:\u00a0<\/b>\u00a0Is the service provided to Enrollees by doctors who are part of the preferred network of providers in your Primary Medical Group. The PCP is the leading provider of services and is responsible to periodically evaluate your health and coordinate all medical services you need.<\/span><\/p>\n

Copayment<\/b>: Money you need to pay at the time of service.<\/span><\/p>\n

Covered Services:<\/b>\u00a0Services and benefits included in Vital.<\/span><\/p>\n

ELA Puro:\u00a0<\/b>An option available to public employees so they can maintain medical coverage when they lose eligibility in the Medicaid Program and the enrollment for other Insurers contracted under Law 95 has ended. This coverage is the same as the coverage of Plan Vital.<\/span><\/p>\n

Emergency Medical Condition:\u00a0<\/b>A medical problem so serious that you must seek care right away to avoid severe harm.<\/span><\/p>\n

Emergency Services:\u00a0<\/b>Treatment of an emergency medical condition to keep it from getting worse.<\/span><\/p>\n

Enrollment Counselor:\u00a0<\/b>An individual or entity that performs choice counseling, or enrollment activities, or both.<\/span><\/p>\n

Grievance:<\/b>\u00a0A formal claim made by the Enrollee in writing, by telephone or by visiting your plan or the Health Advocate Office,<\/span> regarding an expression of dissatisfaction about any matter that is not an Adverse Benefits Determination.<\/span><\/p>\n

HIPAA (Health Insurance Portability and Accountability Act):<\/b>\u00a0The law that includes regulations for establishing safe electronic health records that will protect the privacy of a person\u2019s medical information and prevent the misuse of this information.<\/span><\/p>\n

High Cost High Needs Program:<\/b>\u00a0 A specialized program of coordinated care for Enrollees with specific conditions that require additional management due to the cost or elevated needs associated with the condition.<\/span><\/p>\n

Hospital:\u00a0<\/b>A facility that provides medical-surgical services to patients.<\/span><\/p>\n

Insurer (plan)<\/b>: The company contracted with ASES to provide your medical services under Plan Vital.<\/span><\/p>\n

Medical Record:\u00a0<\/b>Detailed collection of data and information on the treatment and care the Patient receives from a health professional.<\/span><\/p>\n

Medically Necessary<\/b>: Services related to (i) the prevention, diagnosis, and Treatment of health impairments; (ii) the ability to achieve age-appropriate growth and development; or (iii) the ability to attain, maintain, or regain functional capacity. Additionally, Medically Necessary services must be:<\/span><\/p>\n