Basic Plan SPD >> Glossary

Allowed amount means the maximum the Fund will pay for a covered service. The allowed amount is based on an agreement with the provider. If you receive covered health care services from a non-network provider in an emergency, the allowed amount is the amount billed by the provider unless the claims administrator negotiates a lower rate.

Congenital Anomaly means a physical developmental defect that is present a birth and is identified within the first 12 months of birth.

Contributing employer (or “employer”) is a person, company or other employing entity that has signed a collective bargaining agreement or participation agreement with the union or trust, and the agreement requires contributions to the Health Fund for work in covered employment.

Co-payment means the flat-dollar fee you pay for office visits and certain covered services. The Plan then pays 100% of remaining covered expenses.

Covered employment means work in a classification for which your employer is required to make contributions to the Fund.

Covered  health services means those health services, including services, supplies or pharmaceutical products, which the Fund determines to be:

• provided for the purpose of preventing, diagnosing or treating sickness, injury, mental illness, substance abuse, or their symptoms;
• consistent with nationally recognized scientific evidence as available, and prevailing medical standards and clinical guidelines as described on the following page;
• not provided for the convenience of the covered person, physician, facility or any other person;
• included in the covered services section of this SPD;
• provided to a covered person who meets the Plan’s eligibility requirements, as described under the eligibility section; and
• not identified in the exclusions section.

In applying the previous definition, "scientific evidence" and "prevailing medical standards" have the following meanings:

• “scientific evidence” means the results of controlled clinical trails or other studies published in peer-reviewed, medical literature generally recognized by the relevant medical specialty community; and
• “prevailing medical standards and clinical guidelines” means nationally recognized professional standards of care including, but not limited to, national consensus statements, nationally recognized clinical guidelines, and national specialty society guidelines.

The claims administrator maintains clinical protocols that describe the scientific evidence, prevailing medical standards and clinical guidelines supporting its determinations regarding specific services. You can access these clinical protocols (as revised from time to time) on www.myuhc.com or by calling the number on the back of your ID card. This information is available to physicians and other health care professionals on United- HealthcareOnline.

Covered Services are the services for which the Fund provides benfits under the terms of the Plan.

Designated Facility means a facility that has entered into an agreement with the claims administrator or with an organization contracting on behalf of the Plan to provide covered health services for the treatment of specified diseases or conditions. A designated facility may or may not be located within your geographic area. To be considered a designated facility, a facility must meet certain standards of excellence and have a proven track record of treating specified conditions.

Doctor means a licensed and qualified provider (M.D., D.O., D.C., or D.P.M.) who is authorized to practice medicine, perform surgery and/or prescribe drugs under the laws of the state or jurisdiction where the services are rendered, acts within the scope of his or her license and is not the patient or the parent, spouse, sibling (by birth or marriage) or child of the patient.

Durable Medical Equipment (DME) means medical equipment that is all of the following:

• used to serve a medical purpose with respect to treatment of a sickness, injury or their symptoms;
• not disposable;
• not of use to a person in the absence of a sickness, injury or their symptoms;
• durable enough to withstand repeated use;
• not implantable within the body; and
• appropiate for use, and primarily used, within the home.

Emergency means a condition whose symptoms are so serious that someone who is not a doctor—but who has average knowledge of health and medicine—could reasonably expect that, without immediate medical attention, the following would happen:

• the patient’s health would be placed in serious jeopardy

• there would be serious problems with the patient’s body functions, organs or parts

• there would be serious disfigurement, or

• the patient or those around him or her would be placed in serious jeopardy, in the event of a behavioral health emergency.

Severe chest pains, extensive bleeding and seizures are examples of emergency conditions.

Injury means bodily damage other than sickness, including all related conditions and recurrent symptoms.

In-network benefits are benefits for covered services delivered by providers and suppliers who have contracted with the Fund, UHC or Medco or with any other administrators under contract to the Fund, to provide services and supplies at a pre-negotiated rate. Services provided must fall within the scope of their individual professional licenses. There are no out-of-network hospital or medical benefits.

Network means the same as in-network.

Participating provider means a provider that has agreed to provide services, treatment and supplies at a pre-negotiated rate under the medical and prescription drug plans.

Personal Health Support means programs provided by the claims administrator, UHC, that focus on prevention, education and closing the gaps in care designed to encourage an efficient system of care for you and your covered dependents.

Sickness means physical illness, disease or pregnancy. The term sickness as used in this SPD does not include mental illness or substance abuse, regardless of the cause or origin of the mental illness or substance abuse.