The dollar amount allowed by SelectHealth for a specific covered service.
The payments and privileges to which you are entitled by your Certificate of Coverage and Contract.
Coverage required by the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA).
A percentage of the allowed amount stated in your Member Payment Summary (MPS) that you must pay for covered services to the provider and/or facility.
COBRA Coverage and/or Utah mini-COBRA Coverage.
A fixed amount stated in your Member Payment Summary that you must pay for covered services to a Provider or Facility.
An amount stated in your Member Payment Summary that you must pay each year for covered services before we make any payment. Some categories of benefits may be subject to separate deductibles.
|Diagnostic Test, Major|
Diagnostic tests categorized as major by SelectHealth. We categorize tests based on several considerations, such as the invasiveness and complexity of the test, the level of expertise required to interpret or perform the test, and the facility where the test is commonly performed. Examples of common major diagnostic tests are:
- imaging studies such as MRIs, CT scans, and PET scans
- neurologic studies such as EMGs and nerve conduction studies.
- cardiac nuclear studies or cardiovascular procedures such as coronary angiograms
- gene-based testing and genetic testing
If you have a question about the category of a particular test, please contact Member Services.
|Diagnostic Test, Minor|
Tests not categorized as major diagnostic tests are considered minor diagnostic tests. Examples of common minor diagnostic tests are:
- bone density tests
- certain EKGs
- common blood and urine tests
- simple X-rays such as chest and long bone X-rays
- spirometry/pulmonary function testing
Charges from providers and facilities that exceed SelectHealth’s allowed amount for covered services. You are responsible to pay for excess charges from nonparticipating providers and facilities. These charges do not apply to your out-of-pocket maximum.
The maximum accumulated amount SelectHealth will pay for certain covered services (as allowed by the Affordable Care Act) during the member’s lifetime. The limit includes all amounts paid on behalf of the member under any prior health benefit plans insured by SelectHealth (including those sponsored by former employers) or any of its affiliated or subsidiary companies. If applicable, the lifetime maximum is specified on the Benefit Summary/Member Payment Summary .
|Medical Necessity/Medically Necessary|
Services that a prudent healthcare professional would provide to a patient for the purpose of preventing, diagnosing, or treating an illness, injury, disease, or its symptoms in a manner that is in accordance with generally
- accepted standards of medical practice in the United States;
- clinically appropriate in terms of type, frequency, extent, site, and duration; and
- not primarily for the convenience of the patient, physician, or other provider.
When a medical question-of-fact exists, medical necessity shall include the most appropriate available supply or level of service for the member in question, considering potential benefit and harm to the member. Medical necessity is determined by the treating physician and by SelectHealth’s medical director or his or her designee. The fact that a provider or facility, even a participating provider or facility, may prescribe, order, recommend, or approve a service does not make it medically necessary, even if it is not listed as an exclusion or limitation. FDA approval, or other regulatory approval, does not establish medical necessity.
|Member Payment Summary (MPS)||
A summary of your benefits by category of service. This personalized document is available on My Health.
A lower level of benefits available for covered services obtained from a nonparticipating provider or facility, even when such services are not available through participating providers or facilities.
The maximum amount specified on the Member Payment Summary (MPS) that you must pay each year to providers and/or facilities as deductibles, copays, and coinsurance. Except when otherwise noted on the MPS, we will play 100 percent of allowed amounts during the remainder of the year once the out-of-pocket maximum has been satisfied. Some categories of benefits may be subject to separate out-of-pocket maximums. Payments made for excess charges and non-covered services are not applied to the out-of-pocket maximum.
The higher level of benefits available to you when you obtain covered services from a participating provider or facility.
Prior approval from SelectHealth for certain services.
Services such as annual physical exams, associated tests, well-child visits, immunizations, and cancer screenings. Care provided for the diagnosis or monitoring of illness based on symptoms the member is experiencing is not considered preventive care and will apply to the appropriate medical benefit .
Certain examinations, procedures, immunizations, screenings, X-rays, and laboratory tests that can detect disease conditions not known to currently exist, or which, in the case of immunizations, prevent the development of disease.
|Primary Care Physician or Provider (PCP)|
A general practitioner who attends to common medical problems and provides preventive services and health maintenance. The following types of physicians and providers, and their associated physician assistants and nurse practitioners, are PCPs:
- Certified Nurse Midwives
- Family Practice
- Internal Medicine
- Obstetrics and Gynecology (OB/GYN)
|Secondary Care Provider (SCP)|
Physicians and other providers who are not Primary Care Physicians or Primary Care Providers. Examples of SCPs include:
- Orthopedic Surgeons
- Otolaryngologists (ENTs)
Utah mini-COBRA Continuation coverage required by Utah law for employers with fewer than 20 employees.