Helpful Health Insurance Definitions:

The words used to describe health insurance may be different from what you usually use.  Here is a listing of definitions that may help you:

Appeal: A verbal or written complaint about a decision made by Neighborhood Health Plan of Rhode Island.

Benefit Period: The period of time you have health insurance.

Benefits: The health and other services you can get as a Member of Neighborhood Health Plan of Rhode Island.

Complaint, Informal: A verbal or written statement that a Member is not happy with Neighborhood Health Plan of Rhode Island physical or behavioral health care received or requested and denied.  An Informal Complaint can be resolved immediately without having to be considered as a grievance.  An Informal Complaint can be resolved immediately without having to be considered as a grievance.  Complaints may be voiced or filed by 1) a Member; 2) the Member’s Authorized Representative; or 3) a doctor acting on behalf of the Member.

Duplicate Coverage: Other insurance, (such as Medicare, Worker’s Injury Coverage, coverage from an auto accident, or Employer) that covers the same services as RIte Care.  Neighborhood Health Plan of Rhode Island will work with your other insurances for payment.

Durable Medical Equipment and Medical Supplies (DME): This is equipment that is used at home. Examples of medical equipment are a wheelchair or a walker. Examples of medical supplies can be diapers or bandages.

Emergency Medical Care: This is medical care and treatment needed when you are seriously sick or injured. This is when you need treatment right away. If you don’t get treatment, it could cause death, harm your body or seriously hurt your overall health.

Family Planning: This is health education that helps you make the right choices about birth control.

Fraud: Not telling the truth and/or knowing that the lie could result in abuse or misuse of benefits.

Grievance: This is a verbal or written complaint about the medical care or services you get. This is when an investigation is needed. This is when a formal review process happens. A Grievance may be filed by: 1) a Member; 2) the Member’s Authorized Representative; or 3) a doctor acting on behalf of the Member. A verbal Grievance must be followed by a written statement within ten (10) days. If you need help filing a written statement, a Member Services Specialist can help you.

HMO: Stands for “Health Maintenance Organization”.  Also called a health plan or “managed care organization”.

Health plan: The benefits given by your health insurance company.  You go to the doctors and hospitals that are part of that plan.

Home Health Care: These are medical services and care that are given in the home. 

Hospice: This is care for a Member who might not live more than six (6) months.

Hospital: A medical care facility that has a contract with Neighborhood Health Plan of Rhode Island.

Identification Card (ID): A card with information about your Neighborhood Health Plan of Rhode Island program.

Immunizations: These are shots that help you to not get sick.

Managed Care: Care that is managed by your PCP. This care helps to keep you healthy and get the best care from your medical plan.

Medically necessary: This is a service or care that is right for your illness, injury or medical condition.

Member: A person who is in the Neighborhood Health Plan of Rhode Island managed care program.

Member Responsibilities: This is what you have to do as a the Neighborhood Health Plan of Rhode Island Member. (link)

Member Rights: As a Member you can pick a Primary Care Physician. You can get the medical care you need. You can voice your Complaints or Grievances. (link)

Network Provider: A doctor, clinic, group, or facility that works with Neighborhood Health Plan of Rhode Island.  They help to give medical care to Members.

Non-Contracting Provider: Any doctor who does not have a contract with Neighborhood Health Plan of Rhode Island.

Non-Covered Benefits: Services that are not covered and that Neighborhood Health Plan of Rhode Island will not pay for.

Preventive Care: These are health services you and your family can get to help you not
get sick, get a disease, or hurt yourself.

Primary Care Provider (PCP): The doctor you have picked from the list that was sent to you. This PCP will help you with all your health care.

Practitioner: Another word for doctor.

Primary Care Site: The office where your doctor or nurse practitioner is located.

Provider: A doctor or nurse practitioner that helps care for you or your family. They may be a specialist, focusing mostly on one aspect of health or the body. They work with your primary care provider to keep you well.

Referral: This is a form from your PCP sending you to see another doctor for care.

Second Opinion: This is when you or your PCP asks another doctor about your sickness.

Well Child Check Ups: Well Child Health Checks are good for babies, children and teens even if they are not sick. Shots and other care your child’s PCP gives at the visit can help prevent sickness.

Urgently Needed Services: These are services that are needed to stop damage to a Member’s health.