Glosario
Aquí tiene algunos términos que podría encontrar en este sitio web o en su Manual para asegurados.
A
Apelación
A request for your managed care organization to review services that were denied or terminated.
B
C
Queja
An expression of dissatisfaction expressed orally or in writing to the managed care organization.
Copayment (Copago)
Un monto fijo (por ejemplo, $15) que usted paga por un servicio de atención médica con cobertura, por lo general, cuando recibe el servicio. El monto puede variar según el tipo de servicio de atención médica con cobertura.
D
Durable Medical Equipment (DME, equipos médicos duraderos)
Equipo solicitado por un prestador de servicios médicos para uso diario o prolongado. Coverage for DME may include, but is not limited to: oxygen equipment, wheelchairs, crutches, or diabetic supplies.
E
Emergency Medical Condition
An illness, injury, symptom, or condition that is sudden and severe. Emergencies can damage bodily functions or body organs. Sin ayuda médica inmediata, su salud o su vida podrían correr peligro.
Emergency Medical Transportation (Transporte médico de emergencia)
Servicios de ambulancia por tierra o por aire en caso de un problema médico de emergencia.
Servicios de emergencia
Care you get in an emergency room to stop a severe medical condition from getting worse.
Excluded Services
Health care services that your health insurance or health plan may not cover.
F
G
Inconformidad
A formal, written complaint to the managed care organization that requires further review.
H
Habilitation Services and Devices
Health care services, such as physical or occupational therapy that help a person keep, learn, or improve skills and functioning for daily living.
Home Health Care (Atención médica en el hogar)
When a health professional visits you at home. Por lo general, da seguimiento a sus problemas de salud actuales o a su recuperación después de una estadía en el hospital.
Hospice Services (Atención médica para pacientes terminales)
Services that provide comfort and support for people in the last stages of a terminal illness and their families.
Hospital Outpatient Care (Atención hospitalaria para pacientes ambulatorios)
Atención médica en un hospital que, por lo general, no requiere una estadía de una noche.
Hospitalization (Hospitalización)
Atención médica en un hospital que requiere la admisión como paciente hospitalizado y que, por lo general, requiere una estadía de una noche.
I
In-Network Provider
A provider who has a contract with your health plan to provide covered services to you. A participating provider is also known as an in-network provider.
J
K
L
M
Managed Care Organization (MCO)
A health plan contracted by HHSC to deliver Medicaid and CHIP benefits to members.
Medically Necessary (Médicamente necesario)
Servicios o suministros de atención médica necesarios para prevenir, diagnosticar o tratar una enfermedad, una lesión, un problema médico o una afección, o sus síntomas, y que cumplen con las normas médicas establecidas. BCBSTX incluye toda la atención médicamente necesaria que tiene cobertura bajo Medicaid.
N
Network (Red)
Los centros, profesionales médicos y proveedores contratados por su aseguradora o cobertura médica para prestar servicios de atención médica.
O
Out-of-Network Provider
A provider who is not contracted with your health plan to provide covered services to you. It may be more difficult to obtain prior authorization from BCBSTX if you go to an out-of-network provider. In some cases, such as when there are no other providers, BCBSTX can contract to pay a provider that is not in our network. An out-of-network provider is also known as a non-participating provider.
P
Cobertura
A benefit, like Medicaid, which provides and pays for your health care.
Medicamentos con receta
Drugs and medications require a prescription by law. For STAR and CHIP members, your plan covers prescription drugs that are on your Preferred Drug List.
Prestador de atención médica primaria
Un médico de atención primaria es su médico personal, quien le brindará la mayor parte de su atención médica. PCPs can be a Medical Doctor (M.D.), Doctor of Osteopathic Medicine (D.O.) or other health care provider who is licensed, certified or accredited, as required by state law.
Autorización previa
Some services for health care and certain drugs require approval from Blue Cross and Blue Shield of Texas. This approval is called "prior authorization." If BCBSTX does not approve the services or drugs, the costs will not be covered (paid for) by BCBSTX.
Prestador de servicios médicos
Un profesional médico es un médico, una instalación o un profesional de la salud con licencia. Su médico de atención primaria es un profesional médico. Providers offer medical services and treatment to health plan members.
Servicios para profesionales de la salud
Health care that is coordinated by a licensed medical provider. This care may be handled by a Medical Doctor, Doctor of Osteopathic Medicine, Nurse Practitioner, or other health care provider.
Q
R
Rehabilitation Services and Devices
Health care services, such as physical or occupational therapy, that help a person keep, get back or improve skills and functioning for daily living that have been lost or impaired because a person was sick, hurt or disabled.
S
Skilled Nursing Care (Atención de enfermería especializada)
Skilled nursing or rehab care that is supplied by licensed health professionals, like nurses, and physical therapists. Esta atención se suele brindar después de una lesión, una cirugía o para ayudarle a controlar una enfermedad de por vida.
Specialist (Especialista)
Un especialista es un profesional médico que es un experto capacitado en un área específica de la salud. Puede tratarse de un determinado sistema del cuerpo, una enfermedad o un tratamiento.
T
U
Atención médica inmediata
La atención médica inmediata incluye servicios de atención médica por una enfermedad, lesión o problema médico que requiere atención inmediata. However, it isn't serious enough to go to an emergency room (ER) for.
