Ambulatory Care – The health services provided without hospitalizing the patient. Services may be provided in a physician’s office, clinic, health center or hospital outpatient facility.

Authorized Service – A health care service or procedure that must be pre–certified or authorized in advance by DMC Care

Case Management – The process that reviews, organizes and coordinates services and resources to optimally respond to an individual’s health care needs through the continuance of inpatient and outpatient care.

Continuous Quality Improvement – DMC Care’s ongoing process designed to systematically monitor and evaluate the quality and appropriateness of patient care, pursue opportunities to improve patient care and resolve identified problems.

COB (Coordination of Benefits) – The practice of coordinating a patient’s various medical coverage’s to avoid duplicate payments for medical treatment. COB is done prior to payment by most health plans.

Co-Payments – The portion of the In-Network charge for services, such as physician office visits or prescription drugs, which is paid out-of-pocket by the DMC Care member.

Deductible – The portion of the out-of-network expenses members are responsible for when obtaining services from a non-contracted, out-of-network provider.

DMC Care Plan – Is the preferred provider plan sponsored by The Detroit Medical Center and its network of Participating Physicians.

Emergency – An urgent/emergent medical condition is defined as the sudden onset of acute signs or symptoms of sufficient severity which, 1) while not likely to cause death or irreparable harm if not treated immediately, requires treatment with dispatch; 2) cannot be electively scheduled; 3) will invariably result in the patient’s death or permanent impairment of the patient’s health or bodily functions if there is a delay in treatment.

Fee-For-Service – A method of reimbursement, where payment is based upon the service rendered.

In-Network – A physician, hospital or ancillary provider that has signed a contract with DMC Care to provide services to DMC Care members.

Medical Necessity (Medically Necessary) – A state for which medical or health services are ordered or arranged for and are reasonably expected to improve the member’s illness or disease. DMC Care reserves the right to refer to prevailing standards of medical care in its determination of Medical Necessity.

Member – The Subscriber or a covered dependent who is entitled to receive DMC Care covered services.

Non-Participating Provider – A physician, hospital or other ancillary provider that has not contracted to provide services to DMC Care members.

Participating Physician – A physician, dully licensed in the State of Michigan, who contracts with DMC Care in writing, or directly or indirectly through (1) a physician independent practice association or (2) a corporation which contracts with DMC Care, in writing, to provide covered services to covered persons.

Participating Provider – A physician, hospital or other ancillary provider that has contracted to provide services to DMC Care members.

Prior–Authorization –The process by which authorization is granted prior to a scheduled admission and/or the rendering of particular ambulatory, diagnostic or surgical procedure. During pre-certification of inpatient admissions, length of stay is also assigned, based upon the admitting diagnosis.

Risk Management – The process that identifies, objectively assesses and attempts to prevent events that are inconsistent with accepted standards of medical practice, in the delivery of health care services, which could result in potential harm to patients, physicians or other health care providers.

Subscriber – An employee eligible to receive services under the Plan.

Third–Party Administrator (TPA) – A firm that provides claims processing and other administrative services to self-funded employer groups.

Utilization Review- A process of review of the use of medical services in terms of patterns or rates of use of a single service or type of service such as hospital care, physician visits, and prescription drugs.