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Abuse: The excessive and improper use of a product, service or benefit, which results in unnecessary or excessive costs for the health care system. 

Access: The guarantee that the Enrollee will be able to receive all the medically necessary services included in the GHP coverage without any barriers.

Administrative Referral: Written authorization issued by the Health Plan for the Enrollee to receive the required service, if medically necessary, when the PCP or other PMG physician does not provide a Referral within the required time period.

Advance Directives: 
Written or verbal instructions, such as wills or powers-of attorney related to decisions about services and health care expressed by the person in advance in case an event occurs and he/she may be unable to make such decisions.

Ancillary Services: All those supplementary services provided to the Patient to assist in the diagnosis and Treatment of an illness or injury. Examples of these services include but are not limited to laboratory, radiology, therapies, etc.

Authorization: 
A written document through which a person freely and voluntarily authorizes  another person or provider to represent him/her to apply, use and disclose  health information for medical or Treatment purposes or to initiate an action such as a Grievance. It may also be used to annul a previous authorization. 

Auto Enrollment:
Automatic enrollment in the Health Plan of a Medicaid certified eligible person once the Health Plan is notified of such eligibility.

CHIP: 
Children Health Insurance Program, a federal program that provides medical Service Coverage to low-income children under age 18 through health plans qualified to offer coverage under this program.

Coinsurance:
A percentage of the cost of a health service which the Enrollee must pay after receiving the service.

Commonwealth Population:
The Commonwealth Population is comprised of the following: (i) Certain persons who are older than twenty-one (21) and  younger than sixty-five (65) years of age, inclusive of the age limits, and who do not qualify for either Medicaid or CHIP; (ii) Police officers of the Commonwealth and their dependents; (iii) Surviving spouses of deceased police officers enrolled at the time of death;(iv) Survivors of domestic violence referred by the Office of the Women’s Advocate; (v) Veterans; and (vi) Commonwealth employees and pensioners whose eligibility for the GHP is not based on income.

Complaint:
An informal claim on the quality of care, customer service or treatment received by providers, personnel of your Health Plan, or PMG. It does not include disputes involving medical services, coverage or payment for services.

Consultation:
An opinion requested by a health professional to another on a matter related to the health condition of a Patient.

Coordinated Care
:  Is the service provided to Enrollees by doctors who are part of the preferred network of providers of your PMG. The PCP is the leading provider of services and is responsible to periodically evaluate your health and coordinate all medical services you need.

Coordination of Benefits:
It refers to the order in which health services are paid when the person has more than one health plan. One of the plans is considered the primary plan. The GHP will always be considered the last payor.

Copayment
: An established fixed amount that is the Enrollee’s contribution to the expense for a medical service he/she receives. 

Covered Services:
Those services and benefits included in the GHP coverage.

Deductible:
A fixed amount pre-determined by ASES, which the Enrollee must pay when he/she receives, health services.

ELA Puro
: An option available to public employees so they can maintain medical coverage when they lose eligibility in the Medicaid Program for excess of income and the enrollment for other health plans contracted under Law 95 has ended; or is chosen by the public employee as his/her health plan during the enrollment period for Law 95.. This coverage is the same as the coverage of the GHP.

Enrollee:
A person who after being certified as eligible under the Medicaid Program has completed the enrollment process with the Health Plan and for whom the Health Plan has issued the ID card that identifies the person as a GHP Enrollee. 

Federal Population:
CHIP and Medicaid eligible individuals.  

Good Cause: 
Refers to situations that allow Enrollees to change his/her PCP or PMG. These are: 1) The Enrollee moved outside the Region, 2) The Enrollee’s religious or moral convictions conflict with the services offered by Providers in the PMG, 3) The Enrollee needs related services to be provided concurrently; not all services are available within the Preferred Provider Network associated with a PMG; and the Enrollee’s PCP or any other Provider has determined that receiving the services separately could expose the Enrollee to an unnecessary risk, 4) Other acceptable reasons include, but are not limited to, poor quality of care, lack of Access to services covered or lack of providers with experience to provide the health care the Enrollee needs. ASES will determine if the reason constitutes a Good Cause.

Grievance:
A formal claim made by the Enrollee in writing, by telephone or by visiting your Health Plan or the Health Advocate Office, requesting a solution be granted when a service has been denied or allowed on a limited basis. A service; reduction, suspension or termination of a previously authorized service; total or partial denial of payment for a service; not having received services in a timely manner; when your Health Plan has not acted on a situation according to the established terms, refusal of your Health Plan to let the Enrollee exercise his/her right to receive services outside the network.

Health Plan:
The managed care organization or insurance company that is providing services in the GHP program for your region.  There is one health plan per region.

HIPAA (Health Insurance Portability and Accountability Act):
The law that includes regulations for establishing safe electronic health records that will protect the privacy of a person’s medical information and prevent the misuse of this information.

Hospital:
A facility that provides medical-surgical services to hospitalized Patients.

Identification (ID) Card:
A card your Health Plan delivers to you once the Auto Enrollment is completed or you complete the subscription process, which identifies the Enrollee by name and contract number, and includes information on coverage, Copayments, customer service and health advice telephone numbers.

Medical Record:
Detailed collection of data and information on the Treatment and care the Patient receives from a health professional.

Medicare Beneficiary:
Persons aged 65 or more, who are disabled or have renal disease, which have Medicare Parts A coverage for Hospital services or Parts A and B for Hospital, ambulatory and medical services. 

Medicaid
: Program that provides health insurance for people with low or no income and limited resources, according to federal and local regulations.

Primary Care Physician (PCP)
: A licensed medical doctor (MD) who is a provider and who, within the scope of practice and in accordance with Puerto Rico certification and licensure requirements, is responsible for providing all required primary care to Enrollees.   The PCP is responsible for determining services required by Enrollees, provides continuity of care, and provides Referrals for Enrollees when Medically Necessary.  A PCP may be a general practitioner, family physician, internal medicine physician, obstetrician/gynecologist, or pediatrician.

Patient
: Person receiving Treatment for his mental and physical health.

Post-Stabilization Services:
Covered Services, relating to an Emergency Medical Condition or Psychiatric Emergency, that are provided after an Enrollee is stabilized, in order to maintain the stabilized condition or to improve or resolve the Enrollee’s condition.

Preauthorization:
Permission your Health Plan grants in writing to you, at the request of the PCP, Specialist or sub-specialist, to obtain a specialized service.

Prescription:
Original written order issued by a duly licensed health professional, ordering the dispensing of a product, drug or formula.

Preferred Provider Network:
Health professionals duly licensed to practice medicine in Puerto Rico contracted by your Health Plan for the Enrollees to use as their first option. Enrollees can access these providers without Referral or Copayments if they belong to their PMG.

Primary Medical Group (PMG):
Health professionals grouped to contract with your Health Plan to provide health services under a Coordinated Care model.

Referral:
Written authorization a PCP issues to an Enrollee to receive services from a Specialist, sub-specialist or facility outside the preferred network of the PMG.

Semi-Private Room:
Hospital room with two beds.

Service Coverage:
All the services offered to the GHP Enrollees under the Basic, Special, Mental, Dental and Pharmacy Coverages. 

Special Coverage Registry:
A form the PCP and, on some occasions, the specialist, fills out and sends to the Health Plan when the Enrollee is diagnosed with one or more of the conditions that are part of the Special Coverage; for the Patient to receive Treatment and services directly from necessary Specialists or sub-specialists without the need of a Referral or prescription authorization.

Specialist:
A health professional licensed to practice medicine and surgery in Puerto Rico that provides specialized medical and complementary services to the primary physicians. This category includes: cardiologists, endocrinologists, neurologists, surgeons, radiologists, psychiatrists, ophthalmologists, nephrologists, urologists, physiatrists, orthopedists, and other physicians not included in the definition of PCP.

Second Opinion:
Additional Consultation the Enrollee makes to another physician with the same medical specialty to receive or confirm that the initially recommended medical procedure is the Treatment indicated for his condition.

Treatment:
To provide, coordinate or manage health care and related services offered by health care providers.

Urgency:
A medical condition that poses no risk of imminent death that can be treated in the doctor's office or in the facilities with extended hours and not in emergency rooms. An Urgency can become an emergency if not properly dealt with at the right time.

Waste: Is the overutilization of services, misuse of resources or other practices that, directly or indirectly, result in unnecessary costs.
 

Enrollee Services
1-844-336-3331 (toll free)
787-999-4411 TTY (hearing impaired)
Monday through Friday
from 7:00 a.m. to 7:00 p.m.

Postal Address
PO BOX 72010
San Juan, PR 00936-7710

Physical Address
Fundación Ángel Ramos 
Ave. Chardón  
Hato Rey, PR

Policies

Non Discrimination