“Primary Care Physician (PCP)” means a Participating Physician who supervises, coordinates
and provides primary care services to Enrollees, including the initiation of their referral for specialist
services and other non-PCP services, and who meets all the other requirements for PCP contained in
CAREPLUS’ rules and regulations and in the Primary Care Physician Agreement. Also referred to
“Primary Care Services” means Covered Services customarily provided by a PCP in his or her
office as well as services customarily provided by an attending PCP to institutionalized patients.
This includes, by way of example and not limitation, the primary care services as set forth in
Attachment “A” of the PCP Agreement.
“QIO (Quality Improvement Organization)” means an Organization comprised of practicing doctors and other health care experts under contract to the Federal government to monitor and
improve the care given to Medicare enrollees. QIOs review complaints raised by enrollees about the
quality of care provided by physicians, inpatient hospitals, hospital outpatient departments, hospital
emergency rooms, skilled nursing facilities, home health agencies, Medicare health plans, and
ambulatory surgical centers. The QIOs also review continued stay denials for enrollees receiving
acute inpatient hospital facilities as well as coverage terminations in SNFs, HHAs and CORFs.
“Special Needs Plan” or “SNP” were created by Congress in the Medicare Modernization Act
(MMA) of 2003 as a new type of Medicare managed care plan focused on certain vulnerable groups
of Medicare beneficiaries: the institutionalized, dual-eligibles and beneficiaries with severe or
disabling chronic conditions. SNPs offer the opportunity to improve care for Medicare beneficiaries
with special needs by through improved coordination and continuity of care and by combining
benefits available through Medicare and Medicaid.
“Specialist Physician” means a Participating Physician who is Board Certified or has met the
academic requirements to sit for the Board in a certain medical specialty; who provides services to
Enrollees within the range of such specialty; who elects to be designated as a Specialist Physician by
CAREPLUS; and who meets all other requirements for Specialist Physicians contained in
CAREPLUS’ rules and regulations and in the Agreement between CAREPLUS and the Specialist
“Specialist Services” means those services of a Specialist Physician, within the scope of his/her
Board Certified or Board Eligible specialty, that are:
(1) provided upon the referral of a PCP pursuant to CAREPLUS’ rules and regulations;
(2) Covered Services, but not PCP Services.
“Subscriber” means any individual who has entered into a Subscriber Agreement with CAREPLUS
directly or through his or her employer for the provision of Covered Services. Dependents that are
eligible to receive Covered Services under CAREPLUS’ applicable Subscriber Agreement shall be
considered as Enrollees.
“Urgent Care” means care provided for those problems which, though not life-threatening, could
result in serious injury or disability unless medical attention is received (e.g., high fever, animal
bites, fractures, severe pain) or do substantially restrict a Member’s activity (e.g., infectious
illnesses, flu, respiratory ailments, etc.)
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