Action: A health plan denial of a service or payment or the failure to provide a service in a timely manner.

Administrative Hearing: A Department of Human Service (DHS) hearing related to an Action that is held when requested by a health plan member. Members can request an Administrative Hearing from DMAP or AMH up to 45 days after an action or decision made by FamilyCare. We encourage members to contact FamilyCare as the first contact for questions regarding any action or decision made by FamilyCare.

Advance Directive: A form telling your doctor, family and anyone else who may take care of you, about the type of medical care you want if you are physically or mentally unable to do so.

Appeal: A request by a member or the member’s representative for a review of an Action.

Customer Service: The department of employees at FamilyCare that receives most of your calls and answers questions about your benefits and our services, helps you choose a Primary Care Provider, and assists in answering questions about claims and referrals.

Declaration of Mental Health Treatment: A form telling your provider, family and anyone else who may take care of you, about the type of mental health care you want if you are physically or mentally unable to do so.

Department of Human Services (DHS): Oregon’s statewide health and human services agency, which includes the Division of Medical Assistance Programs (DMAP) and Addiction and Mental Health Division (AMHD).

Emergency Care: Care you receive for unforeseen illness or injury which threatens life or limb or health of your unborn child. Such as sudden bleeding that does not stop, loss of consciousness, trouble breathing, suspected heart attack, and broken bones.

Exceptional Needs Care Coordination (ENCC): Additional assistance provided to members who have complex needs. These services are for persons age 65 or older, persons with disabilities and children in foster care.

Excluded Services: Services that are not covered by the Oregon Health Plan.

Grievance: Dissatisfaction with any matter other than an Action.

Limited Services: Services that are covered for only a limited period of time or limited number of visits. Services can be limited to treat certain diagnoses or conditions.

Mental Health Primary Care Provider (MHPCP): The provider you choose to take care of your mental health needs including treatment for chemical dependency. Your MHPCP will set up a care plan for you from therapy and counseling to crisis planning.

Obstetrician: A provider who takes care of all your health care needs when you are pregnant and who can deliver your baby at the hospital.

Primary Care Provider (PCP): The provider you choose to take care of your basic healthcare needs, who coordinates all your health care and gives referrals if services are needed outside of his or her office.

Routine Care: Care from your PCP for such health care needs as immunization (shots), well visits, sore throat, colds, flu, back pain, tension headaches or follow-up emergency visits (if you have visited the emergency room).

Service Area: The geographic location covered by the Health Plan.

Specialist: Anyone who practices a very specific type of medicine such as an Ear, Nose and Throat doctor, Physical Therapist or Surgeon, etc.

Urgent Care: An illness or injury that must be seen within 24-48 hours, such as high fever, repeated vomiting, repeated diarrhea that is not an immediate threat to your health.