Glossary

National Committee for Quality Assurance (NCQA)

NCQA is an independent, not-for-profit organization that evaluates managed care plans. The NCQA accreditation process is nationally recognized and evaluates how well a health plan manages all aspects of its system and the extent to which it helps to continuously improve health care for individuals. Consider looking into health plan accreditation status by visiting www.ncqa.org.

Necessary, Medically Necessary, Medically Necessary Services or Medical Necessity

Medical services or supplies that are appropriate and effective for the treatment of an illness or injury in accordance with clinical research findings or accepted medical standards, as described in the covered benefits section of individual plan documents. Health benefits plans typically pay only for services and supplies that are medically necessary.

Network

Also called "provider network." A panel of physicians, hospitals and other health care professionals who contract with a health benefits plan to provide services, typically at a negotiated rate of payment. With certain plans, an individual must access care from a network provider in order to receive the maximum level of benefits.

Non-participating Provider

This term is generally used to mean physicians, hospitals and other health care professionals who have not contracted with a health plan to provide services. Also called "non-preferred provider."