Glossary of Terms

Acupuncture
The practice of insertion of needles into specific exterior body locations to relieve pain, to induce surgical anesthesia, or for therapeutic purposes.

Adjudication
The formal process of making a decision on a claim or resolving a disputed claim in claims administration.

Allergy Treatment
The introduction of small quantities of allergens to the patient, usually in the form of skin testing to determine what the patient is allergic to.

Allowable Charge
Charges for medical services or supplies provided by a hospital or physician which qualify as covered expenses as stated in the health plan's certificate of coverage.

Ambulatory Services
Health care services provided to patients who are able to return home without an overnight stay in a medical facility. Typically, ambulatory services include preventive, diagnostic, and treatment services provided on an outpatient basis.

Ambulatory Surgery
Intermediate level surgical procedures that usually are too complex to be performed in a physician's office but do not require inpatient hospitalization.

Appeals
A formal request to reconsider a determination denying certification of an admission, extension of stay or other health care service.

Authorization
The approval of care or service, such as hospitalization, surgical procedure, and/or outpatient treatment or services. This may also include approval of certain medications.

B

Benefit
The amount of money payable by a health plan for the cost of covered services, as defined in the Certificate of Coverage.

Benefit Period
The maximum length of time for which benefits will be paid under the terms of the policy.

Brand Name Drug
Proprietary covered drugs approved by the Federal Food and drug Administration (FDA)

C

Case Management
A standardized program that focuses on coordinating a number of services needed by covered persons, who have prolonged, expensive, or chronic conditions. It includes a standardized, objective assessment of the covered person's needs, and the development of an individualized service or care plan that is goal oriented and based on the needs of the of the covered person.

Certification
A determination by a utilization review organization that an admission, extension of stay, or other health care service has been reviewed and based on the information provided, meets the medical review requirements of the health plan.

Chemotherapy
A method of treatment for internal disease ( usually cancer) involving the use of potent chemicals or drugs.

Chiropractic Care
A system of therapeutics that attributes disease to dysfunction of the nervous system and attempts to restore normal function by manipulation and treatment of the body structures, especially those of the vertebral column.

Claim
An itemized statement of health care services and their costs provided by a hospital, physician's office, or other provider facility. Claims are submitted to the insurer for payment of the costs incurred by the covered person.

COBRA (Consolidated Omnibus Budget Reconciliation Act)
A federal law which, among other things, requires employers to offer employees and their dependents who would otherwise lose their group health plan eligibility, continuation of coverage under the firm's group plan. Employers are required to make health plans available for periods ranging from 18 to 36 months.

Coinsurance
A provision of a program by which the insured shares in the cost of covered services on a percentage basis. The health plan assumes only a certain percentage of the cost while the covered person pays the remainder.

Continuation
A situation where an insured person who would otherwise lose coverage under a health plan due to certain occurrences, such as termination of employment or divorce, is allowed to continue his/her coverage under specified conditions and length of time. (See COBRA)

Contraception
A method to control the ability of becoming pregnant. This is usually accomplished by means of medication, device, or surgical procedures.

Contract
A legal agreement between an individual subscriber or an employer group and a health plan that describes the benefits and limitations of the coverage.

Contract Holder
The group, entity or person to whom a contract is issued

Conversion Option
The option of an individual to convert a group health policy to an individual policy at the time the individual ceases to a member of the group, usually either through termination or retirement. The conversion may result in different benefits and rates.

Coordination of Benefits (COB)
When the covered person is covered by another plan or plans, the benefits under the policy and the other Plan(s) will be coordinated so benefits from all sources do not exceed 100 percent of allowable medical expenses. This means one Plan pays its full benefits, then the other Plan(s) pay(s).

Co-payment (or co-pay)
A specific payment by the covered person at the point of each health service visit. It does not accumulate like a deductible and is not subject to an out-of-pocket maximum.

Covered Services
Any service or supply describe in the Certificate or any Rider for which benefits may be payable in accordance with the terms of the Policy.

Custodial Care
Services or supplies, regardless of where or by whom they are provided which a person without medical skills or background could provide or could be trained to provide; or are provided mainly to help the covered person with daily living activities, including (but not limited to): walking, getting in and/or out of bed, exercising and moving the covered person, bathing, using the toilet, administering enemas, dressing and assisting with any other physical or oral hygiene needs, assistance with eating by utensil, tube or gastrostomy, homemaking, such as preparation of meals or special diets, and house cleaning, acting as a companion or sitter, or supervising the administration of medications which can usually be self-administered, including reminder of when to take such medications, primarily provide a protective environment, primarily part of a maintenance treatment plan or are not part of an active treatment plan intended to or reasonably expected to improve the covered person's sickness, injury or functional ability; primarily provided for the convenience or comfort of the covered or covered person's companion, family member or sitter, or provided because the covered person's home arrangements are not appropriate or adequate to accommodate his or her needs.

Customary and Reasonable (C&R)
See Usual, Customary and Reasonable.

D

Day Treatment Center
An outpatient psychiatric facility, which is licensed to provide outpatient care and treatment of mental or nervous disorders or substance abuse under the supervision of physicians.

Deductible
The amount of out-of-pocket expenses that must be paid for health services by the covered person before the health plan benefit payment begins. This is usually based on a calendar year.

Dental Care
The evaluation, diagnosis, prevention and/or treatment (nonsurgical, surgical or related procedures) of diseases, disorders and/or conditions of the oral cavity, maxillofacial area and/or the adjacent and associated structures and their impact on the human body; provided by a dentist, within the scope of his/her education, training and experience, in accordance with the ethics of the profession and applicable law.

Dependent
An individual other than a health plan subscriber who is eligible to receive health care services under the subscriber's contract. Generally, dependents are limited to the subscriber's spouse and minor children.

Diagnostic Tests
Tests and procedures ordered by a physician to determine if the patient has a certain condition or disease based upon specific signs or symptoms demonstrated by the patient. Such diagnostic tools include, but are not limited to radiology, ultrasound, nuclear medicine, laboratory, pathology services or tests.

Drug Formulary
A listing of prescription medications which are approved for use and /or coverage by the Health Plan and which will be dispensed through participating pharmacies to a covered person. The list is subject to periodic review and modification by the Health Plan.

Durable Medical Equipment
Means medically necessary equipment that is able to withstand repeated or prolonged use; primarily and customarily used to serve a medical purpose; not generally useful to a person in the absence of injury or sickness; and is suited for use in the home. This included supplies that are necessary for use with the equipment. Also referred to as Medical Equipment.

E

Effective Date
The date a health plan contract goes into effect.

Emergency Care
Care for a person with a medical condition or behavioral condition of sudden onset that manifests itself by acute symptoms of sufficient severity (including sever pain) such that a person who possesses an average knowledge of health and medicine could reasonably expect the absence of immediate medical attention to result in placing the health of the insured person in serious jeopardy, serious impairment to bodily functions, serious disfigurement of the insured person, serious impairment of any bodily organ or part of the insured person, or in the case of behavioral condition, placing the health of the insured person or other persons in serious jeopardy.

Enrollee
An individual who is enrolled and eligible for coverage under a health plan contract. Also called Member, Insured, Participant.

Exclusions
Specific conditions or circumstances listed in a health benefit contract or employee benefit plan for which the policy or plan will not provide benefit payments.

Experimental Procedures
Health care services (e.g., medical, surgical, psychiatric, substance abuse, or other services, supplies, treatments, procedures, drug therapies, devices, etc.) which a health plan has determined to be unproven by scientific evidence or not generally accepted by informed health care professionals in the U.S. as effective in treating the condition, illness, or diagnosis for which their use is proposed. Not approved the Food and Drug Administration.

Expiration Date
This may be either the date on which the health insurance master group contract expires or the date that an individual or employee ceases to be eligible for coverage under a group health plan.

Explanation of Benefits (EOB)
A statement sent by a health plan to a covered person who files a claim. The explanation of benefits (EOB) lists the services provided, the amount billed, and the payment made. The EOB statement must also explain why a claim was or was not paid, and provide information about the individual's rights of appeal.

F

Formulary
See Drug Formulary.

G

Generic Drug
Drugs covered by the health plan which are chemically equivalent to Brand Name Drugs whose patent has expired and which are approved by the Federal Food and Drug Administration (FDA).

H

Health Benefit Plan
The health insurance product offered by a health plan that is defined by the benefit contract and represents a set of covered services and provider network.

Health Maintenance Organization (HMO)
A legal entity or organized system of health care that provides directly or arranges for a comprehensive range of basic and supplemental health care services to a voluntarily enrolled population in a geographic area on a primarily prepaid and fixed periodic basis.

Hearing Services
The study, examination, and treatment of defects and diseases of the ear, by inspection, medical treatment and/or devices.

HMO
See Health Maintenance Organization

Home Health Care
Medical care provided by trained personnel in the patient's home for patients who do not need the more extensive treatment provided by a hospital, skilled nursing facility, or extended care facility, or for patients who are not capable of going to a medical facility for outpatient care

Home Infusion Therapy
The administration of intravenous drug therapy in the home. Home infusion therapy includes the following services: solutions and pharmaceutical additives; pharmacy compounding and dispensing services; durable medical equipment and ancillary medical supplies necessary to provide the infusion therapy; and nursing services

Hospice
A program that provides care to the terminally ill; is licensed/certified by the jurisdiction which it operates; is supervised by a staff of physicians with at least one physician on call 24 hours a day; provides 24-hour a day nursing services under the direction of a registered nurse (RN) and has a full time administrator; and provides an ongoing quality assurance program

Hospital
A facility which is licensed by the proper authority in the jurisdiction in which they are located, that provides inpatient services for the care and treatment of patients; has a registered graduate nurse (RN) always on duty; has a laboratory and x-ray facility, as a regular practice, charges patients for its services, and has a resident physician on duty or call at all times; or is accredited by the Joint Commission on the Accreditation of Healthcare Organizations, the American Osteopathic Association or the Commission on the Accreditation of Rehabilitative Facilities, if the function of such facility is primarily to provide rehabilitation specifically for treatment of a physical disability.

I

I.D. Card/Identification Card
A card issued to a covered person and possibly his/her dependents, which allows the covered person to identify themselves or their covered dependent to a provider for health care services. The card is subsequently used by the provider to determine benefit levels and to prepare the billing statement.

Indemnity
The traditional type of health insurance in which the covered person is reimbursed for covered expenses without regard to choice of provider. Also known as fee-for-service plans.

Immunizations
Process of protecting from or making resistant to a disease or infection, usually through a vaccination, either by injection or oral consumption of the vaccine.

In-Network
Refers to the use of providers who participate in the health plan's provider network. Many benefit plans encourage enrollees to use participating (in-network) providers to reduce the enrollee's out-of-pocket expense.

Infertility
Term used to describe the inability to conceive or an inability to carry a pregnancy to a live birth after a year or more of regular sexual relations without the use of contraception.

Infusion Therapy
Treatment accomplished by placing therapeutic agents into the vein, including intravenous feeding. Such therapy also includes enteral nutrition, that is the delivery of nutrients into the gastrointestinal tract by tube.

Inpatient
A person who is admitted to a hospital for medical care, is assigned a bed designated for routine, special, psychiatric, or rehabilitation care, and occupies the bed for 24 hours or more.

Investigational Procedure
See Experimental Procedures.

M

Managed Care
A system of managing and financing health care delivery to ensure that services provided to managed care plan members are necessary, efficiently provided, and appropriately priced.

Maternity Care
Care that promotes the overall health of mother and child from conception, during pregnancy and delivery, and through the post partum period after delivery.

Medical Equipment (DME)
See Durable Medical Equipment.

Medically Necessary
Those covered services required to preserve and maintain the health status of a covered person in accordance with the accepted standards of medical practice in the medical community in the area where services are rendered. In other words, services or treatments are considered medically necessary and appropriate if they could not have been omitted without adversely affecting the patient's condition or the quality of medical care provided.

Member
An individual or dependent who is enrolled in and covered by a managed health care plan. Also referred to as an Enrollee, Beneficiary, Participant, Covered Person, Subscriber, and Eligible Individual.

Mental health/Behavioral Health
A condition or disease regardless of its cause, listed in the most recent edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders.

N

Network
The doctors, clinics, hospitals, and other medical providers that a health plan contracts with to provide health care to its members. Members are generally limited to network providers for full coverage of their health costs.

Network Provider
The doctors, clinics, hospitals, and other medical providers that are in the network(s) of the health plan.

Non-Participating Provider
A provider that has not contracted with a health plan to provide health care services to covered persons. Generally health care benefits are reduced when a non-participating provider is utilized.

O

Occupational Therapy
Medically directed treatment of physically or mentally disabled individuals by means of constructive activities such as walking, eating, drinking, dressing, toileting, and bathing, designed by a qualified occupational therapist to promote the restoration of useful function.

Out of Network
The use of health care providers who have not contracted with the health plan to provide services. HMO members are generally not covered for out-of-network services except in emergency situations. Members enrolled in preferred provider organizations (PPO) and point-of-service (POS) coverage can go out-of-network, but will pay some additional costs.

Out-of-Pocket Maximum
The amount which a covered person must pay for deductibles, coinsurance and copays in a defined time period (generally calendar year) before the health plan covers all remaining medical services at 100%.

Outpatient
A patient who received medical services at a health facility without being admitted to the facility for an overnight stay, also referred to as "Ambulatory".

Outpatient Surgery
Any institution, place or building devoted primarily to the performance of one day or same day surgery without anticipation of the overnight say of patients.

P

Partial Day Treatment
A program offered by appropriately licensed psychiatric facilities that includes either a day or evening treatment program for mental health or substance abuse.

Participating Provider
A provider who has contracted with a managed care plan to provide medical services to plan members. The provider may be a hospital or other medical facility, a pharmacy, a physician, or other practitioner who has contractually accepted the terms and conditions as set forth by the plan. Also called Preferred Provider.

PCP
See Primary Care Physician

Physical Therapy
Rehabilitation concerned with the restoration of function and the prevention of disability following disease, injury, or loss of a body part.

Plan Benefit Maximum
The maximum amount that a health plan will pay toward the cost of services incurred by an individual or family in a specified period, usually a calendar year.

Point of Service (POS)
A health care plan that permits covered persons to choose providers outside the plan's network at any time, yet is designed to encourage the use of providers in the network. If a provider is affiliated with the POS plan, the service is usually covered in full after a small copayment. If an out-of-network provider is chosen, reimbursement may be significantly reduced.

Pre-Authorization
The process of obtaining prior approval as to the appropriateness of a service or medication. Prior authorization does not guarantee coverage.

Preventive Care
Comprehensive health care that emphasizes priorities for prevention, early detection, and early treatment of disease or its consequences. Preventive care usually includes routine physical examinations, immunizations, and wellness programs.

Pre-Certification
An administrative procedure whereby a health provider submits a treatment plan to a third party before treatment is initiated. The third party usually reviews the treatment plan, indicating one or more of the following; patient's eligibility, guarantee of eligibility time, covered services, amounts payable, application of appropriate deductibles, copayment factors and maximums.

Pre-Existing Condition
A physical and/or mental condition of an insured person that existed prior to the issuance of his or her insurance policy or that existed prior to issuance and for which treatment was received.

Preferred Provider Organization (PPO)
A type of managed care plan which contracts with independent providers (hospitals, physicians, ancillary providers) for negotiated discounted fees for services provided to covered persons. The covered persons usually have free choice of providers but have a financial incentive (e.g., reduced copayments, lower deductibles) to use participating providers.

Prescription
A written order or refill notice issued by a licensed medical profession for drugs which are only available through a pharmacy.

Primary Care Physician (PCP)
The physician a member must contact before having access to medical care benefits. The PCP provides basic health care services and serves as a manager of the delivery of all other health care for which benefits may be payable in accordance with the utilization review and quality assurance programs of the plan.

Prior Authorization
See Pre Authorization.

Prosthetic Devices
An artificial substitute for a missing body part, such as an arm or leg, used for functional reasons, because a part of the body is permanently damaged, is absent or is malfunctioning.

Provider
An individual or organization that provides health care services. Providers may include but not limited to: physicians, hospitals, physical therapists, medical equipment suppliers, and pharmacists.

Provider Network
That set of providers contracted with a health plan to provide services to the covered person(s).

R

Radiation Therapy
The use of ionizing radiation in the treatment of disease, usually cancer. These services are provided by a radiation therapies or a physician qualified in therapeutic radiology.

Reasonable and Customary
See Customary and Reasonable.

Referral
A recommendation by a physician and/or managed care plan for a covered person to be evaluated and/or treated by a different physician.

Respiratory Therapy
Treatment to preserve or improve lung function.

S

Second Opinion
A covered person is encouraged or required to obtain an additional medical opinion(s) from other specialists prior to making a decision about surgical procedures.

Service Area
The geographical area covered by the health plan within which it provides direct service benefits.

Skilled Nursing Facility (SNF)
A facility, either free-standing or part of a hospital, with a professionally trained staff that provides medical treatment, continuous nursing, rehabilitation, and various other health and social services to patients who are not in an acute phase of illness, but who require skilled care on an inpatient basis in lieu of hospital inpatient services. SNFs must be certified by Medicare and meet specific qualifications, including 24-hour nursing coverage, availability of physical, occupational and speech therapies, and other requirements.

Speech Therapy
The study, examination, and treatment of defects and diseases of the voice, speech, and spoken and written language, and the use of appropriate substitutional devices and treatment.

Subscriber
The individual who is responsible for payment of premiums or whose employment is the basis for eligibility for membership in a group health plan. Sometimes called member or enrollee.

Substance Abuse/Chemical Dependency
The consumption of alcohol or other chemical agents at dosages that place a person's social, economic, psychological and physical welfare in potential hazard, or endangers public health, morals, safety or welfare, or a combination of these.

U

Utilization Management (UM)
A management tool used by managed care plans involving the systematic process of reviewing and controlling patients' use of medical services and providers' use of medical resources in order to optimize efficiency and appropriateness of care. UM includes an array of techniques, such as second surgical opinion, preadmission certification, concurrent review, case management, discharge planning, and retrospective chart review.

Utilization Review
Assessment of treatment in accordance with guidelines and standards that are established and accepted by health care professionals using medical necessity criteria. The assessment occurs before and during the delivery of health care. Its purpose is to enhance the cost-effectiveness of health care through reviewing its appropriateness.

Usual, customary and Reasonable (UCR)
Usual Fee, the fee usually charged for a given service by an individual provider to his or her private patient, that is, his or her own usual fee. Customary Fee, the range of usual fees charged by providers of similar training and experience in an area. Reasonable Fee, a fee that meets the two previous criteria or, in the opinion of the responsible medical or dental association's review committee, is justifiable considering the special circumstances of the particular case in question.

Urgent Care
Care for injury, illness, or another type of condition (usually not life threatening) which should be treated within 24 hours. Also referred to as after-hours care.