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Administrative Services Only (ASO):
A contract between a self-insured
plan and an insurance company, where the company does not
assume risk, but performs only specifically contracted services
(e.g., claims processing, and/or utilization management)
Assignment of Benefits:
When a covered person authorizes his or her health benefits
plan to directly pay a health care provider for covered
services.
Authorization:
A determination made by the plan that a service (inpatient
admission, outpatient service, or referral) is approved.
Behavioral Health Care:
Treatment of mental health and/or substance abuse disorders.
Beneficiary:
A person who is eligible to receive insurance benefits.
Benefits:
The amount payable by an insurer to a claimant, assignee,
or beneficiary under the terms of a health care plan.
Billed Charges:
The actual dollar amount billed by a doctor or other provider
of healthcare services for a particular service.
Capitation: A method of
payment for healthcare services based on the number of patients
who are covered for specific services rather than the cost
of services that are actually provided.
Carrier:
A term used to identify the party insurer to the group contract
that agrees to underwrite (carry the risk) and provide certain
type of coverage and service.
Carve Out:
An arrangement in which a payor arranges for coverage of
a specific category of services through a contract with
a separate set of providers or specialty HMO/PPO.
Examples: Mental Health or Vision Services
Claim:
Notification to an insurance company or managed care organization
that a dollar payment is due for procedures/services rendered
under the terms of the policy.
Closed Panel:
Most frequently this term describes the situation where
a physician has ceased accepting any additional new patient.
Coinsurance:
The amount of the carrier allowable designated to be paid
by the patient (i.e., 20% coinsurance and 80% insurance
payment).
Co-payment:
An out pocket dollar amount or percentage of charges a member
pays to the physician/provider for specified covered services.
Coordination of
Benefits: Two or more insurance
carrier determination of payable amounts so that total reimbursement
does not exceed either the actual charges or the primary
payer’s allowable.
Consultation:
A consultation is a type of service
provided by a physician whose opinion or advice regarding
evaluation and/or management of a specific problem is requested
by another physician.
Covered Charges:
Charges for medical care or supplies which, if incurred
by a covered person create a liability for the insured under
terms of a group policy.
CPT-4:
Current Procedural Terminology
is a listing of descriptive terms and five-digit identifying
codes for reporting of medical services and procedures performed.
Credentialing:
Examination of a physician’s or other health care provider’s
credentials to determine whether he or she should be entitled
to clinical privileges at a hospital or to a contract with
an MCO.
Deductible: The amount of covered expenses which
must be paid by the employee before benefits are payable
by the insurance company.Denial:
A determination that a service is not covered and/or
not payable by the health plan.
Dependent: An individual
who receives health insurance through a spouse, parent,
or other family member.
Diagnosis:
The identification of a diseases or condition through examination.
Effective Date: The day that health plan coverage
goes into effect or is modified.
Eligibility Person: Person
who meets the qualifications of a health pan contract.
EOB (Explanation of Benefits):
A document typically provided to an insured and a provider
after services are rendered. The document is generally
sent by the claim paying party and provides a summary of
how a claim was paid based on the benefit plan.
Evaluation and Management (E&M):
Term used in CPT referring to codes for patient visit,
hospital admission and discharge, critical care and consultation
services.
Exclusive Provider Organization
(EPO): A MCO that utilizes a closed network of
providers and a primary care gatekeeper.
Fee Schedule: Maximum dollar or unit allowances
for health services that apply under a specific contract.
Gatekeeper:
A primary care physician
who must authorize all specialists.
Health Care Provider:
Any individual or entity that provides
a health care service such as a physician, group practice,
hospital, nursing home, laboratory, home health agency,
physical therapist or pharmacy.
Health Maintenance
Organizations ( HMO):
An organization
that provides a wide range of comprehensive health care
services for a specified group at a fixed periodic payment.
HCFA 1500:
A universal form, developed by HCPA, for providers of
services to bill professional fees to health carriers.
Indemnity Insurance:
Traditional health insurance through which the insured person
is reimbursed for covered medical expenses after meeting
the policy deductible.
Inpatient: A patient admitted
to a hospital, who is receiving services under the direction
of a physician for at least 24 hours.
Independent Physicians Association
(IPA): An association of physicians that contracts
with a health maintenance organization, limited service
health organization, or preferred provider plan to provide
health care services.
Managed Care Plan: Any health plan that requires
or creates incentives for an enrollee to use providers that
are owned, managed, or under contract with the insurer offering
the health benefit plan.
Medicare: A federally
sponsored program that provides hospital benefits, supplementary
medical care, and catastrophic coverage’s to elderly persons.
Non-Covered Services: Those services which
are not covered health services under the health plan.
Open Access: Open access arrangements allow members
to see participating providers, usually specialists without
referral from the health plan’s gatekeeper.
Out-of-Network:
When a patient goes to a provider not contracted by the
managed care plan the patient is “out-of-network”.
Open Panel: A type of health plan other
than a closed panel plan that provides incentives for the
member to use providers selected by the plan.
Outpatient Treatment: Treatment rendered
in a hospital, clinic or office setting where the patient
is admitted, treated and released the same day.
Par Provider:
A shorthand term for participating provider.
Participating Provider:
A physician, pharmacy, hospital, medical facility or other
health care provider that has contracted with a managed
care plan to provide services to that plan’s enrollees.
Also called a preferred provider.
Patient:
The person under medical treatment.
Point of
Service (POS) Plan:
A type of managed care plan that allows a member to choose
to receive a health service from either a network or a non-network
provider. Using a provider within the network results
in a lower co-payment for the member. You may be able
to access providers without a referral. However, it
may cost more. If you go outside the network, some
of your care will be covered. You may have to pay
a higher percentage of the charges.
Preferred
Provider Organization (PPO): A program in which contracts are established with specific
providers, usually referred to as preferred providers.
However, you do not need a referral to see a specialist.
Also, the plan will pay for a portion of your care if you
see a provider outside the network. If you see a doctor
within the network, you may pay a co-payment. With some
plans, you may also pay a deductible and/or coinsurance.
If you choose to go outside the network, you will be responsible
for a larger portion of the cost of your care, as well as
any deductible and/or coinsurance that applies.
Primary Care Physician (PCP): Responsible for delivering and coordinating members care,
including referral to specialists. Typically either
internist, pediatricians general or family practitioners.
Preauthorization/Pre-certification:
A provision in insurance policies that requires prior approval
by a managed care plan or limited service health organization
in order for services to be covered by the plan.
Referral: An authorization granted by the Participating
Physician/Primary Care Physician for use to another provider.
Third-Party Administrator (TPA): An administrative
organization other than the MCO or employer that collects
premiums, pays claims and/or provides administrative services.
Utilization Management/Review:
Evaluation of the necessity, appropriateness and efficiency
have the use of medical services, procedures, and facilities
on a prospective, concurrent, or retrospective basis.
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