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Glossary

Please note: Your plan is fully described in your plan documents. Should the definitions in this glossary and your plan documents disagree, or should provisions contained in your plan documents be omitted from this glossary, your plan documents will always govern.

Acupuncture

An alternative health procedure based on ancient Chinese methods, gaining acceptance in Western hospitals, involving insertion of thin needles at specific pressure points in the body.

Adjudication

Determination of the amount of payment for a claim.

Administrative Costs

The costs assumed by an insurance company or managed care plan for administrative services such as claims processing, billing and overhead costs.

Administrative Services Only (ASO)

An arrangement under which an insurance carrier or an independent organization will, for a fee, handle the administration of claims, benefits and other administrative functions for a self-insured group. This type of arrangement usually requires the employer to be at risk for the cost of health care services to be provided.

Agent

An individual licensed by the State who sells insurance to a payer and who provides service to the policyholder for the insurer. Could be sole-proprietor, member of a large firm or employee of the insurance company. Paid by a fee/commission from insurer.

Allergy Treatment

Treatment of allergy, which may involve allergy testing and physician's services.

Allowable Charge

The maximum fee that a third party will reimburse a provider for a given service. An allowable charge may not be the same amount as either a reasonable or customary charge.

Alternate Care Facility

A licensed residence, other than a nursing facility, where care services are delivered (i.e. hospice, assisted living, Alzheimer's or Christian Science setting).

Ambulatory Setting

A type of health care setting where health services are provided on an outpatient basis. Ambulatory settings usually include physicians' offices, clinics and surgery centers.

Ambulatory Surgery

Surgical procedures performed that do not require an overnight hospital stay.

Ambulatory Services

Health services that are provided on an outpatient basis, in contrast to services provided in the home or to persons who are inpatients in a hospital.

Ancillary Services

Hospital services other than room and board, and professional services. They may include X-ray, drug, laboratory or other services.

Appeal(s)

An individual's dispute over the denial of a claim payment or the denial of provision of a health care service, or a coverage denial based on a contractual exclusion or limitation.

Assignment

Agreement by the provider to accept any reimbursement from a third-party payer as payment in full for the services rendered.

Authorization

The approval of care, for hospitalization, outpatient procedure, certain specialty, etc., by a managed care or insurance company for its member, subscriber, or insured.

Average Length of Stay

A measure used to determine the average number of days patients spend in a facility.

Bed Days/1000

The number of inpatient days per 1000 health plan members.

Beneficiary

A person who is eligible to receive insurance benefits.

Benefit

Payments provided for covered services under the terms of the policy. The benefits may be paid to the insured, or on his behalf, to others.

Benefit Consultant

An individual or organization hired by a group plan holder to review, analyze, and make recommendations on benefit strategies, including benefit plan design, carrier selection, pricing, etc. An insurance professional who provides information, advice and counseling for their clients.

Benefit Period

The maximum length of time for which benefits will be paid.

Birthing Center

A facility that allows mothers to give birth in a home-like setting.

Board Certified

A term used to describe a physician who has passed an examination given by a medical specialty board and who has been certified as a specialist in that medical area.

Board Eligible

A physician who has graduated from an approved medical school and is eligible to take a specialty board examination.

Broker

One who represents a client in solicitation, negotiation or procurement of contracts of insurance, and who may render services incidental to those functions. By law, the broker may also be an agent of the insurer for certain purposes such as delivery of the policy or collection of the premium.

Brand Name Drug(s)

Those drugs that are marketed under a specific trade name by a pharmaceutical manufacturer. In most cases, these drugs are still under patent protection, meaning the manufacturer is the sole source for the product.

Capitation

A method of payment for health services in which an individual or institutional provider is paid a fixed, per capita amount for each person served without regard to the actual number or nature of services provided to each person. Capitation is a common method of paying physicians in health maintenance organizations.

Case Management

A utilization management program that assists the patient in determining the most appropriate and cost effective treatment plan. It is used for patients who have prolonged, expensive or chronic conditions, helps determine the treatment location (hospital, other institution or home) and authorizes payment for such care if it is not covered under the patient's benefit agreement. The purpose of case management is to provide optimum patient care in the most cost-effective manner.

Certification

See pre-certification

Chemotherapy

Treatment of malignant disease by chemical or biological antineoplastic agents.

Chiropractic (Care)

An alternative medicine therapy administered by a provider such as a chiropractor, osteopath or physical therapist. The provider adjusts the spine and joints to treat pain and improve general health.

Claim

A request for payment for benefits received or services rendered. A billing record as generated and submitted by a provider or subscriber using paper or electronic media.

COBRA

The federal law that requires employers with more than 20 employees to extend group health insurance coverage for up to 36 months after a qualifying event (e.g. termination of employment, reduction in hours, divorce). The right to continue such coverage ends when a qualified beneficiary becomes covered under any other group health plan that does not contain any pre-existing condition or other limitations.

Coinsurance

An arrangement under which the covered person pays a fixed percentage of the cost of medical care after the deductible has been paid. For example, an insurance plan might pay 80% of the allowable charge, with the insured individual responsible for the remaining 20%, which is then referred to as the coinsurance amount.

Coinsurance Maximum

The total amount of coinsurance that an individual pays each year before the carrier pays 100% of allowable charges for covered services. Coinsurance amounts differ with each contract.

Concurrent Review

The review and assessment of an ongoing inpatient hospitalization to assure it remains the most appropriate setting for the care being rendered.

Consolidated Omnibus Budget Reconciliation Act of 1985

See "COBRA".

Continuation

See "COBRA".

Contraception

Deliberate prevention of conception or impregnation using methods such as oral drugs, injectable drugs, implants, diaphragms.

Contract

A legal agreement between an individual or an employer group and a carrier that describes the benefits and limitations of the coverage.

Contract Holder

An individual entitled to health benefits according to a Plan benefit contract issued to him or to a group of which he is a member. This definition excludes dependents. Under a group plan, the contract holder is the group.

Conversion(Option)

The exercise of an option to purchase individual coverage by a person who is leaving an employee group, typically at retirement.

Coordination of Benefits

The anti-duplication provision to limit benefits for multiple group health insurance in a particular case to 100% of the covered charges and to designate the order in which the multiple carriers are to pay benefits. Under a COB provision, one Plan is determined to be primary and its benefits are applied to the claim. The unpaid balance is usually paid by the secondary Plan to the limit of its liability.

Copayment or Copay

A type of member cost sharing that requires a flat amount per unit of service or unit of time. This is usually a percentage of the charges but may also be a dollar amount for specified services. The most common percentage copayment is 20%. A common copay is $5-$15 per visit.

Covered Medical Expense

Those expenses payable according to the terms of the subscriber's contract. The charges for these services are still subject to any cost sharing components or limits, such as deductibles, coinsurance, copayments and maximums included in the contract.

Covered Services

Hospital, medical and other health care expenses incurred by the covered person that entitle him/her to benefits under a contract. The term defines the type and amount of expense, which will be considered in the calculation of benefits.

Credentialing

An examination of a health care provider's credentials to determine if they should be granted clinical privileges at a health care facility or with a managed care organization.

Custodial Care

Care provided primarily to assist a patient in meeting the activities of daily living, but not care requiring skilled nursing services.

Customary and Reasonable (C&R)

The amount customarily charged for the service by other physicians in the area (often defined as a specific percentile of all charges in the community), and the reasonable cost of services for a given patient after medical review of the case.

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

An amount the covered person must pay before payments for covered services begin. The deductible is usually a fixed amount or a percentage determined by the individual's contract, and is calculated based on the lower hospital/provider actual charges or payment benefit. For example, an insurance plan might require the insured to pay the first $250 of covered expense during a calendar year.

Dental Care

Under a medical plan, dental care is dental treatment which due to the nature of the procedure or patient's medical condition, may be provided in a hospital setting.

Dependant

Person (spouse or child) other than the subscriber who is covered in the subscriber's benefit certificate.

Diagnosis Code

A numerical classification that describes diseases, injuries and causes of death. International Morbidity Code, Manual of the International Statistical Classification of Diseases & Injuries and AMA Standard Nomenclature of Disease are different diagnosis coding methods.

Diagnosis Related Groups (DRGs)

A method of grouping related diagnosis and their associated medical or surgical treatment. A coding system used to determine the amount that Medicare will reimburse hospitals and other designated providers for the delivery of inpatient services. HCFA uses these groupings to establish the amount that it will reimburse hospitals for the care given to Medicare beneficiaries. Each DRG corresponds to a specific patient condition. Each DRG has a pre-established fixed amount that is paid for any patient in the DRG category.

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 radiology, ultrasound, nuclear medicine, laboratory, pathology services or tests.

Discharge Planning

The process of assessing a patient's treatment plan during hospitalization to effect an appropriate and timely discharge. The hospital and attending physician have major responsibility for this function, with the Plan promoting, monitoring and assisting the providers.

Disease Management Programs

Interventions and educational programs designed for individuals with chronic diseases designed to prevent recurrence of symptoms, maintain high quality of life and prevent future need for medical resources by using an integrated, comprehensive approach to health care. Pharmaceutical care, continuous quality improvement, practice guidelines and case management all play key roles in this effort.

Drug Formulary

A listing of preferred pharmaceutical products that health plans, working with an expert panel of physicians and pharmacists, have developed to encourage the dispensing of quality, cost effective medications. Formularies can be classified as: * Open, in which doctors are encouraged to prescribe medications on the formulary but which allow nonformulary drugs to be covered without prior authorization; * Restricted, in which only medications on the formulary list are covered; * Managed, in which doctors are encouraged to prescribe medications on the formulary, but nonformulary drugs are covered with prior authorization.

Durable Medical Equipment

Mechanical devices, equipment and supplies which enable a person to maintain functional ability.

Effective Date

The date on which the coverage or a change in coverage of a contract goes into effect at 12:01 a.m.

Emergency Care

Care for patients with severe or life-threatening conditions that require immediate medical attention.

Enrollee

An individual who is enrolled and eligible for coverage under a health plan contract. Synonymous with member.

Exclusions

Specific conditions or circumstances that are not covered under the contract.

Experimental Procedures

Services that are not recognized under generally accepted medical standards as safe and effective for treating a particular condition.

Expiration Date

The date coverage expires.

Explanation of Benefits (EOB)

A form sent to the covered person after a claim for payment has been processed by the carrier that explains the action taken on that claim. This explanation might include the amount that will be paid, the benefits available, reasons for denying payment or the claims appeal process.

Flexible Benefits

A generic name for employee benefits programs which offer employees a choice of benefit components.

Formulary

See Drug Formulary.

Gatekeeper

Term given to a primary care provider who coordinates all medical care for a patient and determines whether services such as tests or referral to a specialist are necessary.

Generic Drug(s)

Safe, effective and, equivalent to brand name medications that may cost considerably less than the brand name medications. Generic drugs must meet the same high standards of quality as brand name drugs and are formulated to have the same effect in the body as the brand name version. Generic drugs often become available when a brand name drug's patent expires.

Health Benefit Plan

A health insurance product offered by a health plan company that is defined by the benefit contract and represents a set of covered services and a provider network.

Health Maintenance Organization (HMO)

An organization that provides a wide range of comprehensive health care services for a specific group at a fixed periodic payment or a pre-paid health care plan under which people enroll by paying a set annual fee. Members then receive all the medical services they need through a group of affiliated doctors and hospitals, often with no additional copayments or fees. Members are generally limited to using providers designated by the HMO.

Hearing Services

Testing and services related to hearing.

HMO

See Health Maintenance Organization.

Home Health Care

Health services rendered to an individual as needed in the home. Such services are provided to aged, disabled, sick or convalescent individuals who do not need institutional 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; ancillary medical supplies; and, nursing services.

Hospice

A facility or service that provides care for terminally ill patients and support to their families, either directly or on a consulting basis with the patient's physician. Emphasis is on symptom control and support before and after death.

Hospital

An institution whose primary function is to provide inpatient services, diagnostic and therapeutic, for a variety of medical conditions, both surgical and non-surgical. In addition, most hospitals provide some outpatient services, particularly emergency care.

ID Card/Identification Card

A card issued by a carrier to a covered person, which allows the individual to identify himself or his covered dependents 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.

In Area Services

Medical services received within a health plan's authorized service area and administered by a health plan's participating provider.

Indemnity

(1) Benefits paid in a predetermined amount in the event of a covered loss. (2) A traditional carrier that reimburses for medical services provided to patients based on bills submitted after the services are rendered. Also known as fee-for-service.

Immunizations

Specific types of injections to prevent infectious diseases and viral infections.

In-Network

Refers to the use of providers who participate in the carrier's provider network. Many benefit plans encourage covered persons to use participating (in-network) providers to reduce the individual'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. Also includes the presence of a condition recognized by a physician as the cause of infertility.

Infusion Therapy

The administration of intravenous drug therapy. Infusion therapy includes the following services: solutions and pharmaceutical additives; pharmacy compounding and dispensing services; durable medical equipment; ancillary medical supplies; and, nursing services.

Inpatient

Service provided while the patient is admitted to the hospital for at least a 24-hour period.

Investigation Procedures

Those that have progressed to limited use on humans, but which are not widely accepted as proven and effective within the organized medical community.

Lifetime Maximum

Maximum amount that Major Medical will pay toward a subscriber's claim in a lifetime. The amount varies depending on the type of coverage the subscriber carries.

Managed Care

Any form of health plan that initiates selective contracting to channel patients to a limited number of providers and that requires utilization review to control unnecessary use of health services.

Maternity Care

The care of women before and during childbirth as well as the care of newborn babies.

Medical Equipment

See Durable Medical Equipment

Medically Necessary

Procedures, supplies, equipment or services determined to be: appropriate for the symptoms, diagnosis or treatment of a medical condition, and provided for the diagnosis or direct care and treatment of the medical condition; and 3) within the standards of good medical practice within the organized medical community; and 4) not primarily for the convenience of the patient's physician or other provider; and 5) the most appropriate procedure, supply, equipment or service which can be safely provided.

Member

An individual or dependent who is enrolled in and covered by a health care plan. Also called enrollee or beneficiary.

Mental Health/Behavioral Health

Conditions that affect thinking and the ability to figure things out which affect perceptions, mood and behavior. Such disorders are recognized primarily by symptoms or signs that appear as distortions of normal thinking, or distortions of the way things are perceived (seeing or hearing things that are not there). Disorders can also be recognized by moodiness, sudden or extreme changes in mood, depression, highly agitated or unusual behavior.

Mental Health Parity Act

A federal health benefits law passed in 1996, effective January 1, 1998, which restricts health plans from applying lower annual and aggregate lifetime limits to mental illness than limits imposed on medical illness. The law exempts group health plans from complying with its provisions if mental health parity results in an increase in the cost under the plan or coverage of at least one percent. The law applies to all group health plans (insured and self-insured) with over 50 employees.

Network

The doctors, clinics, hospitals and other medical providers that a carrier contracts with to provide health care to its covered persons. Individuals are generally limited to network providers for full coverage of their health costs.

Network Provider

See "Provider Network".

Non-Participating Provider

A Medical provider who has not contracted with a carrier or health plan to be a participating provider.

Occupational Therapy

Treatment to restore a physically disabled person's ability to perform activities such as walking, eating, drinking, toileting and bathing.

Out of Network

The use of health care providers who have not contracted with the carrier to provide services. HMO members are generally not reimbursed if they go out-of-network except in emergency situations. Covered persons of preferred provider organizations and HMOs with point-of-service options can go out-of-network, but must pay additional costs including deductibles and co-insurance.

Out of Pocket Maximum

Refers to the maximum amount that a covered employee will have to pay for expenses covered under the plan. It is a sum of deductible and coinsurance amounts.

Outpatient

A patient who is receiving ambulatory care at a hospital or other health facility without being admitted to the facility.

Outpatient Surgery

Surgical procedures performed that do not require an overnight stay in the hospital or ambulatory surgery facility. Such surgery can be performed in the hospital, a surgery center, or physician office.

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. Such care is an alternative to inpatient treatment.

Participating Provider

A physician, hospital, pharmacy, laboratory or other appropriately licensed provider of health care services or supplies, that has entered into an agreement with a managed care entity to provide such services or supplies to a patient enrolled in a health benefit plan.

PCP

See Primary Care Physician.

UniCare Pharmacy Network

A prescription drug program that offers the following advantages: * A network of participating pharmacies nationwide. * A convenient mail-order option that saves time and money. * Low copayments and no claim forms when using a participating pharmacy. * Toll-free customer service telephone numbers.

Physical Therapy

Treatment involving physical movement to relieve pain, restore function and prevent disability following disease, injury or loss of limb.

Physician's Current Procedural Terminology (CPT)

A list of medical services and procedures. Each service and/or procedure is identified by its own unique five-digit code. CPT has become the health care industry's standard for reporting of physician procedures and services, thereby providing an effective method of nationwide communication.

Plan Benefit Maximum

Maximum amount the carrier will pay toward an individual's coverage. The amount varies depending on the type of coverage the individual carries.

Point of Service (POS)

An option provided by some HMOs that allows covered persons to go outside the plan's provider network for care, but requires they pay higher cost-sharing than they would for network providers.

Pre-Admission Review

The assessment of medical necessity and appropriateness of elective hospital admissions before hospitalization has occurred.

Pre-Authorization

A procedure used to review and assess the medical necessity and appropriateness of elective hospital admissions and non-emergency outpatient services before the services are provided.

Preventive Care

Proactive health care designed to keep people from getting sick or hurt. It includes immunizations and screenings. A key part of preventive medicine is making sure patients know how to improve their health by altering their lifestyles.

Pre-Certification

Refers to certifying the medical necessity and level of care in advance. Pre-certification does not guarantee that contract benefits will be available.

Pre-Certification Review

Utilization management performed prior to a patient's admission, stay or other service or course of treatment. Also known as Prospective Review.

Pre-Existing Condition

A health condition or medical problem that was diagnosed or treated before enrollment in a new health plan or insurance policy. Some pre-existing conditions may be excluded from coverage.

Preferred Provider

A health care professional and/or facility that contracts with a health plan to provide medical services to covered individuals. Also referred to as a Participating Provider.

Preferred Provider Organization (PPO)

A delivery system where providers are under contract to a carrier to provide care at a discount or for a fixed fee, and the carrier provides incentives to patients to use the contracting providers. The PPO does not assume insurance risk, and it does not facilitate the sharing of risk by its covered persons.

Prescription

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

Primary Care Physician (PCP)

A doctor designated by an HMO or other managed health care company to be the first physician a patient contacts for any medical problem. The doctor acts as the patient's regular physician and as a gate-keeper who determines if the patient needs to see a specialist or requires hospitalization.

Prior Authorization

The process of obtaining pre-approval of coverage for a health care service or medication.

Prosthetic Devices

A device which replaces all or a portion of a part of the human body. These devices are necessary because a part of the body is permanently damaged, is absent or is malfunctioning.

Provider

A licensed health care facility, program, agency or health professional that delivers health care services.

Provider Network

That set of providers with which a carrier has contracted to provide services to the Accountable Health Plan's covered persons. In the case of a "fee-for-service" or non-network Health Benefit Plan, the Provider Network will be deemed to be all licensed providers of covered services.

Radiation Therapy

Treatment of disease by x-ray, radium, cobalt or high energy particle sources.

Reasonable and Customary

The amount customarily charged for the service by other physicians in the area (often defined as a specific percentile of all charges in the community) and the reasonable cost of services for a given patient after medical review of the case. Also known as Usual and Customary (U&C).

Referral

A recommendation by a physician or insurer that an individual receive care from a different doctor or facility.

Respiratory Therapy

Treatment of illness or disease that is accomplished by introducing dry or moist gases into the lungs.

Retrospective Review

A review of claims and medical records for medical necessity and appropriateness after the episode of care is concluded and before and/or after the claim is submitted by the provider.

Second Opinion

The voluntary option or mandatory requirement to visit another physician or surgeon regarding diagnosis, course of treatment or having specific types of elective surgery performed.

Self Funding

When a business funds a benefit plan from its own resources rather than purchasing insurance.

Service Area

The geographic area that an insurer, health plan or health care provider services.

Skilled Nursing Facility

An institution (or a distinct part of an institution) that is primarily engaged in providing skilled nursing care and related services for patients who require medical care, nursing care or rehabilitation services.

Speech Therapy

Treatment or the correction of a speech impairment which resulted from birth, or from disease, injury or prior medical treatment.

Subrogation

Means by which claims are identified as the responsibility of another insurer since treatment of the condition resulted from the action of an outside party. Situations include coverage under another health insurance policy, Worker's Compensation, disability or medical insurance under automobile policies. Subrogation literally means the substitution of one person for another. Under Subrogation, insurers assume, by operation of law or contract, the rights of the insured against the wrongdoer. Where legal, a subrogation right can be asserted when it is determined that an injury was caused by the negligence of another party. This allows an insurance carrier to recover medical expenses paid out as a result of such negligence. Insurance payment must be made before it can be subrogate.

Subscriber

The individual in whose name a contract is issued or the employee covered under an employer's group health contract.

Substance Abuse/Chemical Dependency

Conditions that include, but are not limited to (1) psychoactive substance induced mental disorders; (2) psychoactive substance use dependence; and (3) psychoactive substance use abuse. Chemical dependency does not include addition to, or dependency on, tobacco or food substances (or dependency on items not ingested).

Utilization Management

(1) A process that evaluates health care on the basis of appropriateness, necessity, and quality. For hospital review, it can include pre-admission certification, concurrent review with discharge planning, and retrospective review. (2) One of the six categories of Standards of Quality used by NCQA, which examines the consistency and the reasonableness of the determinations of necessary services. Also looks at how well the plan responds to member and physician appeals. Utilization Management at WellPoint is comprised of the three following components: (i) Pre-Hospital Review — For medical, surgical, obstetrical, mental health and substance abuse admission requests, the WellPoint companies evaluate whether hospitalization is necessary; the proposed length of stay is appropriate; another form of treatment is available and appropriate; and/or if diversion to an alternate care facility is possible. (ii) Continued Stay Review — During a hospital stay, the WellPoint companies continually monitor the patient's progress through the attending physician to ensure adherence to the treatment plan. The WellPoint companies review requests for (and authorize, when appropriate) extended lengths of stay. (iii) Alternate Medical Care — In conjunction with Pre-Hospital Review and Continued stay Review, the WellPoint companies identify patients for whom early discharge to home health care is appropriate. The program then controls home health care utilization through pre-authorization and ongoing evaluation and monitoring; authorizes services and specific dollar amounts by modality; works with the hospital discharge planner to develop an appropriate treatment plan and coordinates the patient's benefits.

Utilization Review

A review process designed to evaluate the appropriateness of health care services.

Usual,Customary and Reasonable

A "usual" charge is the amount that is most consistently charged by an individual physician for a given service. A "customary" charge is the amount that falls within a specified range of usual charges for a given service billed by most physicians with similar training and experience within a given geographic area. A "reasonable" charge is a charge that meets the Usual and Customary criteria, or is otherwise reasonable in light of the complexity of treatment of the particular case. Under a UCR Program, the payment is the lowest of the actual billed charge, the physician's usual charge or the area customary charge for any given covered service.

Urgent Care

An unexpected illness or injury that is not life threatening but requires outpatient medical care that cannot be postponed. An urgent situation requires prompt medical attention to avoid complications and unnecessary suffering, such as a high fever. Examples include skin rashes or ear infections.

Well Baby/Well Child Care

Routine care, testing, checkups and immunizations for a generally healthy child from birth through the age of six.

Wellness Program

A health management program which incorporates the components of disease prevention, medical self-care, and health promotion. It utilizes proven health behavior techniques that focus on preventive illness and disability, which respond positively to lifestyle related interventions. Programs are designed to integrate with existing health care benefits, e.g., flex benefits, HMO, PPO; support the reduction in the demand for health care resources; and address the issues of dependent coverage and services for high-risk employees.