Glossary of Health Care Industry Terms
This Glossary contains general definitions of terms commonly used in the health insurance industry. Since these general definitions may vary from those contained in your contract, it is important that you check your contract for the definitions and actual terms and conditions that apply to your health benefit plan.
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A traditional form of Chinese medicine using a technique which involves the passing of needles through the skin to specific points to induce anesthesia, relieve pain, alleviate withdrawal symptoms of substance abuse or treat other various disorders.
The process used by health benefit plans to determine eligibility for benefits and the amount of payment, if any, for a claim. Also called "adjustment."
Medical treatment by or under the direction of a physician for allergies, which may include testing, evaluation, injections, or administration of serum.
The maximum amount that a health benefit plan will pay for a given Covered Service or supply. Also called Maximum Benefit Allowance, Maximum Allowance.
Surgical procedures performed that do not require an overnight hospital stay. Procedures can be performed in a hospital or a licensed surgical center. Also called Outpatient Surgery.
Services performed that do not require an overnight hospital stay.
A process used to request the health plan re-consider a previous decision made by the health benefit plan or provider. There may be different appeal processes for members, providers, types of products, or state of issue.
See Pre-Authorization or pre-approval.
Covered Services to which the member is entitled under the terms of the policy. Benefit payments may be paid to the member (or Subscriber), or on his behalf, to the medical provider. Benefit design includes the types of benefits offered, limits e.g., number of visits, percentage paid or dollar maximums applied, subscriber responsibility (cost sharing components), or Subscriber incentives to use network providers.
The period of time for which we pay Benefits for Covered Services rendered while the Contract was in effect.
Brand Name Drug
The initial version of a medication developed by a pharmaceutical manufacturer, or a version marketed under a pharmaceutical manufacturer's own registered trade name or trademark.
A coordinated set of activities designed to assist a member in managing with specific health care needs.
Treatment of malignant disease by chemical or biological antineoplastic agents. High dose chemotherapy is a type of chemotherapy often used in conjunction with tissue transplants.
Therapy administered by a licensed Chiropractor, such as spinal adjustments, within the scope of their license and in accordance with standards of chiropractic medicine.
A request for payment of Benefits.
The Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) generally provides that virtually all employers who sponsor group health plans must permit members who lose coverage under the plan as the result of specific events to elect to continue their coverage under the group plan for a certain period of time on a self-paid basis.
A cost sharing feature in which the member pays a fixed percentage of the cost of medical care after the deductible has been satisfied. Coinsurance may also be defined as a Copayment.
See Out of Pocket Maximum.
Voluntary prevention of conception or pregnancy.
An agreement between an individual Subscriber or an employer group and a Health Benefit Plan that describes the duties of each party, including the benefits and limitations of the coverage. One Subscriber could have two contracts (policies) - one for health and one for dental. Can also be called a Benefit Certificate or Policy. The Contract may include more than one document, such as a master group policy, a Benefit certificate, amendments, policies and procedures, or applications.
An option to purchase individual coverage under certain circumstances at a negotiated rate by a Member who is leaving a group.
Coordination of Benefits (COB)
The provision which applies when a member is covered by multiple health benefit plans at the same time. The provision is designed so that the payments by all plans do not exceed 100% of the Covered Services. The provision also designates the order in which the multiple health plans are to pay benefits. Under a COB provision, one plan is determined to be primary and its benefits are applied to the claim first. The unpaid balance is usually paid by the secondary plan to the limit of its responsibility. Benefits are thus "coordinated" among all of the Health Benefit Plans.
Co-payment (or co-pay)
A cost sharing feature where the member pays a fixed dollar amount for the cost of medical care after the deductible has been satisfied. An example of a common co-pay is $10 per physician office visit. Co-payment may also be defined as a Coinsurance.
Hospital, medical, and other health care services and supplies provided to a member for which Benefits are paid under a contract.
Care which is provided primarily to meet the personal needs of the patient. Custodial Care does not require the continuous attention of skilled medical or paramedical personnel. Such care includes help in walking, bathing or dressing. It also includes preparing food or special diets, feeding, administering medicine or any other care which does not require continuing services of medical-trained personnel.
Day Treatment Center
An outpatient psychiatric facility or Hospital which is licensed to provide outpatient care and treatment of mental or nervous disorders or substance abuse under the supervision of physicians. The treatment is typically provided for more than two hours but less than 24 hours/day. This treatment may also be known as "partial hospitalization."
A cost sharing feature in which the member pays a fixed dollar amount prior to being eligible for payment for some or all Covered Services.
Routine preventive and treatment of teeth and the structures directly supporting the teeth. Generally, Dental Care is not covered by the health benefit plan.
Person (for example a spouse or child) other than the Subscriber who is covered in the subscriber's Contract. Also called a "member."
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.
An educational program geared toward members with chronic disease or other medical conditions, to help members better understand and manage their condition.
A list of preferred pharmaceutical products developed in consultation with physicians and pharmacists.
Durable Medical Equipment (DME)
Equipment that meets all of the following criteria: a) can withstand repeated use; b) is used only to serve a medical purpose; c) is appropriate for use in the patient's home; d) is not useful in the absence of illness, injury or disease; and e) is prescribed by a physician. Durable Medical Equipment does not include fixtures installed in a member's home or real estate.
The date on which the health benefit plan goes into effect.
Those health care services that are provided in an emergency facility or setting after the onset of an illness or medical condition that manifests itself by symptoms of sufficient severity that without immediate medical attention could be reasonably expected by the prudent lay person, who possesses an average knowledge of health and medicine, to result in: a) placing the member's physical and or mental health in serious jeopardy; b) serious impairment to bodily functions; or serious dysfunction of any bodily organ or part.
Specific conditions or circumstances that are not covered under the health benefit plan. It is very important to consult the Health Benefit Plan to understand what services are not Covered Services.
Any treatment, procedure, drug, supply or service that does not meet standard treatment criteria as described in the health benefit plan. Expiration Date: The date on which coverage under the health benefit plan expires.
Explanation of Benefits (EOB)
A form that may be sent to the member after a Claim has been processed by the health benefit plan. The form explains the action taken on that Claim. This explanation usually includes the amount paid, the benefits available, reasons for denying payment, or the Claims appeal process.
See Drug List/Formulary.
A drug which is the pharmaceutical equivalent to one or more brand name drugs. Such generic drugs have been approved by the Food and Drug Administration as meeting the same standards of safety, purity, strength, dosage form, and effectiveness as the brand drug.
An employer, association or trust that applies for and accepts health benefit plans on behalf of its members.
Health Benefit Plan
A policy, contract, certificate or agreement issued by a health carrier to provide, deliver, arrange for, pay for or reimburse any of the costs of health care services.
Health Maintenance Organization (HMO)
A type of Health Benefit Plan under which the members are required to receive care through a specific group of participating doctors and hospitals in order to receive Benefits.
Services related to the hearing structures of the ear.
See Health Maintenance Organization.
Home Health Care
Health services other than Custodial Care, rendered by a home health agency to an individual in his or her residence. Such services are provided to disabled, sick or convalescent individuals who do not need inpatient care, but who do need nursing services or therapy, medical supplies and special outpatient services. It is important to read your Contract to determine which services are Covered Services.
Home Infusion Therapy
Receipt of Infusion Therapy at an individual's residence.
A facility or service that provides care for the terminally ill patient and which provides support to the family. The care, primarily for pain control and symptom relief, can be provided in the home or in an inpatient setting.
A facility whose primary function is to provide inpatient and outpatient services, diagnostic and therapeutic, for a variety of medical conditions, both surgical and non surgical.
I.D. Card/Identification Card
A card issued to a subscriber and possibly his/her dependents, which allows the Member to identify himself/herself to a provider in order to obtain health services. The I.D. Card may contain information about the member's benefits.
Inoculations with vaccines to establish resistance to specific infectious diseases.
A traditional health insurance plan that generally does not require use of a specific provider network to receive Benefits.
Refers to the use of providers who participate in the health benefit plan's Provider Network. Many health benefit plans require Members to use participating (in-network) Providers to receive Benefits or the highest level of benefits.
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.
A liquid substance introduced into the body by a vein for therapeutic purposes.
An individual who is receiving care for 24 hours or more as a registered bed patient in a Hospital or other facility, where a room and board charge is made.
See Experimental/Investigational Procedures.
The maximum amount of Benefits the health benefit plan will pay for any Member.
Any form of health benefit plan that uses Network Providers to deliver care to Members. Typically, Benefits are determined by use of Network Providers.
Care required for pregnancy and delivery.
Maximum Allowance or Maximum Benefit Allowance
See Allowable Charge.
See Durable Medical Equipment.
Procedures, treatment, 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 |
| Within generally accepted standards of good medical practice; and |
| Not primarily for the convenience of the Member or the Member's Provider; and |
| The most appropriate procedure, treatment, supply, equipment or level of service which can be safely provided.|
Any person who is enrolled in and covered by a health benefit plan.
Mental Health/Behavioral Health Services
Services primarily to treat any disorder that affects the mind or behavior.
The doctors, clinics, hospitals and other medical providers with whom the health benefit plan contracts to provide health care to its members. Members may be limited to Network Providers for full Benefits.
A Provider in the Network.
A medical provider who has not contracted with a health benefit plan to participate in the Network. Also known as a non-participating provider or out-of-network provider.
Treatment of a physically disabled person by means of constructive activities designed and adapted to promote restoration of the person 's ability to perform activities of daily living and those tasks required by the person's particular occupation or role. It is not recreational or diversionary therapy.
The use of Non-Network Providers. HMO Members are generally not allowed to go Out-of-Network except to receive Emergency Care. Members enrolled in preferred provider organizations (PPO) and point-of-service (POS) Health Benefit Plans can go Out-of-Network, but may pay some additional costs.
The maximum amount that a Member will have to pay for Covered Services under the Health Benefit Plan. The maximum is typically the sum of all Deductible and Co-payment or Coinsurance amounts paid by the Member.
A patient who is receiving care at a hospital, physician office or other health facility without being admitted as an Inpatient. The term "ambulatory" is often used to describe Outpatient care.
Surgical procedures performed that do not require an Inpatient admission. Such surgery can be performed in a Hospital, an Ambulatory Surgery center, or a 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.
A physician, hospital, pharmacy, laboratory, or other appropriately licensed facility or provider of health care services or supplies, that has entered into an agreement with a Health Benefit Plan to provide services or supplies to a Member enrolled in a Health Benefit Plan.
See Primary Care Physician.
Treatment involving physical movement to relieve pain, restore function and prevent disability following disease, injury, or loss of limb.
Point of Service (POS)
A type of health benefit plan that allows Members to go outside the Network for non-Emergency Care, but may result in a lower level of Benefits being paid by the Health Benefit Plan.
A procedure governed by the Contract used to review and assess the medical necessity and appropriateness of elective hospital admissions and non-Emergency Care before the services are provided. Also called Pre-Certification and Prior Authorization.
Care rendered by a physician to promote health and prevent future health problems for a Member who does not exhibit any symptoms (for example routine physical examination, immunizations).
See Pre Authorization.
A health condition (other than a pregnancy) or medical problem that was diagnosed or treated before enrollment in a Health Benefit Plan. Consult your Contract to determine whether Pre-Existing Conditions may be excluded from your coverage.
Preferred Provider Organization (PPO)
A type of Health Benefit Plan designed to give Members incentives to use health care providers designated as Network Providers, but that also provide reduced Benefits for Covered Services received from Non-Network Providers. PPO plans can also be distinguished from HMO plans by the ability of PPO members to see any specialty physician without referral from a PCP.
A narcotic or medicine approved by the Federal Drug Administration for Outpatient use, dispensed under a physician's written order.
Primary Care Physician (PCP)
A physician in the Network selected by the Member to be the first physician contacted for any non-Emergency Care medical problem. The physician acts as the patient's regular physician and coordinates any other care the patient needs, such as a visit to a specialist or hospitalization.
A device which replaces all or 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.
A health care facility, program, agency, physician or health professional that delivers health care services or supplies.
That set of providers contracted to provide services to Members.
Treatment of illness or disease by x-ray, radium, cobalt or high energy particle sources.
See Allowable Charge.
A recommendation by a physician that an Member receive health care services from a specialty physician or facility. Consult your Contract since some Referrals may require Pre Authorization.
Treatment to improve or preserve lung function.
The optional or mandatory requirement to visit an independent physician or surgeon regarding diagnosis, course of treatment or having specific types of elective surgery performed.
The geographic area in which a Health Benefit Plan is authorized to deliver Covered Services through a Network.
Skilled Nursing Care
Covered Services provided primarily for assessing or treating an injury or illness and performed by or under the supervision of a Provider. Your Health Benefit Plan may reserve the right to determine whether such services are Skilled Nursing Care. Not all services provided by a Provider of Skilled Nursing Care are considered Skilled Nursing Care.
Skilled Nursing Facility (SNF)
A licensed facility (or a distinct part of a hospital) that is primarily engaged in providing continuous Skilled Nursing Care and related services.
Treatment to correct a speech impairment which resulted from birth, or from disease, injury, or prior medical treatment.
Eligible employees, retired employees or members of the Group whose coverage is in effect and whose name appears on I.D. Cards. It also means the individual in whose name a Contract is issued. The Subscriber can enroll dependents under family coverage.
Substance Abuse/Chemical Dependency
Misuse, excessive use, or improper use of alcohol or drugs to the extent that such use contributes to physical, mental or social dysfunction.
The process used to determine the Medical Necessity, appropriateness, efficacy or efficiency of health care services. Techniques include inpatient admission review, continued inpatient stay review, discharge planning, post-care review and case management.
Services received for an unexpected episode of illness or injury requiring treatment which cannot be postponed , but is not Emergency Care. Urgent Care conditions include, but are not limited to earache, sore throat, fever not higher than 104º. Treatment of an Urgent Care condition does not require use of an emergency room at a Hospital.
The period of time required by a Member's Group or the Health Benefit Plan, before the Member's coverage under the Health Benefit Plan begins.
Well Baby/Well Child Care
Routine care, testing, checkups and immunizations for a generally healthy child typically from birth through the age of six.
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.