Practice of inserting thin needles to penetrate and stimulate specific points on the body to restore normal functions and energetic balance. It is considered a non-traditional treatment in Western Medicine.

Any medically necessary health expense, part or all of which is covered under any of the plans covering the member for whom claim is made. A health care service or expense including deductibles, coinsurance or copayments that is covered in full or in part by any of the plans covering the member. This means that an expense or service or a portion of an expense or service that is not covered by any of the plans is not an Allowable Expense. Plan documents will show examples of expenses or services that are or are not allowable.

The process used by insurance companies to determine the payment amount for a claim.

Surgical procedures performed that do not require an overnight hospital say. Also see Outpatient Surgery.

Services provided to a member who can walk and is not confined to a bed. Generally applies to same-day or outpatient procedures.

A process used by a member to request the health plan re-consider a previous authorization or claim decision.

See Preauthorization/Precertification.

Payment received for covered services under the terms of the policy.

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

A prescription drug which is protected by trademark registration.

The prepaid amount which the provider receives as compensation for services.

A process of identifying individuals at high risk for problems associated with complex health care needs and assessing opportunities to coordinate care to optimize the outcome.

See Preauthorization/Precertification.

Treatment of malignant disease by chemical or biological antineoplastic agents.

An alternative medicine therapy administered by a licensed Chiropractor. The Chiropractor adjusts the spine and joints to treat pain and improve general health.

A request for payment of benefits for health care services provided to a member.

(Consolidated Omnibus Budget Reconciliation Act of 1985) A federal law that requires employers, with 20 or more employees, to offer continued health insurance coverage to eligible employees (and their beneficiaries) whose group health insurance has been terminated under certain circumstances.

The portion of covered expenses that a member is responsible for paying, after first meeting any applicable deductible amount.

Total amount a member will be required to pay in a year for deductibles and coinsurance. It is a stated dollar amount, determined by the insurance company, in addition to regular premiums.

Methods or devices, such as drugs, sexual practices, or surgical procedures, employed to prevent contraception or impregnation.

A legal agreement between an individual subscriber or an employer group ("Contractholder"), and, a health plan that describes the benefits and limitations of the coverage. Also known as a Benefit Certificate or Policy.

An option to purchase individual coverage at a negotiated rate by a person who is leaving an employee group.

A provision that is intended to avoid claims payment delays and duplication of benefits when a person is covered by two or more plans providing benefits or services for medical, dental or other care or treatment. It avoids claims payment delays by establishing an order in which plans pay their benefits and provides the authority for the orderly transfer of information needed to pay claims promptly. It may avoid duplication of benefits by permitting a reduction of the benefits of a plan when, by the rules established by this provision; it does not have to pay its benefits first. Plan documents will include a description of the Coordination of Benefits provision.

The specified dollar amount or percentage required to be paid by or on behalf of a member in connection with benefits.

Those medically necessary services and supplies which are covered in whole or in part under the plan, subject to all the terms and conditions of the group agreement or group insurance policy.

Any type of care where the primary purpose of the type of care provided is to attend to the member's daily living activities which do not entail or require the continuing attention of trained medical or paramedical personnel. Examples of this include, but are not limited to, assistance in walking, getting in and out of bed, bathing, dressing, feeding, using the toilet, changes of dressings of non-infected, post-operative or chronic conditions, preparation of special diets, supervision of medication which can be self-administered by the member, general maintenance care of colostomy or ileostomy.

A systematic approach to assessing a provider's qualifications and record on issues relating to professional competence and conduct. This includes a review of relevant training, academic background, experience, licensure, certification and/or registration to practice in a health care field.

The amount customarily charged for the service by other providers in the same geographic area (often defined as a specific percentile of all charges in the community), and the reasonable cost of services for a given patient. Also called "Usual, Customary, and Reasonable"(UCR).

 

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

An amount that a Member must pay for Covered Services in a specified time period in accordance with the Member's Plan before the Plan will pay benefits.

Care of services provided by an appropriately credentialed provider for the care and maintenance of the oral cavity including teeth, gum disease and oral surgery.

A person who is eligible to be enrolled for coverage by the subscriber as determined by the employer and agreed upon with the plan. Examples would be a subscriber's spouse or child.

Tests and procedures ordered by a provider to determine if a patient has a specific 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, and laboratory and pathology services or tests.

A listing of prescription drugs and insulin established by the health plan which includes both Brand Name Prescription Drugs, and Generic Prescription Drugs. This list is subject to periodic review and modification by the health plan. Drugs listed on the formulary are covered under the drug plans, with copayments that vary on plan design. Non-formulary is also designated on the formulary.

Equipment which is a) made for and mainly used in the treatment of a disease or injury; b) made to withstand prolonged use; c) suited for use while not confined as an inpatient in the Hospital; d) not normally of use to persons who do not have a disease or injury; e) not for use in altering air quality or temperature; and f) not for exercise or training.

The date on which the coverage under a member's plan goes into effect at 12:01a.m.

An emergency medical condition is a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in (I) placing the health of the individual (or, with respect to a pregnant woman, the health of the woman and her unborn child) in serious jeopardy, (ii) serious impairment to bodily functions, or (iii) serious dysfunction of any bodily organ or part. Also called Medical Emergency.

An individual who is enrolled and eligible for covereage under a Health Benefit Plan. See Member.

Specific conditions or circumstances that are not covered for benefits under the Plan.

Surgical or medical treatments, procedures, drugs, or research studies that are not recognized as acceptable medical practice and any such services where federal or other governmental agency approval is required but has not been granted.

The date indicated in an insurance contract as the date coverage expires.

An itemized receipt that lists the details of payments or denials made for a claim.

See Drug Formulary.

 

A prescription drug which is not protected by trademark registration, but is produced and sold under the chemical formulation name.

The health insurance or HMO product offered by a licensed health benefits company that is defined by the benefit contract and represents a set of covered services or expenses accessible through a provider network, if applicable, or direct access to licensed providers and facilities.

HIPAA is a federal law enacted in 1996. It was designated to improve availability and portability of health coverage by:

• limiting exclusions for pre-existing conditions;
• providing credit for prior health coverage;
• allowing transmittal of the coverage information (i.e., covered family members and coverage period) to a new insurer;
• providing new rights to allow individuals to enroll for health coverage when they lose their health coverage or have a new dependent;
• prohibiting discrimination in enrollment/premiums;
• guaranteeing availability of health insurance coverage for small employers.

HIPAA's Administrative Simplification and Privacy (AS&P) Act final rules took effect in April 2001. The purpose of these rules is to improve the efficiency of the health care system by standardizing the electronic exchange of health information and protecting the security and privacy of member-identifiable health information.

A third party, usually a legal entity, which arranges payment for the provision of basic and supplemental health services to its members from a network of independently contracted providers and facilities on a prepaid or reduced fee basis. For most plans, members are required to select a network primary care physician to provide routine care and provide referrals for specialty and hospitals services when appropriate.

Care or services provided by an appropriately credentialed provider for the care and maintenance of the auditory senses. Does not usually include hearing aids or other devices.

Skilled nursing and other therapeutic services provided by a home health care agency in a home setting as an alternative to confinement in a hospital or skilled nursing facility.

The administration of intravenous drug therapy in the home.

This is palliative and supportive care, either on an inpatient or outpatient basis, given to a terminally ill person and to his or her family. The focus of hospice programs is to enable terminally ill patients to remain, for as long as they can, in the familiar surroundings of their home.

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

A card issued to a member, which allows the member to identify himself/herself as a health plan member to a provider for health care services. The provider uses the card to determine benefit levels and to prepare the billing statement.

A substance given to a member to create a resistance to specific disease, also called a "vaccination."

A traditional Health Benefit Plan that reimburses for medical services provided to members based on bills submitted after the services are rendered. Also known as a fee-for-service plan. These plans generally do not have a specific Provider Network unless they are a Preferred Provider Network Plan (PPO).

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 legal entity or other group of providers that contract with managed care plans while maintaining their separate practice. A member who selects an IPA-affiliated primary care office generally will be referred to specialists and hospitals affiliated with the IPA, unless the member's medical needs extend beyond the capability of these providers.

Refers to the use of providers who participate in the health plan's provider network.

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

Service provided after the patient is admitted to the hospital. Inpatient care lasts 24 hours or more.

Any form of health plan that uses selective provider contracting to have patients seen by a network of contracted providers and that requires pre-authorization of certain services.

Services that generally include prenatal care, normal delivery services and routine newborn nursery care.

See Emergency.

See Necessary

A subscriber or dependent who is enrolled in and covered by a health care plan. Also called Enrollee.

A dysfunctional manifestation in the individual that may be physical, psychological or behavioral, and for which treatment is generally provided by under the direction of a mental health professional such as a psychiatrist, a psychologist or a psychiatric social worker.

 

Services or supplies that are appropriate and consistent with the diagnosis in accordance with accepted medical standards as described in the Covered Benefits section of the plan documents.

The physicians, hospitals and other health care providers the insurance company contracts with to provide health care to its members at negotiated rates.

See Participating Provider.

This term is generally used to mean providers who have not contracted with a health plan to provide services at reduced fees. Also referred to as Out-of-Network.

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

The use of health care providers who have not contracted with the health plan to provide services. Members enrolled in preferred provider organizations (PPO) and point-of-service (POS) coverages can go out-of-network for covered expenses, but will pay additional costs in the form of deductibles and coinsurance and will be subject to benefit and lifetime maximums. Because reduced fees are not negotiated with out-of-network providers, the insurance company will calculate reimbursement based on the usual, customary and reasonable charge, (see definition). Members are responsible for all charges above UCR in addition to any deductible and coinsurance provisions.

The maximum amount of out-of-pocket a member will have to pay for. The maximum is the sum or all paid deductibles and copayments or coinsurance amounts. This does not include any amount that exceeds the usual and customary amounts for out-of-network services.

Care provided in a clinic, emergency room, hospital or non-hospital surgical facility without admission to the hospital or facility.

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. Also see Ambulatory Service.

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.

Any physician, hospital, skilled nursing facility, or other individual or entity involved in the delivery of health care or ancillary services which contracts to provide Covered Services to Members for a negotiated charge. Also called Preferred Care Provider.

See Primary Care Physician.

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

Plan documents include the Group Agreement, Group Policy, and Certificate or Evidence of Coverage (or Certificate of Insurance).

Maximum dollar amount attributed to certain Benefits without a plan. For example, infertility coverage may have a benefit maximum of $10,000

A point of service plan provides benefits for covered services received from both participating and non-participating providers. Member must pay higher out-of-pocket fees to receive care from a non-participating provider in the form of deductibles and coinsurance.

Certain healthcare services, such as hospitalization or outpatient surgery, require precertification to ensure coverage for those services. When a member is to obtain services requiring precertification through a participating provider, this provider should precertify those services prior to treatment.

A health condition (other than a pregnancy) or medical problem that was diagnosed or treated during a specified timeframe prior to enrollment in a new health plan. Some pre-existing conditions may be excluded from coverage during a specified timeframe after the effective date of coverage in a new health plan. Plan documents will provide specific information on pre-existing conditions.

See Participating Provider.

A type of Health Benefit Plan designed to give members incentives to use health care providers designated as "preferred providers," but that also give substantial coverage for services received from other health care providers.

An order of a prescriber for a prescription drug. If it is an oral order, it must promptly be put in writing by the pharmacy.

Basic medical services where the focus is for prevention, early detection, and early treatment of conditions such as routine physical examination and immunization.

A Participating Physician who supervises, coordinates and provides initial care and basic medical services as a general or family care practitioner, or in some cases, as an internist or a pediatrician to members, initiates their Referral for specialist care, and maintains continuity of patient care.

See Preauthorization.

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.

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

See Network.

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

Specific directions or instructions from a Member's PCP, in conformance with Plan policies and procedures, which direct a Member to a Participating Provider for medically necessary care. A referral may be written or electronic.

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

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

The geographic area in which an insurance company is prepared to offer health care coverage through a Network of Participating Providers.

An institution or a distinct part of an institution that is licensed or approved under state or local law, and which is primarily engaged in providing skilled nursing care and related services as a Skilled Nursing Facility, extended care facility, or nursing care facility approved by the Joint Commission on Accreditation of Health Care Organizations or the Bureau of Hospitals of the American Osteopathic Association, or as otherwise determined by the health plan to meet the reasonable standards applied by any of the aforesaid authorities.

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

The employee covered under an employer's group agreement or group insurance policy. The subscriber can enroll eligible dependents as determined by the contract holder under family coverage.

Abuse of or addiction to drugs, which may or may not (depending on the governing state law) include abuse of or addiction to alcohol.

A Physician who provides medical care in any generally accepted medical or surgical specialty or subspecialty.

See Customary and Reasonable.

Services received for an unexpected illness or injury that is not life threatening but requires immediate outpatient medical care that cannot be postponed. An urgent situation requires prompt medical attention to avoid complications and unnecessary suffering or severe pain, such as a high fever.

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