Terms Glossary

Accreditation
An evaluative process in which a healthcare organization undergoes an examination of its operating procedures to determine whether the procedures meet designated criteria as defined by the accrediting body, and to ensure that the organization meets a specified level of quality.

Acupuncture
A traditional Chinese medical practice of insertion of fine needles into specific exterior body locations to relieve pain, to induce surgical anesthesia, and for therapeutic purposes.

Acute Illness
A physical condition or illness that begins abruptly and requires medical care or restricted activity for a short period of time (usually 3 months or less).

Adjudication
The process by which a claim is paid or denied based on eligibility and contract determination.

Admission
Formal acceptance as an inpatient by an institution, hospital or healthcare facility.

Admitting Physician
The physician responsible for admission of a patient to a hospital or other inpatient health facility

Advance Directive
Any spoken or written decision with your instructions and preferences for medical treatment. If you sign an advance directive, your family and your doctor will know who to talk to about your care or what kinds of treatment you want or don′t want if you are too sick or incompetent to decide. If you become unable to make decisions about your healthcare treatment, your family may not be able to make decisions for you unless you sign a healthcare proxy directive.

Allergy Treatment
The treatment of the allergic patient may include identifying the offending agent by means of various testing methods. Once the agent is identified, treatment is provided by avoidance, medication, or immunotherapy.

Allowable Charge
The maximum fee that a health plan will reimburse a provider for a given service.

Allowance
The amount an individual provider/member is entitled to receive for a certain service.

Allowed Amount
The maximum reimbursement the member′s health plan allows for a specific service in or out of network. This amount may be:

• a fee negotiated with participating providers
• a customary charge based on the amount -charged by most providers in the member′s area
• an allowance established by law
• an amount set on a Fee Schedule of Allowance

Ambulatory Care
All types of health services that are provided on an outpatient basis.

Ambulatory Care Facility
A medical care center that provides a wide range of healthcare services, including preventive care, acute care, surgery and outpatient care in a centralized facility.

Ambulatory Surgery
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.

Ancillary Services
Auxiliary or supplemental services (i.e. diagnostic services, physical therapy, medications) used to support diagnosis and treatment of a patient′s condition.

Annual out-of-pocket Coinsurance Maximum
The most you will have to pay in out-of-pocket costs for coinsurance on covered services during a calendar year. Charges in excess of the allowed amount (see definition) are not applied toward this maximum.

Appeal(s)
A process used by a provider or member to request the health plan sponsor to reconsider a previous authorization or claim decision.

Assignment
An agreement in which a patient assigns to another party, usually a physician or hospital, the right to receive payment from a public or private healthcare program for the service the patient has received.

Attending Physician
Physician primarily responsible for the care of a patient during hospitalization.

Balance Billing
Billing a member or other responsible party for the difference between the insurer′s payment and the actual charge.

Behavioral Healthcare
The provision of mental health and substance abuse services.

Benefit(s)
Services available to a member as defined in the Summary Plan Description. Benefit design includes the types of benefits offered, limits (e.g. number of visits, percentage paid or dollar maximums applied), member responsibility (cost sharing components), and member incentives to use network providers.

Benefits Exhausted
When the maximum number of visits for a specific service is reached, further benefits will not be considered.

Billed Charge
The amount a physician or other practitioner actually bills a patient for a medical service or procedure.

Billing Address
The address to which a billing statement will be sent.

Board Certification
A process by which a physician who has been tested for proficiency in a medical specialty or subspecialty, by a medical specialty board, has passed those tests and therefore been certified as proficient in that medical specialty.

Board Eligible
Denoting a physician who has completed the educational requirements necessary for eligibility to take the specialty board examinations.

Brand Name Drug
A prescription drug that has been patented and is only available through one manufacturer.

Carrier
An insurance company that either administers self-insured and/or insured plans.

Carryover (4th Quarter) Deductible
An option sometimes contained in a health benefit plan where deductible amounts incurred under a member′s contract in the last three months of the year are applied towards the deductible of the next calendar/benefit year.

Case Management
A program that assists the patient in determining the most-appropriate and cost effective treatment plan including coordinating and monitoring the care with the ultimate goal of achieving the optimum healthcare outcome.

Charges not Covered
Provider charges that exceed the insurer′s payment for services, or services not covered by your health policy

Chemotherapy
Treatment of malignant disease by chemical or biological antinoeplastic agents.

Chiropractic Care
An alternative therapy administered by a licensed Chiropractor. The chiropractor′s specialty is the relief, correction and prevention of musculo-skeletal problems of the spine, peripheral joints and related areas through manipulation.

Chronic Care
A pattern of medical care that focuses on long-term care with chronic diseases or conditions.

Claim
An itemized statement of healthcare services and their costs provided by hospital, physician′s office or other healthcare facility. Claims are submitted to the plan by either the plan member or the provider for payment of the costs incurred.

Claim Form
An application for payment of benefits under a healthcare plan.

Clinical Professionals
Doctors, nurses and other healthcare professionals are clinical professionals.

COB
See ‘Coordination Of Benefits’.

COBRA
See ‘Consolidated Omnibus Budget Reconciliation Act’.

Coinsurance
Cost-sharing requirement that the insured pay a designated percentage of the allowed amount for covered services.

Coinsurance Maximum
The most you will have to pay in out-of-pocket costs for coinsurance on covered services during a calendar year.

Concurrent Care
Medical care rendered within the aftercare period of surgery, by other than the surgeon, and the condition is different from the one treated surgically.

Consolidated Omnibus Budget Reconciliation Act(COBRA)
A federal act which requires each group′s health plan to allow employees and certain dependents to continue their group coverage for a stated period of time following a qualifying event that causes the loss of group health coverage. Qualifying events include reduced work hours, death, or divorce of a covered employee and termination of employment.

Consultation
Services rendered by a physician whose opinion or advice is requested by another physician for further evaluation or management of the patient.

Continuation of Coverage
Procedure by which individuals transferring from one insurance plan to another are allowed uninterrupted coverage from the date of original enrollment.

Contraception
The process by which pregnancy is prevented by either barring conception of an embryo or the implantation of it within the uterine wall.

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.

Coordination of Benefits (COB)
The provision which applies when an enrollee is covered by two health plans at the same time. The provision is designed so that the payments of both plans do not exceed 100% of the covered charges. 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” between the two health plans.

Co-payment(or co-pay)
The fixed dollar amount that your policy requires you to pay as your share of the cost of certain services each time you receive care.

Condition Management Programs
A coordinated system of preventive, diagnostic and therapeutic measures intended to provide cost-effective, quality healthcare for a patient population who have or are at risk for a specific chronic illness or medical condition.

Cost Sharing
The provision of a health plan policy that requires insured individuals to pay some portion of the covered medical expenses. Several forms of cost sharing are deductible, copayment and coinsurance.

Covered Services
The services for which the “Plan” provides benefits under the terms of your contract.

Custodial Care
Maintenance care of a patient which is designed to assist the patient in daily living and not primarily provided for the treatment of an illness, disease or condition. Custodial care includes but is not limited to help in walking, bathing and feeding.

Customary Charges
The fees most providers charge for a certain procedure. These charges are determined based on charge data collected from providers in a geographical area at a certain time period.

Date of Service
The date on which a service was rendered.

Deductible
Dollar amount that an insured person or family must pay each year before an insurer will assume any liability for the remaining cost of covered services.

Denial of Benefits
A rejection of an entire claim or part of a claim.

Dependent
Person (spouse or child) other than the subscriber who is covered in the subscriber′s benefit certificate. Also called a “Member” or “Beneficiary”.

Diagnostic Service
A test or procedure rendered because of specific symptoms which is directed toward the determination of the definite condition or disease.

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, or pathology services.

Discharge Date
Date the patient left the hospital.

Drug Formulary
A list of preferred pharmaceutical products that health plans, working with pharmacists and physicians, have developed to encourage greater efficiency in the dispensing of prescription drugs without sacrificing quality.

Durable Medical Equipment
Mechanical devices, equipment and supplies which enable a person to maintain functional ability. Also called Medical Equipment.

Effective Date
The date on which the coverage of a plan goes into effect at 12:01 a.m.

Elective Surgery
Surgery for a condition that is not considered an emergency.

Eligibility
A determination of whether or not a person meets the requirements to participate in the plan.

Eligibility Period
The period of time a group stipulates must elapse before a group member becomes eligible for benefits.

Emergency
An emergency is a medical or behavioral condition of which the onset is sudden. It manifests itself by symptoms of such severity that a prudent lay person with an average knowledge of medicine and health could reasonably expect that the absence of immediate medical attention would result in: placing the health of the afflicted person in serious jeopardy; placing the health of an individual with a behavioral health condition or others in serious jeopardy; causing serious impairment of the individual′s bodily functions; causing serious dysfunction of any bodily organ or part; causing serious disfigurement of the afflicted individual.

Emergency Care
Care for patients with severe or life-threatening conditions that require immediate intervention.

Employee Retirement Income Security Act(ERISA)
This law, enacted in 1974, applies to employee benefit plans, including health benefits. The law is designed to protect the interest of employees and requires full disclosure to the employees of their rights under the plan.

Enrollee
An individual who is enrolled and eligible for coverage under a health plan contract. Also called “Member”.

EOB
See ‘Explanation Of Benefits’.

EPO
See ‘Exclusive Provider Organization’.

ERISA
See ‘Employee Retirement Income Security Act’.

Exclusion
Specific conditions or circumstances that are not covered under the benefit agreement. It is very important to consult the benefit contract to understand what services are not covered benefits.

Exclusive Provider Organization (EPO)
A healthcare benefit arrangement that is similar to a preferred provider organization in administration, structure and operation but which does not cover out-of-network care.

Experimental Procedures
Procedures that are mainly limited to laboratory research.

Expiration Date
The date indicated in a contract as the date coverage expires at 12:00 midnight.

Explanation of Benefits (EOB)
A form sent to the enrollee after a claim for payment has been processed by the health 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.

Extended Care Facility
An institution devoted to providing medical, nursing or custodial care for an individual over a prolonged period of time as during the course of a chronic disease or during the rehabilitation phase after an acute illness.

Facility
A facility is a hospital, ambulatory surgical facility, birthing center, dialysis center, rehabilitation facility, skilled nursing facility or other provider certified under New York Public Health Law. A hospice is a facility.

Family Deductible
The dollar amount of the member′s health benefit coverage that must be met each calendar year before payment can be made on claims. There is a maximum out-of-pocket amount that will satisfy the family deductible. Once that deductible is reached, all claims are then paid at 100% of allowable charges.

Fee For Service Payment
A payment method in which the insurer will reimburse the member or provider directly for each covered medical expense.

Fee Schedule
The fee determined by the insurer to be acceptable for a procedure or service that the physician agrees to accept as payment in full.

Full Time Student
A dependent enrolled at an accredited institution of learning. The student′s principal residence, when not away at school, must be the same as their parents.

Generic Drug
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 and effectiveness as the brand name drug.

Grievance
A request to change an adverse determination that was based on administrative policies, procedures or guidelines.

Health Benefit Plan
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 Insurance Portability and Accountability Act(HIPAA)
A federal act that protects people who change jobs, are self-employed or who have pre-existing medical conditions. HIPAA standardizes an approach to the continuation of healthcare benefits for individuals and members of small group health plans and establishes parity between the benefits extended to these individuals and those benefits offered to employees in large group plans. The act also contains provisions designed to ensure that prospective or current enrollees in a group health plan are not discriminated against based on health status.

Health Maintenance Organization (HMO)
A federal act that protects people who change jobs, are self-employed or who have pre-existing medical conditions. HIPAA standardizes an approach to the continuation of healthcare benefits for individuals and members of small group health plans and establishes parity between the benefits extended to these individuals and those benefits offered to employees in large group plans. The act also contains provisions designed to ensure that prospective or current enrollees in a group health plan are not discriminated against based on health status.

Healthcare Financing Administration(HCFA)
The Governmental agency responsible for administering the Medicare and Medicaid programs.

Healthcare Provider
A professionally licensed individual, facility or entity giving health-related care to patients. Physicians, hospitals, skilled nursing facilities, pharmacies, chiropractors, nurses, nurse-midwives, physical therapists, speech pathologist, laboratories, etc. are providers. All network providers are healthcare providers, but not all providers are network providers. See network provider and non-network provider.

HMO
See ‘Health Maintenance Organization’.

Home Health Care
Healthcare services rendered to a member in their home in lieu of confinement in a hospital or skilled nursing facility. Care must be under the supervision of a registered professional nurse. This type of care may include physical, occupation or speech therapy, medical supplies and medication prescribed by a doctor.

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 the terminally ill patient and who 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.

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.

Hospital Affiliation
The hospital in which the provider is associated.

ICU
See ‘Intensive Care Unit’.

I.D. Card (Identification Card)
A card which allows the member to identify himself or his covered dependents to a provider for healthcare services. The card is subsequently used by the provider to determine benefit levels and to prepare the billing statement.

Identification Card
A card which allows the member to identify himself or his covered dependents to a provider for healthcare services. The card is subsequently used by the provider to determine benefit levels and to prepare the billing statement.

Identification Number
A unique number which identifies the member′s enrollment with MagnaCare.

Immunizations
There are two types of acquired immunizations; Active immunization: naturally acquired during an infectious disease or artificially by vaccination with dead or living organisms. Passive immunization: can be naturally acquired during when maternal antibodies are passed to the child via placenta, in the milk or artificially by administering immune sera containing antibodies obtained from animals or humans.

Indemnity
A tradition health insurance plan that reimburses for services provided to patients based on bills submitted after the services are rendered. Also known as fee-for-service plans. These plans generally do not have a specific provider network.

Indemnity Benefits
A type of health insurance product characterized by reimbursement on a fee for service basis, freedom of choice in selecting providers and fewer managed care rules and regulations.
Independent Practice Association (IPA)
An organization comprised of individual physicians or physicians in group practices that contracts with the insurer on behalf of its member physicians to provide healthcare services.

Individual Deductible
The dollar amount of the member′s health benefit coverage that must be met each calendar year before becoming eligible for benefits for the remaining cost of covered services. There is a maximum out-of-pocket amount that will satisfy the individual deductible. Once that deductible is reached, all claims are then paid at 100% of allowable charges.

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

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.

In-Network Provider/Supplier
A healthcare provider such as a physician, skilled nursing facility, home health agency, laboratory etc, who has an agreement with MagnaCare to provide covered services to members.

Inpatient
Service provided after the patient is admitted to the hospital. Inpatient stays are those lasting 24 hours or more.

Inpatient Care
Treatment that is provided to a patient who stays overnight (more than 23 hours) in a hospital or other facility.

Insured
The individual or organization protected in case of loss under the terms of an insurance policy.

Intensive Care Unit (ICU)
A specialized unit in the hospital which concentrates on seriously ill patients needing constant nursing care and observation.

Investigational Procedures
The first step in determining eligibility of a medical procedure for coverage is evaluating its health effects This process is known as ‘Technology Assessment’. Procedures/Services failing this process will be considered “Experimental/Investigational”

IPA
See ‘Independent Practice Asssociation’.

Itemized Bill
A bill from a provider that itemizes all charges for services rendered needed to process for payment.

No J items

No K items

Lifetime Maximum
The maximum amount of benefits your policy will pay for covered expenses over the course of your lifetime.

Limitation
Specific circumstances or services listed in the contract for which benefits will be limited.

Mail Order Pharmacy Program
A program that offers drugs ordered and delivered through the mail to plan members usually providing a three-month supply of the prescribed drug.

Mailing Address
The address designated by the member for all correspondence

Managed Care
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.

Maternity Care
Maternity care includes all services provided to a pregnant female including evaluation and management (ante and postpartum care), diagnostic testing, delivery (c – section or vaginal), and various miscellaneous services.

Medicaid
A jointly funded federal and state program that provides hospital and medical coverage to the low income population and certain aged and disabled individuals.

Medical Card
The card that is presented to doctors and medical facilities showing the person as a member of MagnaCare for medical health insurance benefits.

Maternity Care
Maternity care includes all services provided to a pregnant female including evaluation and management (ante and postpartum care), diagnostic testing, delivery (c – section or vaginal), and various miscellaneous services.

Medical Equipment (DME)
Goods, implements, prosthetics, etc., that are prescribed for patient care, usually in an outpatient setting. Examples of such equipment include hospital beds, wheelchairs, and walkers.

Medically Necessary
MagnaCare regards services, supplies or equipment provided by a hospital or covered provider of health services as medically necessary if MagnaCare determines that they are:

• Consistent with the symptoms or diagnosis and treatment of the patient′s condition, illness or injury;
• in accordance with standards of good medical practice;
• not solely for the convenience of the patient, the family, or the provider;
• not primarily custodial; and the most appropriate level of service for the patient′s safety. The fact that a covered provider may have prescribed, recommended, or approved a service, supply, or equipment does not, in itself, make it medically necessary.

Medicare
A nationwide insurance program for the disabled and people aged 65 and over, created by the 1965 amendments to the Social Security Act and operated under the provisions of the Act. It consists of two separate but coordinated programs, Part A and Part B.

Medicare Carve Out Contract
A contract that stipulates the Medicare-eligible members of a group receive benefits at least equal to benefits received by non-Medicare group members. Members are reimbursed up to the group′s contract limitations, reduced by what Medicare paid or would have paid if the member were Medicare-eligible and Medicare were the primary coverage.

Medicare Part A
This is part of the Medicare law providing benefits for hospitalization, extended care and nursing home care to Medicare beneficiaries with no premium payment for qualified individuals.

Medicare Part B
This is part of the Medicare law providing medical surgical benefits for Medicare beneficiaries for a modest premium.

Medicare Supplement Contract
Health insurance policy designed to supplement Medicare, beginning at the point Medicare coverage ceases for a particular service. Also referred to as a Medigap policy.

Member
A person, including eligible covered dependents, that has coverage with a plan sponsor using MagnaCare.

Member ID Number
A unique number that identifies the person as a member with MagnaCare. Many times the member′s ID is the insured′s social security number.

Member Services
The department responsible for helping members with problems, and questions.

Mental Health/Behavioral Health
Conditions that affect thinking and the ability to figure things out that affect perception, mood and behavior.

Message Center
A secure area on the website which contains e-messages for the member.

Network
The group of physicians, hospital, and other medial care providers that a specific plan has contracted with to deliver medical services to its members.

Network Provider
A doctor, hospital or other healthcare provider who has entered into an agreement with MagnaCare to provide healthcare services to members for a negotiated rate of reimbursement.

No Fault
A law in several states requiring all registered motor vehicles to be covered by personal injury protection insurance. Under this law, a person′s own motor vehicle insurance company pays for expenses relating to an accident regardless of who caused the accident.

Non-Participating Hospital/Facility
A hospital/facility that does not have a participation agreement with MagnaCare to provide hospital/facility services to persons covered under Empire.

Non-Participating Provider
A healthcare provider such as a physician, skilled nursing facility, home health agency, laboratory etc, who does not have an agreement with MagnaCare to provide covered services to members.

Occupational Therapy
Treatment to restore a physically disabled person′s ability to perform activities such as walking, eating, drinking, dressing, toileting, and bathing (activities of daily living).

Omnibus Budget Reconciliation Act(OBRA)
A federal act which set guidelines for Medicare and insurers.

Open Enrollment
A limited time period in which enrollment applications for coverage elections or changes may be made.

Out-of-Network Services
The use of healthcare providers who have not contracted with the health plan to provide services. Depending on your contract, out of network services may not be covered. Please refer to your contract for specific benefit coverage.

Out-of-Network Benefits
Reimbursement for covered services provided by out-of-network providers and suppliers. Out-of-network benefits are generally subject to a deductible and coinsurance and, therefore, have higher out-of-pocket costs. Depending on your contract, out of network services may not be covered. Please refer to your contract for specific benefit coverage.

Out-of-Pocket Maximum
Dollar amount set by the insurer that limits the amount members have to pay out of their own pocket for particular covered healthcare services during a specified time period.

Outpatient Care
Treatment that is provided to a patient who is able to return home after care without an overnight stay in a hospital or other inpatient 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 Hospital/Facility
A hospital or facility that is part of MagnaCare′s provider network and has signed an agreement to provide covered services to its members.

Participating Provider
A healthcare provider such as a physician, skilled nursing facility, home health agency, laboratory etc, who has an agreement withMagnaCare to provide covered services to its members.

Past Plan
The plan with which the member previously had health insurance.

Patient Bill of Rights
Refers to the Consumer Bill of Rights and Responsibilities, a report prepared by the President′s Advisory Commission on Consumer Protection and Quality in the Healthcare Industry in an effort to ensure the security of patient information, promote healthcare quality, and improve the availability of healthcare treatment and services.

Pharmacy Card
The member′s identification card which also identifies the pharmacy coverage and copay requirements.

PCP
See ‘Primary Care Physician’

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

Plan Benefit Maximum
Dollar amount set by the insurer that limits the amount members have to pay out of their own pocket for particular covered healthcare services during a specified time period.

Point of Service (POS)
A type of health benefit plan that allows enrollees to go outside the health plan′s provider network for care, but requires enrollees to pay higher out-of-pocket fees when they do.

POS
See ‘Point Of Service’.

PPO
See ‘Preferred Provider Organization’.

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.

Pre-certification
See ‘Pre-Authorization’

Precertified Services
Services that must be coordinated and approved by MagnaCare′s medical or behavioral healthcare management programs to be fully covered by your plan. Examples may include: planned inpatient surgeries, and medical tests such as MRIs and MRAs. To avoid a reduction or denial of benefits, members must precertify.

Pre-existing Condition
A health condition (other than a pregnancy) 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 Organization (PPO)
A healthcare benefit arrangement designed to supply services at a lower cost to use in-network healthcare providers (who contract with the PPO at a discount). The PPO also provides coverage for services rendered by healthcare providers who are not part of the PPO network at a higher out-of-pocket cost to the member.

Premium
A prepaid payment or series of payments made to a health plan by purchasers and often plan members for health insurance coverage.

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

Prescription Drugs
Drugs and medications that are required by law to be dispensed by written prescriptions from a licensed physician.

Preventive Care
Comprehensive care emphasizing priorities for prevention, early detection, and early treatment of conditions, and generally including routine physical examinations and immunization.

Primary Care Physician (PCP)
A PCP is a family practitioner, general practitioner, internist or pediatrician – who is responsible for delivering or coordinating care.

Primary Carrier
A term used when administering the COB program, which defines the insurance company called upon first to consider payment.

Prior Authorization
The process of obtaining advanced approval of coverage for a healthcare service or medication. Also called Pre-Authorization.

Professional Provider Number
An identification number that identifies a doctor or provider with the insurance company.

Prosthetic Device
A device which replaces all or portion of a part of the human body.

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

Provider Network
A set of providers contracted with a health plan to provide services to the enrollees.

No Q items

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 called “Usual, Customary and Reasonable” (UCR).

Referral
A recommendation by a physician that an enrollee receive care from a specialty physician or facility.

Referral Care
Care you receive from a network provider (for example, a specialist) other than your PCP. However, your PCP is required to provide the referral.

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

Retrospective Review
A review done after services are completed (usually as part of a claim or appeal), that ensures that the care given was medically necessary.

Rider
A provision added to a contract whereby the scope of its coverage is increased or decreased.
Same-Day Surgery
Same-day, ambulatory or outpatient surgery is surgery that does not require overnight stay in a hospital.

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. Refer to your contract for specific guidelines.

Secondary Coverage
A term used when administering Coordination of Benefits that defines the insurance company called upon to consider second payment for services.

Self Insurance
Practice of an individual, group of individuals, employer or organization assuming complete responsibility for the losses that might be insured against such as healthcare expenses. In effect, self insured groups have no real insurance against potential losses and instead maintain a fund out of which is paid the contingent liability subject to self-insurance.

Service Area
The geographic area in which a health plan is prepared to deliver healthcare through a contracted network of participating providers.

Short-term Care
Refers to treatment or care intended to improve or restore a member′s functioning within a reasonable period of time. Short-term care is expected to produce a positive result, not maintain functioning or prevent decline.

Skilled Nursing Facility (SNF)
A licensed institution (or a distinct part of a hospital) that is primarily engaged in providing continuous skilled nursing care and related services for patients who require medical care, nursing care or rehabilitation services.

Specialized Services
Services provided by specialists, not by your PCP. For example, an allergist (who treats allergies) or a radiologist (who uses x-rays for diagnosis and treatment) are specialists.

Specialty Care Center
A facility accredited or designated by an agency or the state or by a voluntary national health organization as having special expertise in treating a specified condition or disease.

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

Stop Loss
Dollar amount set by the insurer that limits the amount members have to pay out of their own pocket for particular covered healthcare services during a specified time period.

Substance Abuse/Chemical Dependency
The use of one or more drugs for purposes other than those for which they are prescribed or recommended.

Third Party Payer
Any organization that pays or insures health or medical expenses on behalf of beneficiaries or recipients such as MagnaCare, commercial insurance companies, Medicare and Medicaid. The individual generally pays a premium for such coverage in all private and some public programs.

Treatment Maximums
Maximum number of treatments or visits for certain conditions. Maximums for in-network and out-of-network services are combined. For example, if the plan has a limit of 30 visits on a covered expense, you would reach the limit if you had 17 visits in-network and 13 visits out-of-network.

UCR
See ‘Usual Customary and Reasonable charge’.

Urgent Care
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 sever pain, such as a high fever.

Usual Customary and Reasonable Charge (UCR)
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 called Reasonable and Customary” (R&C).

Utilization Management
The process of evaluating and determining the coverage for and the appropriateness of medical care services, as well as providing any needed assistance to clinician or patient in cooperation with other parties, to ensure appropriate use of resources. Utilization Management includes prior authorization, concurrent review, retrospective review, discharge planning and case management.

Utilization Review
A formal evaluation (prospective, concurrent or retrospective) of the coverage, medical necessity, efficiency or appropriateness of health services and treatment plans.

No V Items

Waiting Period
A period of time an individual must wait either to become eligible for insurance coverage or to become eligible for a given benefit after overall coverage has commenced.

Waiver of Liability
A provision whereby a provider of service may be relieved from liability for a disallowed claim.
Worker′s Compensation
Insurance carried by employers to cover occupation-related injuries or conditions incurred by the employees.

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