Medical Terms

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Adjudication:  The administrative procedure used to process a claim for service according to the covered benefit.

Administrative Services Only (ASO):  An arrangement in which a licensed insurer provides administrative services to an employer's health benefits plan (such as processing claims), but doesn't insure the risk of paying benefits to enrollees. In an ASO arrangement, the employer pays for the health benefits.

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

Alternative Birthing Center:  A facility offering a "non-traditional" ("not like a hospital") setting for giving birth. While alternative birthing centers can range from free-standing centers to special areas within hospitals, birthing centers are generally known for a more comfortable, home-like atmosphere, allow more participation by the father and have more procedural flexibility than commonly found in hospital births.

Ambulatory Care:  A general term for care that doesn't involve admission to an inpatient hospital bed. Visits to a doctor's office are a type of ambulatory care.

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 care:  Diagnostic and/or supportive services such as radiology, physical therapy, pharmacy or laboratory work.

Appeals:  A process used by a patient or provider to request re-consideration of a previously denied service.

Assignment of benefits:  When a covered person authorizes his or her health benefits plan to directly pay a health care provider for covered services. Traditional health insurance pays benefits directly to the covered person.

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Behavioral care services:  Assessment and therapeutic services used in the treatment of mental health and substance abuse problems.

Beneficiary:  A person who is eligible to receive benefits under a health benefits plan. Sometimes "beneficiary" is used for eligible dependents enrolled under a benefits plan; "beneficiary" can also be used to mean any person eligible for benefits, including both employees and eligible dependents.

Benefits:  The portion of the costs of covered services paid by a health plan. For example, if a plan pays the remainder of a doctor's bill after an office visit co-payment has been made, the amount the plan pays is the "benefit." Or, if the plan pays 80% of the reasonable and customary cost of covered services, that 80% payment is the "benefit."

Benefits package:  A term informally used to refer to the employer's benefits plan or to the benefits plan options from which the employee can choose. "Benefits package" highlights the fact a health benefits plan is a compilation of specific benefits.

Brand-name drug:  A drug manufactured by a pharmaceutical company which has chosen to patent the drug's formula and register its brand name.

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Care management:  A generic term, which has been used in many different ways. Can mean to take a global approach to medical care from prevention through treatment and recovery.

Carrier:  A term historically used for licensed insurance companies, although now is sometimes used to include both licensed insurers and HMOs.

Case management:  Coordination of services to help meet a patient's health care needs, usually when the patient has a condition which requires multiple services from multiple providers. This term is also used to refer to coordination of care during and after a hospital stay.

Charge Amount:  The amount billed by a provider for services rendered to a participant.

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

Claim: A claim is a request for payment under the terms of a health benefits plan.

Claim Status:  Claims are Paid, Pended, Denied, or Received-Not-Yet-Processed.

Clinical Practice Guidelines:  General procedures and suggestions about what constitutes an acceptable range of practices for particular diseases or conditions. These guidelines are usually developed by a consensus of doctors in a given field, such as radiology or cardiology.

Cognitive service:  Diagnostic services a doctor provides during delivery of medical services, consultations or care.

Coinsurance:  A traditional method of paying for covered health services in which a portion of covered expenses are shared by the health benefits plan and the participant. It's a defined percentage of the covered charges for services rendered. For instance, a health plan may pay 80% of the reasonable and customary cost of covered services, and a participant pays 20%.

Consolidated Omnibus Budget Reconciliation Act (COBRA):  A federal statute that requires most employers to offer to covered employees and covered dependents who would otherwise lose health coverage for reasons specified in the statute, the opportunity to purchase the same health benefits coverage that the employer provides to its remaining employees. This continuation of coverage can only last for a maximum specified period of time (usually 18 months for employees and dependents who would otherwise lose coverage due to loss of employment or work hour reduction, or 36 months for dependents who would lose coverage for certain reasons other than employment loss by the employee).

Consultation:  A discussion with another health care professional when additional feedback is needed during diagnosis or treatment. Usually, a consultation is by referral from a primary care physician.

Conversion Option:  The option to purchase individual coverage by a person who will no longer have access to group health insurance.

Coordination of Benefits:  A provision in a contract that applies when a person is covered under more than one group health benefits program. It requires that payment of benefits be coordinated by all programs to eliminate overinsurance or duplication of benefits.

Co-payment (co pay):  What the participant pays at the time of service. Co-payments are predetermined fees for physician office visits, prescriptions or hospital services.

Coverage:  The benefits that are provided according to the terms of a participant's specific health benefits plan.

Covered Services:  Hospital, medical, and other health care services incurred by the enrollee that are entitled to a payment of benefits under a health benefit contract. The term defines the type and amount of expense that will be considered in the calculation of benefits.

Custodial Care:  Care that is provided primarily to meet the personal needs of a patient. The care is not meant to be curative or providing medical treatment

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Date of Service:  The date the service was provided to the participant as specified on the claim.

Day Treatment Center:  An outpatient facility that is licensed to provide outpatient care and treatment, usually for mental or nervous disorders or substance abuse.

Deductible:  The money an individual or family must pay from his or her own funds toward covered medical expenses, usually based on a calendar year. For example, if a plan has a $100 deductible, the deductible is met once the first $100 of the covered medical expenses for that year has been paid. After that, the plan begins to pay toward the cost of covered health care services.

Denied Claim:  Claims that are not issued a bank draft/remittance due to a specific reason code.

Dependent:  A person eligible for coverage under an employee benefits plan because of that person's relationship to an employee. Spouses, children and adopted children are often eligible for dependent coverage.

Designated Centers for Specialized Care:  Medical centers selected to provide an advanced level of care for a disease or delivery of a specific procedure.

Diagnostic Tests:  Tests and procedures ordered by a physician to help diagnose or monitor a patient's condition or disease. Diagnostic tools include radiology, ultrasound, nuclear medicine, laboratory and pathology services or tests.

Discharge planning:  Identifying a patient's health care needs after discharge from inpatient care.

Disenrollment:  Voluntarily terminating one's participation in a health benefits plan.

Duplicate coverage:  When a person has coverage for the same health services under more than one health benefits plan.

Durable medical equipment:  Equipment that can withstand repeated use and is primarily and usually used to serve a medical purpose, is generally not useful to a person in the absence of illness or injury, and is appropriate for use in the home.

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Effective Date:  The date on which coverage under a health benefits plan begins.

Eligible:  Provisions contained in each health benefits plan that specify who qualifies for coverage under that plan.

Emergency:  An accident or sudden illness that a person with an average knowledge of medical science believes needs to be treated right away or it could result in loss of life, serious medical complications or permanent disability. Whenever there's a serious accident or sudden illness, and symptoms are severe and they occur unexpectedly, seek medical help immediately.

Examples of emergency situations include: uncontrolled bleeding, seizure or loss of consciousness, shortness of breath, chest pain or squeezing sensations in the chest, suspected overdose of medication or poisoning, sudden paralysis or slurred speech, severe burns, broken bones or severe pain.

Employee Assistance Program (EAP):  An assessment and referral program or a short-term counseling program that is pre-purchased by some employers and is available to their employees, their dependents and household members. Visits to the EAP are separate from your behavioral health care benefits plan with no co-payment required.

Employee Retirement Income Security Act (ERISA):  Federal legislation that applies to retirement programs and to employee welfare benefit programs established or maintained by employers and unions.

Experimental Procedures:  Experimental, investigational or unproven procedures and treatments.

Explanation of benefits (EOB):  A statement provided by the health benefits administrator that explains the benefits provided, the allowable reimbursement amounts, any deductibles, coinsurance or other adjustments taken and the net amount paid. A participant typically receives an explanation of benefits with a claim reimbursement check or as confirmation that a claim has been paid directly to the provider.

Extended care facility (ECF):  A medical care institution for patients who require long-term custodial or medical care, especially for chronic disease or a condition requiring prolonged rehabilitation therapy.

Extension of benefits:  When a person's coverage is extended under certain conditions, such as disability, after their group health coverage would otherwise have ended.

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Flexible benefits plan:  A type of benefits program that offers employees a menu of benefit options, allowing them to create a benefits package which best suits their individual needs.

Formulary:  A list of preferred, commonly prescribed prescription drugs. These drugs are chosen by a team of doctors and pharmacists because of their clinical superiority, safety, ease of use and cost.

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Generic drug:  A prescription drug that has the same active-ingredient formula as a brand-name drug. A generic drug is known only by its formula name and its formula is available to any pharmaceutical company. Generic drugs are rated by the Food and Drug Administration (FDA) to be as safe and as effective as brand-name drugs and are typically less costly.

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Home Health Care:  Health services rendered in the home to an individual who is confined to the home. Such services are provided to individuals who do not need institutional care, but who need nursing services or therapy, medical supplies and special outpatient services.

Hospice:  A health care facility that provides supportive care for the terminally ill.

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In-Network:  Refers to the use of providers who participate in a 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.

Infertility:  Term used to describe a condition or 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.

Infusion Therapy:  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.

Inpatient care:  Care given to a patient admitted to a hospital, extended care facility, nursing home or other facility.

Intracorp:  A CIGNA subsidiary offering an array of utilization management (UM) and cost containment services. Intracorp is the oldest and largest UM firm in the country.

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Long-term care: The range of services typically provided at skilled nursing, intermediate-care, personal care or eldercare facilities.

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Maintenance medication:  Medications that are prescribed for long-term treatment of chronic conditions, such as diabetes, high blood pressure or asthma.

Managed Behavioral Health:  This is a program that covers your mental health and substance abuse care needs. In most cases, in-network benefits need to be pre-authorized. The services that may be covered under the benefit plans are: individual therapy, family therapy, group therapy, psychiatric evaluation, psychiatric medication management, intensive outpatient services, inpatient and partial hospitalization. Benefits plans vary by employer (covered services and number of available outpatient visits and inpatient days each year).

Medical Necessity:  Medical necessity is a term used to refer to a course of treatment seen as the most helpful for the specific health symptoms you are experiencing. You and your health professional determine the course of treatment jointly. This course of treatment strives to provide you with the best care in the most appropriate setting.

Medicare:  Title XVIII of the Social Security Act that provides payment for medical and health services to the population aged 65 and over regardless of income, as well as certain disabled persons and persons with ESRD.

Medicare Part A:  Hospital insurance provided by Medicare that can help pay for inpatient hospital care, medically necessary inpatient care in a skilled nursing facility, home health care, hospice care and end-stage renal disease treatment.

Medicare Part B:  Medicare-administered medical insurance that helps pay for certain medically necessary practitioner services, outpatient hospital services and supplies not covered by Part A hospital insurance of Medicare coverage. Doctors' services are covered under Part B even if they're provided to a member in an inpatient setting. Part B can also pay for some home health services when the beneficiary doesn't qualify for Part A.

Medigap:  A term used to describe health benefits coverage that supplements Medicare coverage.

Member:  An individual or dependent that is enrolled in and covered by a managed health care plan. Also called Enrollee or Beneficiary.

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Network:  A group of health care providers under contract with a managed care company within a specific geographic area.

Non-Participating Provider:  A medical provider who has not contracted with a health plan.

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

Open enrollment:  A period when eligible persons can enroll in a health benefits plan.

Out-of-area benefits:  Benefits the health plan provides to covered persons for covered services obtained outside of the network service area. The details of such benefits will vary from plan to plan.

Out of Network:  The use of health care providers who have not contracted with the health plan to provide services.

Out of Pocket:  Co-payments, deductibles or fees paid by participants for health services or prescriptions.

Outpatient care:  Any health care service provided to a patient who is not admitted to a facility. Outpatient care may be provided in a doctor's office, clinic, the patient's home or hospital outpatient department.

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Partial Day Treatment:  A program offered by appropriately licensed facilities that includes either a day or evening treatment program, usually for mental health or substance abuse.

Participant:  A person who is eligible to receive health benefits under a health benefits plan. This term may refer to the employee, spouse or other dependents.

Participant ID:  The unique identifier associated with a participant.

Participating Provider:  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 managed care entity to provide services or supplies to a patient enrolled in a health benefit plan.

Pended Claim:  Claims that require additional information prior to completing the adjudication process due to a specific reason code.

Physical therapy:  Rehabilitation concerned with restoration of function and prevention of physical disability following disease, injury or loss of body part.

Pre-Admission Certification/Continued Stay Review (PAC/CSR):  The process through which the reviewer evaluates the attending physician's request for admission to an acute care hospital and length of stay. Medical necessity is determined using established criteria. If PAC/CSR is part of the health benefit plan, the admission or continued stay must be certified for full payment of a claim.

Precertification:  The process of obtaining certification from the health plan for routine hospital stays or outpatient procedures. The process involves reviewing criteria for benefit coverage determination.

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.

Preferred Provider Organization (PPO) plan:  A network-based, managed care plan that allows the participant to choose any health care provider. However, if care is received from a "preferred" (participating in-network) provider, there are generally higher benefit coverages and lower deductibles.

Prescription drug:  A drug that has been approved by the Federal Food and Drug Administration which can only be dispensed according to physician's prescription order.

Preventive care:  Medical and dental services aimed at early detection and intervention.

Primary care:  The basic, comprehensive, routine level of health care typically provided by a person's general or family practitioner, internist or pediatrician.

Primary Care Physician (PCP):  A physician, usually a family or general practitioner, internist or pediatrician, who provides a broad range of routine medical services and refers patients to specialists, hospitals and other providers as necessary. Under some benefits plans, a referral by the primary care physician is required to obtain services from other providers. Each covered family member chooses his or her own PCP from the network's physicians

Prosthetic Devices:  A device that replaces all or a part of the human body because a part of the body is permanently damaged, is absent or is malfunctioning.

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Radiation Therapy:  Treatment of disease by radiation, radium, cobalt or high-energy particle sources.

Reason Code:  Reason codes provide explanations of claim status for pended and denied claims.

Reasonable and Customary (R&C) and Usual Customary and Reasonable (UCR) Charges / Balance Billing:  These are all terms that apply to out of network claims for both your Medical and Dental Plans.  If employees go in network then the participating medical and dental providers must accept the insurance carriers contracted fees.  However, if you go out of network, then the insurance carrier will only pay the reasonable and customary reimbursement rate for that service.  If a member happens to be using a particularly expensive provider that is charging more than the reasonable and customary fees, then the member will be responsible for the coinsurance amount PLUS any charges in excess of what the insurance carrier reimbursed the provider.

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

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Service area:  The geographical area covered by a network of health care providers.

Skilled Nursing Facility (SNF):  A licensed facility that provides nursing care and related services for patients who do not require hospitalization in an acute care setting.

Specialists:  Providers whose practices are limited to treating a specific disease (e.g., oncologists), specific parts of the body (e.g., ear, nose and throat), a specific age group (e.g., pediatrician), or specific procedures (e.g., oral surgery).

Speech Therapy:  Treatment to correct a speech impairment that resulted from birth or from disease, injury or prior medical treatment.

Status change:  A lifestyle event that may cause a person to modify their health benefits coverage category. Examples include, but are not limited to, the birth of a child, divorce or marriage.

Submission Date:  The date the claim was submitted and/or received by the insurance carrier.

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Transitional Benefits/plans:  When an employer changes insurance carriers, transition plans enable participants already in treatment to transition to an in-network health provider. It gives the patient and their current provider a specific number of days to contact the insurance carrier in order to discuss the patient's treatment plan and obtain authorization to continue treatment at the in-network benefit level for a specified period of time, or to transition to a contracted professional.

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Urgent Care:  When prompt medical attention is needed in a non-emergency situation, that's called "urgent" care. Examples of urgent care needs include ear infections, sprains, high fevers, vomiting and urinary tract infections. Urgent situations are not considered to be emergencies.

Usual, Customary or Reasonable (UCR):  The amount reimbursed to providers based on the prevailing fees in a specific area.