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Adjudication: The administrative
procedure used to process a claim for service according to the covered benefit.
Administrative Services Only
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
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
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
Cognitive service: Diagnostic
services a doctor provides during delivery of medical services, consultations
Coinsurance: A traditional method of
paying for covered health services in which a portion of covered expenses
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
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
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
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,
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
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
Emergency: An accident or sudden illness
that a person with an average knowledge of medical science believes needs
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
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
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
Formulary: A list of preferred, commonly
prescribed prescription drugs. These drugs are chosen by a team of doctors
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
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
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.
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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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
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Network: A group of health
care providers under contract with a managed care company within a specific
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.
Stay Review (PAC/CSR): The process through which the reviewer
evaluates the attending physician's request for admission to an acute
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
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.
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
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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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
amount reimbursed to providers based on the prevailing fees in a specific