AHP - Insurance Terms

Medicare SELECT

A Medicare supplement that uses a preferred provider organization (PPO) to supplement Medicare Part B coverage.

Mutual Company

A company that is owned by its members or policyowners.

Benchmarking

A method of planning and implementing quality management programs that consists of identifying the best practices and best outcomes for a specific process and emulating the best practices to equal or surpass the best outcomes.

Primary Source Verification

A process through which an organization validates credentialing information from the organization that originally conferred or issued the credentialing element to the practitioner.

Claim Form

An application for payment of benefits under a health plan.

Direct Care Provider

An individual or organization that offers care directly to the patient. The direct care provider is in the same physical location as the patient and offers care to patients from within the local Plan's service area. Some examples are: (1) a provider who physically examines the patient, (2) a lab that performs the blood draw from a patient, or (3) a technician who fits a prosthetic limb to the patient.

Claim

An itemized statement of healthcare services and their costs provided by a hospital, physician's office or other provider facility. Claims are submitted to the insurer or managed care plan by either the plan patient or the provider for payment of the costs incurred.

Managed Dental Care

Any dental plan offered by an organization that provides a benefit plan that differs from a traditional fee-for-service plan.

Coding Errors

Documentation errors in which a treatment is miscoded or the codes used to describe procedures do not match those used to identify the diagnosis.

Primary Care

General medical care that is provided directly to a patient without referral from another physician. It is focused on preventive care and the treatment of routine injuries and illnesses.

Prepaid Care

Healthcare services provided to a health maintenance organization (HMO) patient in exchange for a fixed, monthly premium paid in advance of the delivery of medical care.

24-Hour Managed Care

The application of managed care principles (techniques to reduce costs and improve quality of heallthcare) to 24-hour coverage.

Patient Services

The broad range of activities that an MCO and its employees undertake to support the delivery of the promised benefits to patients and ensure patient satisfaction.

Claims Investigation

The process of obtaining all the information necessary to determine the appropriate amount to pay on a given claim.

Fee-For-Service (FFS) Payment System

A benefit payment system in which an insurer reimburses the group patient or pays the provider directly for each covered medical expense after the expense has been incurred.

Unbundling

A coding inconsistency that involves separating a procedure into parts and charging for each part rather than using a single code for the entire procedure. It also refers to the process of identifying and classifying the risk represented by an individual or group.

Parent Company

A company that owns another company.

Electronic Health Record (EHR) or Electronic Medical Record (EMR)

A computerized record of a patient's clinical, demographic, and administrative data. Also known as a computer-based patient record.

Termination Without Cause

A contract provision that allows either the MCO (managed care organization) or the provider to terminate the contract without providing a reason or offering an appeals process.

Termination With Cause

A contract provision, included in all standard provider contracts, that allows either the MCO (managed care organization) or the provider to terminate the contract when the other party does not live up to its contractual obligations.

Disease Management

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. Also known as disease state management.

Other Party Liability (OPL)

A cost containment program that recovers money for healthcare where primary responsibility does not exist because of another group health plan or contractual exclusions. Includes coordination of benefits, Workers' Compensation, subrogation, and no-fault auto insurance.

Dental Point Of Service (Dental POS) Option

A dental service plan that allows a patient to use either a dental health maintenance organizations (DHMO) network dentist or to seek care from a dentist not in the health maintenance organization's (HMO) network. Patients choose in-network care or out-of-network care at the time they make their dental appointment and usually incur higher out-of-pocket costs for out-of-network care.

Standard Of Care

A diagnostic and treatment process that a clinician should follow for a certain type of patient, illness or clinical circumstance.

Underwriting Manual

A document that provides background information about various underwriting impairments and suggests the appropriate action to take if such impairments exist.

Medicare

A federal government program established under Title XVIII of the Social Security Act of 1965 to provide hospital expense and medical expense insurance to elderly and disabled persons.

Health Insurance Portability And Accountability Act (HIPAA)

A federal law that outlines the requirements that employer-sponsored group insurance plans, insurance companies and managed care organizations must satisfy in order to provide health insurance coverage to individuals and groups.

Deductible

A flat amount the patient must pay before the insurer will make any benefit payments. The deductible is usually a set amount or percentage determined by the patient's contract and is set for a given period of time.

Ambulatory Surgery/Surgical Center (ASC)

A free-standing center that performs various types of surgery.

Accountable Care Prganization (Aco)

A group of healthcare providers that agrees to deliver coordinated care, meeting performance benchmarks for quality and affordability in order to manage the total cost of care for their patient populations.

Group Model HMO

A health maintenance organization (HMO) that contracts with a group of physicians with multiple specialties who are employees of the group practice. Also known as a group practice model HMO.

Network Model HMO

A health maintenance organization (HMO) that contracts with multiple group practices of physicians or specialty groups.

Health Maintenance Organization (HMO)

A healthcare system that assumes or shares both the financial risks and the delivery risks associated with providing comprehensive medical services to a voluntarily enrolled population in a particular geographic area, usually in return for a fixed, prepaid fee.

Medicaid

A joint federal and state program that provides hospital expense and medical expense coverage to the low-income population and certain aged and disabled individuals.

Large Group

A large pool of individuals for which health coverage is provided by the group sponsor. A large group may be defined as more than 250, 500, 1,000, or some other number of patients, depending on the managed care organization.

Formulary

A listing of drugs, classified by therapeutic category or disease class, that are considered preferred therapy for a given managed population and that are to be used by an MCO's (managed care organization) providers in prescribing medications.

Ambulatory Care Facility (ACF)

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.

24-Hour Coverage

A plan under which an employer's group health plan, disability plan and workers' compensation program are merged, integrated or coordinated (depending on state regulations) into a single health benefit plan that covers employees 24 hours a day.

Medicare Supplement

A private medical expense insurance policy that provides reimbursement for out-of-pocket expenses, such as deductibles and coinsurance payments, or benefits for some medical expenses specifically excluded from Medicare coverage.

Accreditation

A process in which a healthcare organization undergoes an evaluation 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.

Coinsurance

A provision in a patient's coverage that limits the amount of coverage by the plan to a certain percentage, commonly 80 percent. Any additional costs are paid by the patient out of pocket.

Drug Utilization Review (DUR)

A review program that evaluates whether drugs are being used safely, effectively and appropriately.

Hospice Care

A set of specialized healthcare services that provide support to terminally ill patients and their families.

Copayment

A specified dollar amount that a patient must pay out-of-pocket for a specified service at the time the service is rendered.

Point-Of-Service (POS) Plan

A type of Health Benefit Plan that allows patients to go outside the network for non-emergency care, but may result in a lower level of benefits being paid by the Health Benefit Plan.

Clinical Practice Guideline

A utilization and quality management mechanism designed to aid providers in making decisions about the most appropriate course of treatment for a specific clinical case.

Precertification

A utilization management technique that requires a healthcare insurance plan patient or the physician in charge of the patient's care to notify the plan, in advance, of plans for a patient to undergo a course of care such as a hospital admission or complex diagnostic test. Also known as prior authorization.

Federal Employee Health Benefits Program (Fehbp)

A voluntary health insurance program for federal employees, retirees and their dependents and survivors.

Health Reimbursement Arrangements (HRA)

Accounts that employers can establish for employees to reimburse a portion of their eligible family patients' out-of-pocket medical expenses, such as deductibles, coinsurance and pharmacy expenses.

Health Savings Account (HSA)

Allows patients to save money into tax-advantaged accounts. Qualified contributions made to HSAs are tax-deductible, and funds withdrawn to pay for qualified medical expenses are tax-free.

Flexible Spending Account (FSA)

Allows patients to use pre-tax dollars for certain eligible medical and dependent care expenses. Patients fund their FSAs with contributions that come out of their paycheck.

Small Group

Although the size limit of each MCO (managed care organization) may vary, a small group generally refers to a group containing at least two and less than a hundred patients for which health coverage is provided by the group sponsor.

Hold Harmless Agreement

An agreement with a provider not to bill the subscriber for any difference between billed charges for covered services (excluding coinsurance) and the amount which the provider has contractually agreed to accept for those services.

National Account

An employer that has offices or branches in more than one location, but offers uniform healthcare coverage of benefits to all of its employees.

Utilization Review (UR)

An evaluation of the medical necessity, appropriateness and cost-effectiveness of healthcare services and treatment plans for a given patient.

Indirect Care, Support, And Remote Provider (National Provider)

An individual or organization that offers care to patients from outside the local plan's service area. Services may be provided from a single site or from multiple locations. The provider of service is the one who files a claim for a service supplied to the patient. The patient's location at the time of service is irrelevant. Often the patient and the indirect care provider are in different physical locations.

PII (Personally Identifiable Information)

An individual's first name or first initial and last name in combination with any one, or more, of the following: (1) Social Security number; (2) driver's license number or state identification card number; or (3) account number, credit or debit card number, in combination with any required security code, access code or password that would permit access to an individual's financial account. PII does not include publicly available information that is lawfully made available to the general public from federal, state or local government records or widely distributed media. PII, as used in these Inter-Plan Programs, Policies, and Provisions, may have other meanings as assigned by various state laws related to data security breach notification.

Contract Management System

An information system that incorporates patientship data and provider reimbursement arrangements and analyzes transactions according to contract rules.

Plan

An insurance coverage in which a patient is enrolled, that spells out financial obligations on the part of both the insurance company offering the plan and the patient to compensate for provided medical services.

Dental Preferred Provider Organization (Dental PPO)

An organization that provides dental care to its patients through a network of dentists who offer discounted fees to the plan patients.

Dental Health Maintenance Organization (DHMO)

An organization that provides dental services through a network of providers to its patients in exchange for some form of prepayment.

Ancillary Services

Auxiliary or supplemental services, such as diagnostic services, home health services, physical therapy and occupational therapy, used to support diagnosis and treatment of a patient's condition.

Out-Of-Pocket Maximums

Dollar amounts set by MCOs (managed care organizations) that limit the amount a patient has to pay out of his/her own pocket for particular healthcare services during a particular time period.

State Children's Health Insurance Program (SCHIP)

Established by the Balanced Budget Act, this program is designed to provide health assistance to uninsured, low-income children either through separate programs or through expanded eligibility under state Medicaid programs.

Specialty Services

Healthcare services that are generally considered outside standard medical-surgical services because of the specialized knowledge required for service delivery and management.

Pharmaceutical Cards

Identification cards issued by a pharmacy benefit management plan (PBM) to plan patients. These cards assist PBMs in processing and tracking pharmaceutical claims. Also known as drug cards or prescription cards.

Pre-Existing Condition

In group health insurance, generally a condition for which an individual received medical care during the three months immediately prior to the effective date of coverage.

Prior Authorization

In the context of a pharmacy benefit management (PBM) plan, a program that requires physicians to obtain certification of medical necessity prior to drug dispensing. Also known as a medical-necessity review. See also precertification.

Indemnity (aka Traditional) Insurance

Indemnity insurance, also known as Traditional Insurance or Fee-for-Service, allows patients to select any healthcare provider for services. Indemnity insurance offers the most freedom of choice and control over healthcare, but benefits are typically lower than those associated with managed care programs.

Medigap Policies

Individual medical expense insurance policies sold by state-licensed private insurance companies.

PHI (Protected Health Information)

Information that relates to an individual's past, present, or future physical or mental health or condition, or the past, present, or future payment for the provision of health care to an individual, including demographic information, received from or on behalf of a health care provider, health plan, clearinghouse, or employer, which either identifies the individual or could be reasonably used to identify the individual. It includes such information contained in any form or medium (electronic, paper, oral, etc.).

Annual And Lifetime Maximum Benefit Amounts

Maximum dollar amounts set by MCOs (managed care organizations) that limit the total amount the plan must pay for all healthcare services provided to a subscriber per year or in his/her lifetime.

Screening Programs

Preventive care programs designed to determine if a health condition is present even if a patient has not experienced symptoms of the problem.

Immunization Programs

Preventive care programs designed to monitor and promote the administration of vaccines to guard against childhood illnesses, such as chicken pox, mumps and measles, as well as adult illnesses, such as pneumonia and influenza.

Health Promotion Programs

Programs designed to educate and motivate patients to prevent illness and injury and to promote good health through lifestyle choices, such as smoking cessation and dietary changes. Also known as preventive care programs or wellness programs.

Prescription Benefit Management Plan

See pharmaceutical cards.

Medical Advisory Committee

The MCO (managed care organization) committee that evaluates proposed policies and action plans related to clinical practice management, including changes in provider contracts, compensation and changes in authorization procedures. Medical advisory committees also review data regarding new medical technology and examine proposed medical policies.

Medicare Part A

The Medicare component that provides basic hospital insurance to cover the costs of inpatient hospital services, confinement in nursing facilities or other extended care facilities after hospitalization, home care services following hospitalization and hospice care.

Medicare Part B

The Medicare component that provides benefits to cover the costs of physicians' professional services, whether the services are provided in a hospital, a physician's office, an extended-care facility, a nursing home or an insured's home.

Coordinated Care Plans (CCP)

The Medicare+Choice delivery option that includes health maintenance organizations, or HMOs (with or without a point-of-service component), preferred provider organizations (PPOs) and provider-sponsored organizations (PSOs).

Affordable Care Act (Aca)

The Patient Protection and Affordable Care Act (commonly called ACA) was signed into law in 2010 to address access, quality and cost in the healthcare industry. The Patient Protection and Affordable Care Act was signed into law on March 23, 2010, and was amended by the Health Care and Education Reconciliation Act on March 30, 2010. The name "Affordable Care Act" refers to the final, amended version of the law.

Medical Underwriting

The evaluation of health questionnaires submitted by all proposed plan patients to determine the overall insurability of the group.

Fee Schedule

The fee determined by an MCO (managed care organization) to be acceptable for a procedure or service, which the physician agrees to accept as payment in full. Also known as a fee allowance, fee maximum or capped fee.

Medical Director

The health plan physician executive who is responsible for the quality and cost-effectiveness of the medical care delivered by the plan's providers. Also known as a chief medical officer.

Managed Care

The integration of financing and delivery of healthcare within a system that seeks to manage the accessibility, cost, and quality of that care.

Pooling

The practice of an insurance company underwriting a number of small groups as if they constituted one large group.

Behavioral Healthcare

The provision of mental health and chemical dependency (or substance abuse) services.

Prospective Review

The review and possible authorization of proposed treatment plans for a patient before the treatment is implemented.

Telehealth

The use of electronic information and telecommunications technologies to support long-distance clinical health care, patient, and professional health-related education, public health, and health administration.

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.