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- ACCREDITED (ACCREDITATION) look up translate image
- A "seal of approval" for health care facilities. Being accredited means that a facility has met certain quality standards. These standards are set by private, nationally recognized groups that check on the quality of care at health care facilities.
- ACCUMULATION PERIOD look up translate image
- Timeframe within a policy period in which deductible and out-of-pocket amounts are calculated. For most health insurance policies, the accumulation period is a calendar year.
- ACTUARY look up translate image
- An actuary is a health insurance carrier number cruncher responsible for determining what premiums the company needs to charge based in large part on claims paid versus amounts of premium generated. Their job is to make sure a block of business is priced to be profitable.
- ADMINISTRATIVE SERVICES ONLY (ASO) look up translate image
- An arrangement in which an employer hires a third party to deliver employee benefit administrative services to the employer. These services typically include health claims processing and billing. The employer bears the risk for health care expenses under an ASO plan.
- ADMITTING PHYSICIAN look up translate image
- The doctor responsible for admitting you to a hospital or other inpatient health facility.
- ADMITTING PRIVILEGE look up translate image
- Admitting privilege is the right granted to a doctor to admit patients to a particular hospital.
- ADMITTING PRIVILEGES look up translate image
- The right granted to a doctor to admit patients to a particular hospital
- ADVANCE CARE PLANNING CONSULTATIONS look up translate image
- A controversial provision of H.R. 3200 would have paid physicians to provide counseling to elderly or terminally ill patients who request the counseling. The provision ultimately omitted from the passed health reform legislation would have paid for one counseling session at least every five years, during which patients could discuss advance care planning, advance directives, living wills, palliative care and hospice and possible life-sustaining treatments for the terminally ill. Critics said the proposal would create "death panels" and described its intent as "guiding you in how to die."
- ADVANCE DIRECTIVE look up translate image
- An advance directive indicates the person designated to make medical decisions for you if you are unable physically or mentally to make those decisions yourself.
- ADVOCACY look up translate image
- Any activity done to help a person or group to get something the person or group needs or wants.
- AFFORDABLE CARE ACT (ACA) look up translate image
- The Patient Protection and Affordable Care Act (PPACA) also known as the Affordable Care Act or ACA is the landmark health reform legislation passed by the 111th Congress and signed into law by President Barack Obama in March 2010. The legislation includes a long list of health-related provisions that began taking effect in 2010 and will "continue to be rolled out over the next four years." Key provisions are intended to extend coverage to millions of uninsured Americans, to implement measures...(more)
- AFTER CARE look up translate image
- The care or follow-up treatment needed by a patient who has recently undergone surgery, been involved in an accident or has experienced an illness requiring hospitalization.
- AGENT look up translate image
- Licensed salespersons who represent one or more health insurance companies and presents their products to consumers.
- AGENT OF RECORD look up translate image
- The insurance agent recognized by a client to represent the client's interests in doing business with an insurance company.
- ALLOWABLE CHARGE look up translate image
- The amount a benefit plan determines to be a reasonable charge for a service.
- AMBULATORY CARE look up translate image
- All types of health services that do not require an overnight hospital stay
- AMBULATORY SURGERY look up translate image
- Surgery performed on an outpatient basis where the patient is goes home the same day of the surgery.
- ANCILLARY SERVICES look up translate image
- Services, other than those provided by a physician or hospital, which are related to a patient's care, such as laboratory work, x-rays and anesthesia
- ANY WILLING PROVIDER LAWS look up translate image
- Legislation that requires health care plans to accept into their PPO and HMO networks any provider willing to agree to the network's terms and conditions
- APPEAL look up translate image
- Request made to a payer to reconsider a decision, such as a claim denial or denied prior authorization request. Most appeals must be submitted in writing within a specified period.
- ASSIGNMENT OF BENEFITS look up translate image
- When an insured person assign benefits, they sign a document allowing the hospital or doctor to collect health insurance benefits directly from the health insurance company. Otherwise, the insured person pays for the treatment and is later reimbursed by the health insurance company.
- ASSOCIATION look up translate image
- Associations can offer group health insurance plans specially designed for their members and that give their members purchasing power because of the groups larger pool of enrollees.
- ATTACHMENT look up translate image
- A policy modification which changes, restricts or clarifies coverage
- BENEFICIARY look up translate image
- A person eligible for benefit under a health insurance policy
- BENEFIT look up translate image
- Amount payable by the insurance company to a claimant, assignee, or beneficiary when the insured suffers a loss
- BENEFIT CAP look up translate image
- Total dollar amount that a payer will reimburse for covered health care services during a specified period, such as one year
- BENEFIT PACKAGE look up translate image
- The list of covered services a benefit plan offers to a group or individual.
- BENEFITS look up translate image
- The payments or value of services available under the coverage of a plan for treatment of medical costs.
- BOARD CERTIFIED look up translate image
- A physician who has passed examinations given by a medical specialty group and who has, as a result, been certified as a specialist in this area of practice
- BRAND-NAME DRUG look up translate image
- Prescription drugs marketed with a specific brand name by the company that manufactures it, usually the company which develops and patents it. When patents run out, generic versions of many popular drugs are marketed at lower cost by other companies. Check your insurance plan to see if coverage differs between name-brand and their generic twins.
- BROKER look up translate image
- A licensed legal representative of the policyholder, who negotiates with an insurance company on behalf of a customer, but is paid a commission by the insurance company.
- CAPITATION look up translate image
- Capitation represents a fixed monthly dollar amount that a Health Maintenance Organization (HMO) pays to a group of health care providers who have contracted with the HMO. The amount of this fixed dollar amount depends upon the number of HMO enrollees who have chosen this group of health care providers for "primary care" services under the HMO plan. This fixed dollar amount does not vary with how much HMO enrollees use (or don't use) services offered by this group of HMO providers. Not all HMO utilize capitation payments.
- CARE PLAN look up translate image
- A written plan for one's health care
- CARRIER look up translate image
- The insurance company or HMO offering a health plan.
- CASE MANAGEMENT look up translate image
- Comprehensive coordination or supervision of a member's healthcare when the chronically ill or otherwise impaired person may require long-term care.
- CASE MANAGEMENT: look up translate image
- A process whereby an insured person with specific health care needs is identified and a plan which efficiently utilizes health care resources is designed and implemented to achieve the optimum patient outcome in the most cost-effective manner
- CASE MANAGER look up translate image
- A nurse, doctor, or social worker who arranges all services that are needed to give proper health care to a patient or group of patients.
- CATASTROPHIC ILLNESS look up translate image
- A very serious and costly health problem that could be life threatening or cause life-long disability. The cost of medical services alone for this type of serious condition could cause financial hardship.
- CENTERS OF EXCELLENCE look up translate image
- Hospitals that specialize in treating particular illnesses, or performing particular treatments, such as cancer or organ transplants
- CERTIFICATE OF COVERAGE: look up translate image
- A document given to an insured that describes the benefits, limitations and exclusions of coverage provided by an insurance company
- CERTIFICATE OF INSURANCE look up translate image
- The certificate of insurance is a printed description of the benefits and coverage provisions forming the contract between the carrier and the customer. It discloses what is covered, what is not, and dollar limits.
- CLAIM look up translate image
- Form submitted to a payer (by a health care provider or patient) to request payment for items or services
- CLINICAL PRACTICE GUIDELINES look up translate image
- Reports written by experts who have carefully studied whether a treatment works and which patients are most likely to be helped by it
- CO-INSURANCE look up translate image
- Cost-sharing arrangement between an insured person and the health insurance company in which the insured person is required to pay a percentage of the cost for the health care services received. Coinsurance typically applies after satisfaction of a deductible. For example, 80% coinsurance may apply after a $500 deductible has been satisfied.
- CO-PAYMENT (CO-PAY) look up translate image
- Co-payment is a predetermined fee, in addition to what health insurance covers, that an individual pays for health care services. For example, a PPO may require a $20 "co-payment" for normal services delivered during a physician office visit.
- COBRA look up translate image
- Consolidated Omnibus Budget Reconciliation Act. A federal law passed in 1985 that permits many people who lose eligibility under a group health plan to continue using that coverage.
- COINSURANCE look up translate image
- The percentage of costs a patient pays out-of-pocket for medical care.
- COINSURANCE MAXIMUM look up translate image
- The total amount of coinsurance a member pays each year before the benefit plan pays 100% of allowable charges for covered services.
- CONCURRENT REVIEW look up translate image
- Concurrent review involves monitoring the medical treatment and progress toward recovery, once a patient is admitted to a hospital, to assure timely delivery of services and to confirm the necessity of continued inpatient care. This monitoring is under the direction of medical professionals. Concurrent review is a component of "Utilization Review."
- CONSOLIDATED OMNIBUS BUDGET RECONCILIATION ACT (COBRA) look up translate image
- The Consolidated Omnibus Budget Reconciliation Act of 1985, commonly known as COBRA, requires group health plans with 20 or more employees to offer continued health coverage for employees and their dependents for 18 months after the employee leaves the job. Longer durations of continuance are available under certain circumstances. If a former employee opts to continue coverage under COBRA, the former employee must pay the entire premium, plus a 2% administration charge.
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2011-05-19 08:12:22 |
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