Appeal - A formal request to a claim processor, such as a utilization review organization (URO) or third party administrator (TPA), to reconsider a determination not to certify an admission, extension of stay, or other health care service. See your Summary Plan Description for filing instructions.
Beneficiary - Any individual who is eligible, as either a participant, subscriber, or dependent, for health care services provided under a health plan, as defined in the benefit(s) package.
Benefits - Refers to the amount of money payable by a health plan for the cost of covered services, as defined in the benefits package.
Board Certified - A term used to describe a physician who has completed a supervised program of certified clinical residency, passed examinations given by a medical specialty group, and as a result, is certified as a specialist in his/her area of practice.
Board Eligible - A physician who is eligible to take a specialty board examination. Board eligible also includes those who may have failed the examination and remain eligible to take it again.
Case Management - A utilization management (UM) technique frequently used by third party payers and self-insured employers to monitor and coordinate treatment for specific diagnoses, particularly those involving high-cost or extensive services.
Center of Excellence - Refers to selected health care facilities that specialize and have demonstrated success in the performance of certain highly complex medical procedures.
Co-insurance - Requirement of an insurance policy or prepayment plan that a percentage of the provider's charges be paid by the covered employee/dependant.
Comprehensive health care delivery system - Health care facilities and professionals organized and coordinated to provide comprehensive health care to a defined population group.
Concurrent review - Review of the medical necessity of hospital or other health facility admissions upon or within a short period following an admission and the periodic review of services provide during the course of treatment. The initial review assigns an appropriate length of stay to the admission (using diagnosis specific criteria) which may also be reassessed periodically. Where concurrent review is required, payment for unneeded hospitalizations or services is usually denied.
Coordination of Benefits (COB) - Employees may be covered by two or more plans (theirs and their spouse/partner) at the time that services are rendered. COB is a method of integrating benefits under more than one group health insurance plan so that the insured's benefits from all sources do not exceed 100% of the allowable medical expense.Co-payment - Specific dollar amount payable by covered members for specific services, i.e. office visits.
Covered Expenses - Those specified health care expenses that a plan will consider for payment under the terms of the health insurance plan.
Covered Person - An eligible person who meets a health plans eligibility requirements and for whom premium payments are paid for specified benefits of the contract between an insurance carrier and a contract holder.
Covered Services - Specific health care services and products for which reimbursement is provided under the terms of the group health plan.
Credentialing - A process of checking a practitioners references and documenting his/her credentials, including training, experience demonstrated ability, licensure verification, malpractice insurance, etc. Credentialing is carried out by both hospitals and managed care organizations to ensure that only qualified practitioners with current, demonstrated competence have practice privileges at the hospital or other type health care facility, and that they practice within the range of their expertise and abilities.
Deductible - The amount of covered expenses which must be incurred by the insured and paid before benefits become payable by the insurer.
Explanation of Benefits (EOB) - A statement sent to providers and members by the claim payer when a claim for medical services is processed. EOB's outline benefits paid.
Joint Commission on Accreditation of Healthcare Organizations - Private, not-for-profit organization composed of representatives of the American College of Surgeons, American College of Physicians, American Hospital Association, American Medical Association, and American Dental Association, whose purpose is to establish standards for the operation of health facilities and services, conduct surveys, and award accreditation.
Medicare - Federal program, created by Title XVlll--Health Insurance for the Aged, a 1965 amendment to the Social Security Act, that provides health insurance benefits primarily to persons over the age of 65 and others eligible for Social Security benefits.
National Committee for Quality Assurance (NCQA) - An independent, non-profit HMO accrediting organization, composed of independent health care quality experts, employers, labor union officials, and consumer representatives.Out-of-Pocket Maximum (OOP maximum) - OOP maximum refers to the maximum amount that an insured employee will have to pay for expenses covered under the plan during a specified period of time usually annually.
Peer review committee - Committee composed of practicing physicians appointed or elected by a medical society whose purpose is to evaluate the quality and efficiency of patient care practices of physicians.
Preferred provider organization (PPO) - Term applied to a variety of direct contractual relationships between hospitals, physicians, insurers, employers, or third-party administrators in which providers negotiate with group purchasers to provide health services for a defined population, and which typically share the following three characteristics: (1) a negotiated system of payment for services that may include discounts form usual charges or ceilings imposed on a charge, per diem, or per discharge basis, (2) financial incentives for individual subscribers (insurers) to use contracting providers usually in the form of reduced co-payments and deductibles, broader coverage of services, or simplified claims processing, and (3) an extensive utilization review program.
Provider Profiling - The process of collecting and analyzing data linked to the activities of providers (usually physicians) in order to develop provider-specific profiles of practice behavior.
Quality assurance program - Organized set of activities designed to demonstrate that patient care and services provided by a hospital are the best possible within available resources and consistent with achievable goals, through the ongoing assessment of important aspects of patient care, the correction of identified problems, and follow-up activities to verify that corrected problems have not recurred.
Reasonable charges - Physicians' fee limitations determined on the basis of the lowest of actual charge, customary charge, or prevailing charge and other profiles added under the Tax Equity and Fiscal Responsibility Act of 19882 (Public Law 97-248) and Medicare provider-based physician regulations.
Review, concurrent - Evaluation of a patient's need for hospital services, conducted at or shortly after admission, and at specified intervals throughout the inpatient stay.
Review, peer - Concurrent or retrospective review by practicing physicians or other health professionals of the quality and efficiency of patient care practices or services ordered or performed by other physicians or other health professionals.Review, prospective - Review of a proposed schedule of treatment, which could include patient care or discharge plans, and any policies or procedures that specify how care is or will be provided.
Review, Utilization - Evaluation of an admission, the use of ancillary services, and/or length of a hospital stay, using objective medical criteria, to ensure that the services are medically reasonable, necessary, and provided in the most appropriate setting.
Third-party payer - Party to an insurance or prepayment agreement, usually an insurance company, prepayment plan, or government agency, responsible for paying to the provider designated expenses incurred on behalf of the insured.
Unbundling - Practice of billing under Medicare Part B for non-physician services that are provided to hospital inpatients and a that are furnished to the hospital by an outside supplier or another provider. However, under the prospective pricing system, unbundling is prohibited and all non-physician services provided in an inpatient setting are to be paid as hospital services.
Usual, customary, and reasonable payment - Health insurance plans that pay a physician's full charge if it does not exceed that range of usual fees charged by physicians of similar training and experience for the same service within a specific, limited geographic or socioeconomic area, or if it is justified in the special circumstances of a particular patient.
Utilization Review (UR) - A cost-control mechanism used by some insurers and employers in recent years that evaluates health care on the basis of appropriateness, necessity, and quality. For hospital review, it can include preadmission certification, concurrent review with discharge planning and retrospective review.