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Glossary of Terms

A | B | C | D | E | F | G | H | I | J | K | L | M | N | O | P | Q | R | S | T | U | V | W | X | Y | Z
 
 A Top 
  Acupuncture   Acupuncture coverage, including coverage for traditional Chinese herbal supplements, is an option available to employer groups. Health Net has contracted with American Specialty Health Plans (ASHP) to administer acupuncture services and traditional Chinese herbal supplements to Health Net members. Members who have the coverage may obtain acupuncture services through the ASHP network of participating acupuncturists without a referral from the participating physician group (PPG). All acupuncture services, except the initial examination and emergency services, require authorization by ASHP.
  Adjudication   The process used by health plans to determine the amount of payment for a claim.
  Allergy Treatment   Allergy testing, allergy immunotherapy, and allergy injection services are covered under all plans. Some plans also cover allergy serum. Allergy treatment is covered when it is indicated by standard medical practice and is subject to scheduled copayments.
  Allowable Charge   The maximum fee that a health plan will reimburse a provider for a given service.
  Ambulatory Services   Services performed that do not require an overnight hospital stay. Procedures can be performed in a hospital or a licensed medical center. Also called Outpatient Services.

See also: Outpatient.
  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.

See also: Outpatient Surgery.
  Appeals   The process used by a member to request that the health plan re-considers a previous authorization or denial decision.
  Authorization   See Prior Authorization.


 B Top 
  Benefit   Payments provided for covered services under the terms of the policy. The benefits may be paid to the insured, or on his behalf, to the medical provider. Benefit design includes the types of benefits offered and any applicable limits to those benefits, e.g., number of visits, percentage paid or dollar maximums applied, subscriber responsibility (cost sharing components), or subscriber incentives to use network providers.
  Benefit Period   Payments provided for covered services under the terms of the policy. The benefits may be paid to the insured, or on his behalf, to the medical provider. Benefit design includes the types of benefits offered and any applicable limits to those benefits, e.g., number of visits, percentage paid or dollar maximums applied, subscriber responsibility (cost sharing components), or subscriber incentives to use network providers.
  Brand Name Drug   A prescription drug that has been patented and is only available through one manufacturer.

See also: Generic Drug.


 C Top 
  Case Management   A program that assists the member-patient in determining the most-appropriate and cost effective treatment plan. Case management is usually provided to patients who have prolonged expensive or chronic conditions. The program helps determine the treatment location (hospital, other institution or home) and may authorize payment for such care if it is not covered under the member’s benefit agreement.
  Certification   See Pre-Certification.
  Chemotherapy   Treatment of malignant disease by chemical or biological antinoeplastic agents.
  Chiropractic Care   An alternative medicine therapy administered by a licensed Chiropractor. The Chiropractor adjusts the spine and joints to treat pain and improve general health.
  Claim   A request for payment for benefits received or services rendered.
  Co-payment (or co-pay)   A way in which the enrollee shares in the cost of health care. The benefit plan requires the enrollee to pay a flat dollar amount per unit of service. An example of a common co-pay is $10 per physician office visit.
  COBRA   Consolidated Omnibus Budget Reconciliation Act: a federal law that requires most employers with 50 or more employees to provide continuation of coverage for members as prescribed by current federal law.
  Coinsurance   An arrangement under which the insured person pays a fixed percentage of the cost of medical care after the deductible has been paid. For example, a health plan might pay 80% of the allowable charge, with the enrollee responsible for the remaining 20%; the 20% amount is then referred to as the coinsurance amount.
  Coinsurance maximum   This is the maximum dollar amount of Covered Expenses for which the Member is responsible in a Calendar Year. After that maximum is reached, this plan will pay 100% of Covered Expenses incurred during the remainder of that Calendar Year.
  Continuation   When a former plan member has lost eligibility because of a qualifying event (as defined by law), coverage identical to that currently being provided to "similarly situated" active employees must be continued without a lapse if requested by the member. To illustrate, a member, who had Plan A previously, would continue to have the benefits of Plan A as a COBRA member. Examples of qualifying events include: termination of the subscribing member’s employment, divorce or legal separation from the subscribing member, loss of eligibility of the subscribing member’s dependent child, death of the subscribing member.
  Contraception   The use of contraceptive devices or services and supplies that prevent pregnancy.
  Contract or Subscriber Contract   A legal agreement between an individual subscriber or an employer group and a health plan that describes the benefits and limitations of the coverage. One subscriber may have coverage under two contracts e.g., one for health and one for dental. Contract or Subscriber contract may also be referred to as Benefit Certificate or Certificate of Insurance, Evidence of Coverage, Health Benefit Contract or Policy.
  Conversion Option   The exercise of an option to purchase individual coverage at a negotiated rate by a person who is leaving an employee group, typically at retirement.
  Coordination of Benefits (COB)   The provision which applies when an enrollee is covered by two health plans at the same time. The provision is designed so that the payments of both plans do not exceed 100% of the covered charges. The provision also designates the order in which the multiple health plans are to pay benefits. Under a COB provision, one plan is determined to be primary and its benefits are applied to the claim first. The unpaid balance is usually paid by the secondary plan to the limit of its responsibility. Benefits are thus "coordinated" between the two health plans.
  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, which will be considered in the calculation of benefits.
  Custodial Care   Care that is provided primarily to meet the personal needs of the patient. Such care includes help in walking, bathing or dressing. It also includes preparing food or special diets, feeding, administering medicine, or any other care, that does not require continuing services of medical-trained personnel.
  Customary and Reasonable (C&R)   The amount customarily charged for the service by other physicians in the area (often defined as a specific percentile of all charges in the community), and the reasonable cost of services for a given patient after medical review of the case. Also called "Usual, Customary and Reasonable" (UCR).

See also: Usual, Customary and Reasonable.


 D Top 
  Day Treatment Center   An outpatient psychiatric facility, which is licensed to provide outpatient care and treatment of mental or nervous disorders or substance abuse under the supervision of physicians.
  Deductible   An amount the insured person must pay for covered services during a calendar year, January 1 through December 31, before health benefit payments begin.
  Dental Care   Covered Services which are necessary and appropriate for the treatment of your teeth and gums and supporting structures according to a licensed professional dentist or dental policies which meet professionally recognized standards of practice.
  Dependent   Person (spouse or child) other than the subscribing member who is covered under the subscriber's evidence of coverage or benefit certificate. May also be referred to simply as "Member" or "Beneficiary".

See also: Member.
  Diagnostic Tests   Tests and procedures ordered by a physician to determine if the patient has a certain condition or disease based upon specific signs or symptoms demonstrated by the patient. Such diagnostic tools include radiology, ultrasound, nuclear medicine, laboratory, pathology services or tests.
  Drug Formulary or Recommended Drug List (RDL)   A list of preferred pharmaceutical products that health plans, working with pharmacists and physicians, have developed to encourage greater efficiency in the dispensing of prescription drugs without sacrificing quality.
  Durable Medical Equipment (DME)   Mechanical devices, equipment and supplies, which enable a person to maintain functional ability. Also called Medical Equipment.


 E Top 
  Effective Date   The date that you become covered or entitled to receive the benefits provided under the Plan.
  Emergency Care   An injury or sudden, unexpected illness (including severe pain and active labor) of sufficient severity that if the member does not receive immediate treatment, it could present a serious threat to his or her health, could seriously impair physical functions, or could cause a serious dysfunction of any organ or body part if immediate medical treatment is not received.
  Enrollee   An individual who is enrolled and eligible for coverage under a health plan contract. This term encompasses both the subscriber and any of his/her covered dependents, each of whom may also be referred to as a "Member".

See also: Member.
  Exclusions   Specific conditions or circumstances that are not covered under the health plan benefit agreement. It is very important to consult the health plan benefit agreement (may also be called the Evidence of Coverage, Certificate, or Subscriber Contract) to understand what services are not covered benefits.
  Experimental Procedures   Procedures that are mainly limited to laboratory research.
  Expiration Date   The date indicated in the contract as the date coverage expires.
  Explanation of Benefits (EOB)   A form sent to the enrollee after a claim for payment has been processed by the health plan. The form explains the action taken on that claim. This explanation usually includes the amount paid, the benefits available, reasons for denying payment, and the claims appeal process.


 F Top 
  Formulary   See Drug Formulary or Recommended Drug List (RDL).


 G Top 
  Generic Drug   A drug, which is the pharmaceutical equivalent to one or more brand name drugs. Such generic drugs have been approved by the Food and Drug Administration as meeting the same standards of safety, purity, strength and effectiveness as the brand drug.

See also: Brand Name Drug.


 H Top 
  Health Benefit Plan   The plan described and is defined in the health plan benefit contract (may also be referred to as Evidence of Coverage, Subscriber Contract or Certificate), which contract delineates the set of covered health care services and benefits offered, and the health care provider network available, to the member.
  Health Maintenance Organization (HMO)   A type of health care plan under which the enrollees receive all the medical services under a Health Benefit Plan through a specific group of participating doctors and hospitals.
  HMO   See Health Maintenance Organization (HMO).
  Home Health Care   Health services rendered in the home to an individual who is confined to the home. Such services are provided to aged, disabled, sick or convalescent individuals who do not need institutional care, but who do need nursing services or therapy, medical supplies and special outpatient services.

See also: Outpatient.
  Home Infusion Therapy   The administration of intravenous drug therapy in the home. Home infusion therapy includes the following services: solutions and pharmaceutical additives; pharmacy compounding and dispensing services; durable medical equipment; ancillary medical supplies; and, nursing services.
  Hospice   A facility or service that provides care for the terminally ill patient and who provides support to the family. The care, primarily for pain control and symptom relief, can be provided in the home or in an inpatient setting.
  Hospital   An institution whose primary function is to provide inpatient services, diagnostic and therapeutic, for a variety of medical conditions, both surgical and non-surgical. In addition, most hospitals provide some outpatient services, particularly emergency care.

See also: Emergency Care, Inpatient, Outpatient.


 I Top 
  I.D. Card / Identification Card   A card issued to a subscriber and possibly his/her dependents, which allows the subscriber to identify himself or his covered dependents to a provider for health care services. The card is subsequently used by the provider to determine benefit levels and to prepare the billing statement.
  Immunizations   Immunizations and injections that are recommended by guidelines published by the Advisory Committee on Immunization Practices (ACIP) of the U.S. Public Health Service or the American Academy of Pediatrics (AAP).
  In-Network   Refers to the use of providers who participate in the 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.
  Indemnity   A tradition health insurance plan that reimburses for medical services provided to patients based on bills submitted after the services are rendered. Also know as fee-for-service plans. These plans generally do not have a specific provider network.
  Infertility   Term used to describe 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. Also includes the presence of a condition recognized by a physician as the cause of infertility.
  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   Service provided after the patient is admitted to the hospital. Inpatient stays are those lasting 24 hours or more.
  Investigational Procedures   Procedures that have progressed to limited use on humans but are not widely accepted as proven and effective procedures within the organized medical community.


 M Top 
  Managed Care   Any form of health plan that uses selective provider contracting to have patients seen by a network of contracted providers and that requires pre-authorization of certain services.

See also: Health Maintenance Organization (HMO).
  Maternity Care   Health care provided during pregnancy, including care rendered during the pre and post-natal phase of pregnancy, as well as care rendered throughout the entire course of pregnancy, continuing through to infant delivery and circumcision.
  Medical Equipment (DME)   See Durable Medical Equipment (DME).
  Medically Necessary   Services or supplies provided by a licensed health facility or health professional, which are determined by the health plan company and its contracting or employed Physician Group to be:
  • Not Experimental or Investigational.
  • Appropriate and necessary for the symptoms, diagnosis, or treatment of a condition, illness or injury.
  • Provided for the diagnosis or care and treatment of the condition, illness, or injury.
  • Not primarily for the convenience of the Member the Member’s Physician, or anyone.
  • The most appropriate supply or level of service that can safely be provided. For example, outpatient rather than inpatient surgery may be authorized when the setting is safe and adequate.
  Member   An individual or dependent who is enrolled in and covered by a managed health care plan. Also called Enrollee or Beneficiary.

See also: Enrollee.
  Mental Health / Behavioral Health   Conditions that affect thinking and the ability to figure things out and that affect perception, mood and behavior. Such disorders are recognized primarily by symptoms or signs that appear as distortions of normal thinking or distortions of the way things are perceived (seeing or hearing things that are not there.) Disorders can also be recognized by moodiness, sudden or extreme changes in mood, depression, and highly agitated or unusual behavior.


 N Top 
  Network   The doctors, clinics, hospitals and other medical providers that a health plan contracts with to provide health care to its members. In a PPO or HMO, members are generally limited to network providers for full coverage of their health costs.

See also: Health Maintenance Organization (HMO), Out of Network, Preferred Provider Organization (PPO).
  Network Provider   Physicians, Hospitals or other providers of health care who have a written agreement with the health plan to participate in the network. Providers are listed in the Preferred Provider Directory given to each Member upon enrollment and periodically updated.
  Non-Participating Provider   A medical provider who has not contracted with a health plan as a participating provider.


 O Top 
  Occupational Therapy   Treatment to restore a physically disabled person’s ability to perform activities such as walking, eating, drinking, dressing, toileting, and bathing.
  Out of Network   The use of health care providers who have not contracted with the health plan to provide services. HMO members are generally not covered for out-of-network services except in emergency situations. Members enrolled in preferred provider organizations (PPO) and point-of-service (POS) coverages can go out-of-network, but will pay some additional costs.

See also: Health Maintenance Organization (HMO), Network, Point of Service (POS), Preferred Provider Organization (PPO).
  Out-of-Pocket Maximum   Refers to the maximum amount that an enrollee will have to pay for expenses covered under the health plan. The maximum is a sum of all paid deductible and co-payment or coinsurance amounts.
  Outpatient   A patient who is receiving care at a hospital, physician office or other health facility without being admitted to the facility for an overnight stay. The term “ambulatory” is often used to describe outpatient care.
  Outpatient Surgery   Surgical procedures performed that do not require an overnight stay in the hospital or ambulatory surgery facility. Such surgery can be performed in the hospital, a surgery center, or physician office.


 P Top 
  Partial Day Treatment   A program offered by appropriately-licensed psychiatric facilities that include either a day or evening treatment program for mental health or substance abuse. Such care is an alternative to inpatient treatment.
  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, or HMO, to provide services or supplies to a patient enrolled in a health benefit plan.
  PCP   See Primary Care Physician (PCP).
  Physical Therapy   Treatment involving physical movement to relieve pain, restore function and prevent disability following disease, injury, or loss of limb.
  Point of Service (POS)   A type of health benefit plan that allows enrollees to go outside the health plan’s provider network for care, but requires enrollees to pay higher out-of-pocket fees when they do.
  Pre-Authorization   A procedure used to review and assess the medical necessity and appropriateness of elective hospital admissions and non-emergency outpatient services before the services are provided.
  Pre-Certification   Applies to specified services that require review and approval prior to the expense for such services being incurred. If a service is not Pre-Certified, benefits paid for that service will be reduced in accordance with the provisions of your Certificate of Insurance or Evidence of Coverage.
  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. Some pre-existing conditions may be excluded from coverage.
  Preferred Provider Organization (PPO)   A type of health benefit plan designed to give enrollees incentives to use health care providers designated as “preferred providers”, but that also give substantial coverage for services received from other health care providers. PPO plans can also be distinguished from HMO plans by the ability of PPO members to see any specialty physician without referral from a PCP, although some HMOs with a POS feature may allow this as well.
  Prescription   A written order or refill notice issued by a licensed medical profession for drugs which are only available through a pharmacy.
  Preventive Care   Office visits for the evaluation and management of the member’s physical development for prevention of future medical problems.
  Primary Care Physician (PCP)   A doctor selected by the enrollee to be the first physician contacted for any medical problem. The doctor acts as the patient's regular physician and coordinates any other care the patient needs, such as a visit to a specialist or hospitalization.
  Prior Authorization   The process of obtaining advance approval before receiving certain health care services covered under a Certificate of Insurance or Evidence of Coverage.

See also: Pre-Authorization.
  Prosthetic Devices   A device which replaces all or portion of a part of the human body. These devices are necessary because a part of the body is permanently damaged, is absent or is malfunctioning.
  Provider   A licensed health care facility, program, agency, physician or other health professional that delivers health care services.
  Provider Network   The set of providers contracted with a health plan to provide services to the enrollees.

See also: Network.


 R Top 
  Radiation Therapy   Treatment of disease by x-ray, radium, cobalt or high energy particle sources.
  Reasonable and Customary   A charge that falls within the common range of services by a majority of providers for any procedure in a given geographic region, or which is justified based on the complexity or the severity of the treatment for a specific case.
  Referral   A recommendation by a physician that an enrollee receive care from a specialty physician or facility.
  Respiratory Therapy   Treatment of illness or disease that is accomplished by introducing dry or moist gases into the lungs.


 S Top 
  Second Opinion   The voluntary option or mandatory requirement to visit another physician or surgeon regarding diagnosis, course of treatment or having specific types of elective surgery performed.
  Service Area   The geographic area in which a health plan is prepared to deliver health care through a contracted network of participating providers.
  Skilled Nursing Facility (SNF)   A licensed institution (or a distinct part of a hospital) that is primarily engaged in providing continuous skilled nursing care and related services for patients who require medical care, nursing care or rehabilitation services.
  Speech Therapy   Treatment of the correction of a speech imp