Glossary

Accreditation – Certification by a non-governmental accrediting organization that a specified health care provider meets that organization’s standards.

Adjudication – The process used by a health plan to verify and process claims.

Adverse Benefit Determination – A health care treatment decision made by or on behalf of a health plan denying in whole or in part payment for or provision of otherwise covered services requested by or on behalf of a member.

Affordable Care Act – Please see “Patient Protection and Affordable Care Act”

Allowable Charge – The maximum amount that a health plan will pay for a given covered service or supply.

Ambulatory Surgery – Surgical procedures performed that do not require an overnight stay (up to 23 hours).

Ancillary Services – Health care services provided exclusive of room and board, such as supplies and laboratory tests provided under home care, audiology, durable medical equipment (DME), ambulatory surgical centers (ASC), home infusion, hospice care, skilled nursing facility (SNF), cardiac testing, mobile lithotripsy, fitness center, radiology, pulmonary testing, sleep centers, and kidney dialysis.

Appeal – A formal request to the health plan for the review of an adverse benefit determination.

Appeals Process (Procedure) – A formal process whereby a covered person, a representative of a covered person, or attending physician, facility or health care provider on a covered person’s behalf, can contest an adverse determination rendered by a health plan or its designated utilization review entity, which results in the denial, reduction without further opportunity for additional services, or termination of coverage of a requested health service.

Assignment of Benefits – A procedure whereby a person authorizes payment of any allowable benefits directly to a health care provider.

Balance Billing – Balance billing may occur when an out-of-network provider’s charge exceeds the health plan’s allowable charge for that service or procedure. The member may be required to pay the difference between the health plan’s allowable charges and the out-of-network provider’s requested charge.

Benefits – A member’s right to payment for covered services that are available under the plan, subject to the terms, conditions, limitations, and exclusions in the health benefit plan contract.

Board Certified – Physicians or other health care professionals who have passed an examination given by a medical specialty board and have been certified by that board as a specialist in the subject in question.

Case Management – A coordinated set of activities conducted for individual patient management of covered persons with specific health care needs.

CCO – Chief Compliance Officer - The officer primarily responsible for overseeing and managing compliance issues within an organization.

Centers of Excellence – Health care facilities selected for specific services based on criteria such as experience, outcomes, efficiency, and effectiveness.

CEO – Chief Executive Officer- Has ultimate accountability for and authority over the operations, ethics, and compliance of Martin’s Point Health Care.

Claim – A request for payment of benefits.

Claim Lag – The length of time between the service date of a claim and the date the claim is processed.

Clinical Peer – A physician or other licensed health care practitioner who holds a non-restricted license in a state of the United States in the same or similar specialty as typically manages the medical condition, procedure or treatment under review, or other physician or health care practitioner with demonstrable expertise necessary to review a case.

Clinical Review Criteria – The written screening procedures, decision abstracts, clinical protocol and practice guidelines used by a health plan to determine the necessity and appropriateness of health care services.

Coinsurance – The shared cost of covered services paid by the plan and the member. the coinsurance begins only after a member has met his or her deductible (unless otherwise described as part of pharmacy benefit). Coinsurance amounts are often expressed as a percentage of the allowable charge.

Contract – An insurance policy or contract issued to an employer that provides group insurance benefits to its employees.

Coordination of Benefits (COB) – A typical insurance provision whereby responsibility for payment for medical services is allocated between insurers when a person is covered by more than one group health benefit plan.

Copayment (or Copay) – A fixed amount, paid at the time services are rendered, that a member of a health plan pays when seeing a participating provider for services.

Covered Benefits/Health Services – Health care services and benefits to which members are entitled under the terms of their benefit contract.

CMS – The Centers for Medicare and Medicaid Services - CMS is a federal agency within the Department of Health and Human Services (DHHS) that administers the Medicare program and works in partnership with state governments to administer Medicaid, the State Children's Health Insurance Program (SCHIP), and health insurance portability standards.

Discharge Planning – The formal process for determining, prior to discharge from a facility, the coordination and management of the care that a patient receives following discharge from a facility.

Disease Management – An educational program geared toward members with chronic disease or other medical conditions to help members better understand and manage their condition.

Early Intervention Services – Services provided by licensed occupational therapists, physical therapists, speech-language pathologists, or clinical social workers working with children from birth to 36 months of age with an identified developmental disability or delay as described in the federal Individuals with Disabilities Education Act.

Emergency Care – Health care services provided in an emergency facility after the onset of a medical condition that manifests itself by symptoms of sufficient severity, including severe pain, that the absence of immediate medical attention could be reasonably expected by the prudent lay person to result in either serious jeopardy to the mental or physical health of the individual, danger of serious impairment to bodily functions, or serious dysfunction of any bodily organ, or in the case of a pregnant woman, serious jeopardy to the health of the fetus.

Emergency Medical Condition – A medical condition, physical or mental, manifesting itself by acute symptoms of sufficient severity such that the absence of immediate medical attention could reasonably be expected to result in placing the health of the individual (or in the case of a pregnant woman, the health of the woman or unborn child) in serious jeopardy or serious impairment to bodily functions or serious dysfunction of any bodily organ or part. This includes a pregnant woman having contractions, when there is inadequate time for a safe transfer to another hospital before delivery or when that transfer may pose a threat to the health or safety of the woman and unborn child.

Enrollee – An individual who is enrolled in a benefit plan. Enrollees also may be referred to as subscribers or members.

ERISA – The Employee Retirement Income Security Act of 1974, as amended.

Explanation of Benefits (EOB) – A printed explanation sent to health plan members that describes the benefits received and services for which a health care provider has requested payment. It typically indicates the amount that the member may owe to the provider once cost-sharing provisions are applied.

Extended Care Facility – See “Skilled Nursing Facility.”

Facility – An institution providing health care services or a health care setting, including but not limited to appropriately licensed or certified hospitals and other inpatient centers, ambulatory surgical or treatment centers, skilled nursing centers, residential treatment centers, diagnostic, laboratory and imaging centers, and rehabilitation and other therapeutic health settings.

FDRs (First Tier, Downstream and Related Entities) - Any vendor or entity that MPHC has a contractual relationship with to perform a service for our members.

Fee-for-Service – A method of payment that is based on charges for each individual service or treatment rendered.

Formulary – A list of covered prescription drugs established by the plan’s Pharmacy and Therapeutics Committee. Drugs may fall into different categories that are covered at different payment levels. The drugs selected for inclusion in these different categories are determined based on the drug’s cost, efficacy or other considerations. The formulary, or drug list, is reviewed and modified on a regular basis.

Fraud, Waste, and Abuse (FWA)
• Fraud: An intentional act of deception, misrepresentation, or concealment in order to gain something of value.
• Waste: Over-utilization of services and misuse of resources
• Abuse: Excessive or improper use of services or actions that are inconsistent with acceptable business or medical practice

Generic Drug – A drug that is the pharmaceutical equivalent of one or more brand name drugs. Such generic drugs have been approved by the Food and Drug Administration as meeting the same standards for safety, purity, strength, dosage form, and effectiveness as the brand-name drug.

Grievance – A written complaint submitted by or on behalf of a covered person regarding the:
availability, delivery or quality of health care services, including a complaint regarding an adverse determination made pursuant to utilization review; claims payment, handling, or reimbursement for health care services; or, matters pertaining to the contractual relationship between a covered person and a health plan.

Health Insurance Portability and Accountability Act of 1996 (HIPAA) – This is a federal law that affects a member’s health care benefits. One provision of the law allows a person who has group health insurance to qualify immediately for comparable coverage when that person has lost an existing policy due to a job change. A second provision of the law addresses health care information and the privacy and security of a patient’s personal health information.

Health Plan – Also known as health benefit plan, a plan offered or administered by an organization that provides for the financing or delivery of health care services to persons enrolled in the plan, other than a plan that provides only accidental injury, specified disease, hospital indemnity, Medicare supplement, disability income, long-term care, or other limited benefit coverage.

Health Care Professional – A physician or other health care practitioner licensed, accredited or certified to perform specified health services consistent with state law. This definition applies to individuals, not corporations.

Health Care Provider – A practitioner or facility licensed, accredited or certified to perform specified health care services consistent with state law.

Health Care Services – Services for the diagnosis, prevention, treatment, cure or relief of a health care condition, illness, injury, or disease including mental illness and alcohol and chemical dependency.

High-Tech Imaging Procedures – Procedures used to visualize internal organs and structures of the body for purposes of detection and diagnosis of disease or conditions requiring medical attention. Examples include Computerized Axial Tomography (CAT or CT scans) and Magnetic Resonance Imaging (MRIs).

Home Health Care – Necessary care and treatment provided at the member’s residence by a home health care agency or by others under arrangements with a home health care agency.

Hospital – An institution, licensed pursuant to law, that primarily and continuously is engaged in providing or operating medical, diagnostic, and major surgical facilities for the medical care and treatment of sick or injured persons on an inpatient basis for which a charge is made. It provides 24-hour-a-day nursing service by or under the supervision of registered nurses. The definition excludes facilities used primarily for custodial or rehabilitative care or facilities for the aged, drug addicted or alcoholic.

In-Network – Refers to providers who participate in a health plan’s network. Many plans require members to use a participating (in-network) provider to receive benefits at the highest level.

Inpatient – An individual who is receiving care for 24 hours or more as a registered patient in a hospital or other facility, e.g., skilled nursing facility.

Legend Drug – A drug, the label of which, under the Federal Food, Drug and Cosmetic Act, is required to bear the legend: “Caution: federal law prohibits dispensing without prescription.” Such drugs may not be sold to or purchased by the public without a prescription order.

Managed Care Plan– A health benefit plan offered or administered by a carrier that provides for the financing or delivery of health care services to persons enrolled in the plan through arrangements with selected providers to furnish health care services and financial incentives for persons enrolled in the plan to use the participating providers and procedures provided for by the plan.

Mandated Benefit – Specific coverage that an insurer is required to offer by law. Mandated benefits in insurance contracts may vary from state to state according to each state’s insurance laws.

Medic – Medicare Drug Integrity Contractor. An organization that the CMS has contracted with to perform specific program integrity functions for Part D under the Medicare Integrity Program. The medic is CMS’ designee to manage CMS’ audit, oversight, and anti-fraud and abuse efforts in the Part D benefit.

Medically Necessary – Health care services or products provided to an enrollee for the purpose of preventing, diagnosing, or treating an illness, injury, or disease or the symptoms of an illness, injury, or disease in a manner that is:
• Consistent with generally accepted standards of medical practice
• Clinically appropriate in terms of type, frequency, extent, site, and duration
• Demonstrated through scientific evidence to be effective in improving health outcomes
• Representative of ‘best practices’ in the medical profession
• Not primarily for the convenience of the enrollee or physician or other health care practitioner

Medical Necessity is not a guarantee of payment.

Medicare – The Health Insurance for the Aged Act, Title XVIII of the Social Security Amendments of 1965 as then constituted or later amended.

Medicare Compliance Officer (MCO) - Supports the implementation of the compliance program and is the direct liaison with CMS for any compliance related issues including but not limited to external audits. The MCO is responsible for ensuring that all Medicare regulations are satisfied as they relate to the MPHC Generations Advantage program.

Member – Each individual enrolled and eligible for services in the health plan.

Member Services – A group of health plan employees who are trained to help members understand and use benefits in the member’s specific plan.

Network – The doctors, facilities and other medical providers with whom the health plan contracts to provide health care to its members.

Non-Par/Non-Plan/Non-Participating Provider – Any appropriately licensed practitioner, hospital, pharmacy, laboratory or other diagnostic center not contracted with the member’s health plan to provide services.

Nurse – An individual who qualifies under this terminology in accordance with the applicable statutes or administrative rules of the applicable licensing or registry board of the state.

Nurse Midwife - An individual who qualifies under this terminology in accordance with the applicable statutes or administrative rules of the applicable licensing or registry board of the state.

Nurse Practitioner (NP) - A registered nurse who has advanced education in nursing (a master's of science in nursing) and clinical experience in a specialized area of nursing practice. Nurse practitioners collaborate with other health care providers to deliver primary care to patients with common acute or stable chronic medical conditions in ambulatory care settings. Some NPs also function in a specialty, tertiary, or long-term care setting. NPs may offer a variety of services, such as complete physical examinations, health assessments, and patient education. Specialty certification is required for family nurse practitioner (FNP), women's health care nurse practitioner (RNC), neonatal nurse practitioner (NNP), pediatric nurse practitioner (CPNP), adult nurse practitioner (ANP), school nurse practitioner (SNP), gerontological nurse practitioner (GNP), acute care nurse practitioner (CS), and psychiatric/mental health nurse practitioner (PMHNP).

Out-of-Network – The use of non-network providers. Some members have the option to go out-of-network but may pay some additional costs, such as meeting a higher deductible, paying coinsurance and being subject to balance billing.

Outpatient Surgery – Surgical procedures performed that do not require an inpatient admission (up to 23 hours).

Patient Protection and Affordable Care Act (PPACA) – The Patient Protection and Affordable Care Act (PPACA), commonly called Obama-care (or the federal health care law), is a United States federal statute signed into law by President Barack Obama on March 23, 2010. Together with the Health Care and Education Reconciliation Act, it represents the most significant regulatory overhaul of the U.S. healthcare system since the passage of Medicare and Medicaid in 1965.

Participating Provider – A licensed or certified provider of health care services, including mental health services or health care supplies, that has entered into an agreement with a health plan to provide those services or supplies to an individual enrolled in a managed care plan. Also referred to as an in-network provider.

Pharmacy and Therapeutics (P&T) Committee – A group of physicians, pharmacists, and other health care providers who advise a managed care plan regarding safe and effective use of medications. The P&T Committee manages the formulary and acts as the organization’s line of communication between the medical and pharmacy components of the health plan.

Pharmacy Tier Definitions
• Tier 1 – The majority of widely dispensed generic drugs. Tier 1 drugs are covered at the lowest Copayment level. Some brand-name drugs may be included in this category as well.
• Tier 2 – The brand-name equivalents of the generic drugs, plus certain brand-name drugs that are not available as generic drugs.
• Tier 3 – Those generic and brand name drugs not included by the plan on another tier. These may include single-source brand-name drugs that do not have a generic equivalent or a therapeutic equivalent.

Physician – Any Doctor of Medicine (MD) or Doctor of Osteopathy (DO) who is properly licensed and qualifies by law. For purposes of the plan, the term also includes all providers of medical care and treatment when the services are within the scope of the provider’s licensed authority and are provided pursuant to applicable laws.

Physician Assistant (PA) – One who has been trained in an accredited program and certified by an appropriate board to perform certain aspects of a physician's duties, including history taking, physical examination, diagnostic tests, treatment, and certain minor surgical procedures, all under the responsible supervision of a licensed physician.

Policy and Procedure (P&P) - Describes the rationale behind activities, assigns responsibility and accountability, and describes how an activity is performed and a quality control process as applicable.

Practitioner: A professional who provides health care services. Practitioners are usually licensed as required by law.

Pre-admission Review – Review of elective hospitalization prior to a patient’s admission to ensure that the services are necessary and that they should be provided on an inpatient basis.

Preauthorization – Preauthorization is a review of all pertinent medical information to determine medical coverage for designated medical services. A member’s provider can obtain preauthorization from the utilization/medical management department prior to services being rendered. Certification of medical necessity is not a guarantee of payment. Benefits are always paid according to the member’s eligibility and the provisions of the health plan.

Preferred Provider Organization (PPO) - A type of health plan that encourages a member to use in-network providers, but that also provides reduced benefits for covered services if the member chooses an out-of-network provider for care.

Preventive Care – A preliminary examination, test, or procedure for the early detection of disease or disease precursors in apparently well individuals so that health care can be provided early in the course of the disease or before developing a disease. This includes check-ups, physicals, Immunizations, well-baby visits, and screenings such as mammograms, pap smears, prostate exams, and other visits designed to keep members healthy, identify health problems in the early stages, and to help members maintain and improve health.

Primary Care – Initial and basic care, including general internal medicine, general pediatrics, general obstetrics and gynecology, and care customarily provided by general and family practitioners or OB/GYNs.

Primary Care Provider (PCP) – A physician or nurse practitioner or physician’s assistant under the direct supervision of a physician, under contract with a managed care plan to supervise, coordinate, and provide initial and basic care to plan enrollees, maintain continuity of patient enrollee care, and initiate patient enrollee referrals for specialist care.

Prospective Review – Utilization review conducted prior to an admission or a course of treatment.

Provider – A practitioner, facility, institution or organization that provides services for health plan members. Examples of providers include hospitals and home health agencies.

Quality Improvement (QI) – A continuous process that identifies problems, examines solutions to those problems, and regularly monitors the solutions implemented for improvement. This process is often employed to review and improve the administration of health plans or clinical practice.

Registered Nurse First Assistance (RNFA) – A person who is licensed as a registered nurse, is experienced in perioperative nursing, and has successfully completed a recognized program.

Release of Information – A legal document designed to protect a member’s privacy by allowing only the persons designated by the member to obtain or change personal health information. A signed ROI form authorizes the health plan to release or change information to the designated agent.

Referral – A referral is completed by a Primary Care Provider when the PCP believes that it is medically necessary for a member to see another provider or specialist.

Schedule of Benefits – A legal document that outlines copayments, coinsurance and other benefit information for health benefit plans.

Screening – A preliminary procedure, such as a test or examination, to detect the most characteristic sign or signs of a disorder that may require further investigation.

Second Opinion – An opportunity or requirement to obtain a clinical evaluation by an appropriately licensed or certified provider, other than the provider making the initial recommendation for a proposed health service, to assess the clinical necessity and appropriateness of the initially proposed health service.

Self-Funded – A health plan for which the employer assumes all financial risk and is responsible for paying all claims.

Service Area – The area lying within the geographic perimeters of an approved health plan network.

Skilled Nursing Facility – A facility that is operated pursuant to law; is approved for payment of Medicare benefits, or is qualified to receive approval for payment of Medicare benefits; is primarily engaged in providing, in addition to room and board accommodations, skilled nursing care under the supervision of a duly licensed physician; provides twenty-four (24) hour nursing service by or under the supervision of a registered nurse and maintains a daily medical record of each patient. Skilled nursing facilities do not include a facility used primarily for rest or custodial care, care for the aged, or care of drug addicts or alcoholics.

Specialist – A provider who specializes in a particular field of medicine such as orthopedics or gynecology.

Subscriber – The individual, employee, or retiree who is primarily eligible to enroll in the health plan.

Summary Plan Description (SPD) – A document containing specific information, such as covered benefits, about a group benefit health plan.

Summary of Benefits – A document that outlines some of the benefits that an individual may receive if he or she becomes a member in the health plan.

Third-Party Administrator (TPA) – An entity that provides certain administrative services to group benefit plans, such as accounting, claims review, and payment, utilization management, or maintenance of eligibility records.

Unauthorized Provider – A provider who, as determined by the plan, does not hold appropriate and current licensure, certification, or other credentials as applicable to provide the covered service

Urgent Care – Health services that are provided to treat a condition or illness of an individual that, if not treated within 24 hours, presents a serious risk of harm.

Usual, Customary, Reasonable (UCR) Charges – The maximum amount the health plan will consider to be eligible for reimbursement to non-participating providers. The UCR is based on customary fees paid to providers with similar training and experience in a given geographic area.

Utilization Management/Review – Any program or practice by which a person, on behalf of an insurer, nonprofit service organization, third-party administrator, or employer, which is a payor for or which arranges for payment of medical services, seeks to review the utilization, clinical necessity, appropriateness, efficacy, or efficiency of health care services, procedures, providers, or facilities. Techniques may include ambulatory review, prospective review, second opinion, certification, concurrent review, case management, discharge planning, or retrospective review. Decisions regarding medical necessity made by a member’s primary care provider do not constitute utilization review.