Accreditation An evaluative process in which a health care organization undergoes an examination 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.
Annual maximum benefit amount The maximum dollar amount set by an MCO that limits the total amount the plan must pay for all health care services provided to a subscriber in a year.
Appropriateness review An analysis of health care services with the goal of reviewing the extent to which necessary care was provided and unnecessary care was avoided.
Case management A process of identifying plan members with special health care needs, developing a health care strategy that meets those needs, and coordinating and monitoring the care.
Claim An itemized statement of health care 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 member or the provider for payment of the costs incurred.
Claim form An application for payment of benefits under a health plan.
Claimant The person or entity submitting a claim.
Claims administration This is the process of receiving, reviewing, adjudicating, and processing claims.
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.
Co-insurance A method of cost-sharing in a health insurance policy that requires a group member to pay a stated percentage of all remaining eligible medical expenses after the deductible amount has been paid.
Consolidated Omnibus Budget Reconciliation Act (COBRA) A federal act that requires each group health plan to allow employees and certain dependents to continue their group coverage for a stated period of time.
Co-insurance The amount of coverage the plan will pay usually based on a percentage. Additional costs are then paid by you.
Coordination of Benefits (COB) When a person is insured under two contracts, and the sequence in which coverage will apply (primary and secondary).
Co-payment A specific dollar amount that a member must pay for a medical expense out-of-pocket.
Credentialing The process of obtaining, reviewing, and verifying a provider's credentials — the documentation related to licenses, certifications, training, and other qualifications.
Deductible The amount a member must pay before the insurer will make any benefit payments.
Diagnostic and treatment codes Special codes that consist of a brief, specific description of each diagnosis or treatment and a number used to identify each diagnosis and treatment.
DSM-IV The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. This is the standard guide for mental health professionals to diagnosis, code for insurance purposes, and set up a treatment plan.
EO B (Explanation of Benefits) A statement mailed to a member or covered insured explaining how or why a claim was paid or not paid.
Fee-for-service (FFS) payment system Insurer pays for its own service.
Fee schedule The fee for a service the provider agrees to accept as payment in full.
Generic substitution The dispensing of a drug that is the generic equivalent of a drug listed on a pharmacy benefit management plan's formulary.
Health Insurance Portability and Accountability Act (HIPAA) Federal legislation that improves access to health insurance when changing jobs by restricting certain pre-existing condition limitations and guarantees availability and renewability of health insurance coverage for all employers regardless of claims experience or business size.
Health Maintenance Organization (HMO) A prepaid medical group practice plan that provides a comprehensive predetermined medical care benefit package.
Indemnity insurance Often called “fee for service,” this type of insurance plan allows patients to go to any doctor or hospital that they select, anywhere in the United States or abroad.
Lifetime maximum benefit amount The maximum dollar amount that limits the total amount the plan will cover for health care services in the subscriber's lifetime.
Managed care A health care program that controls utilization of health care services, providers, and the fees charged for such services.
Medicaid Administered by the states and funded by the federal government. Within certain guidelines and income requirement will pay certain medical expenses.
Medical advisory committee Committee whose purpose is to review general medical management issues brought to it by the medical director.
Medical director Manages a health care organization and is responsible for finding providers, provider relations, quality and utilization management, and medical policy.
Medicare A federal government hospital expense and medical expense insurance plan primarily for elderly and disabled persons.
Medicare supplement A private medical expense insurance plan that supplements Medicare coverage.
Open Enrollment Period The period when an employee may change health plans; usually occurs once per year.
Patient Bill of Rights Refers to the Consumer Bill of Rights and Responsibilities, a report prepared by the President's Advisory Commission on Consumer Protection and quality in the health care industry. This was created to ensure the confidentiality of patient information, promote health care quality, and improve the availability of health care treatment and services.
Precertification The process of obtaining authorization from the health plan utilizing medical benefits and treatment.
Pre-existing condition Physical and/or mental condition that existed prior to becoming insured. Some plans may cover certain conditions after a waiting period of six months to a year.
Preferred Provider Organization (PPO) A PPO allows patients to see a doctor from the plan's network of physicians for a small co-payment fee.
Premium A prepaid payment or series of payments made to a health plan by purchasers, and often plan members, for medical benefits.
Primary Care Basic or general health care as opposed to specialist care.
Prior authorization Provider must obtain authorization before treatment for the service to be covered.
Psychiatrist A physician who specializes in mental, emotional, and behavioral disorders and can provide medication.
Psychologist A health professional (not a physician) who specializes in the mental or behavioral health and counsels.
Usual, customary, and reasonable (UCR) fee The amount used by traditional health insurance companies as the basis for physician reimbursement.
Utilization management (UM) Managing the use of medical services to ensure that a patient receives necessary, appropriate, high-quality care in a cost-effective manner.
Utilization review (UR) The evaluation of the medical necessity, efficiency, and/or appropriateness of health care services and treatment plans.
Utilization review committee Committee that reviews utilization, coverage, and providers.