A
Access
The availability of medical care to a patient. This can be determined by location, transportation, type of medical services in the area, etc.
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Accident Insurance
A form of insurance against loss by accidental bodily injury to the insured.
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Accidental Death and Dismemberment
A policy or a provision in a Disability Income policy which pays either a specified amount or a multiple of the weekly disability benefit if the insured dies, loses his or her sight, or loses two limbs as the result of an accident. A lesser amount is payable for the loss of one eye
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Accidental Death Benefit
An extra benefit which generally equals the face of the contract or principal sum, payable in addition to other benefits in the event of death as the result of an accident. See also Double Indemnity and Multiple Indemnity. (LI,H)
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Actual Charge
The actual amount charged by a physician for medical services rendered.
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Acute Care
Skilled, medically necessary care provided by medical and nursing personnel in order to restore a person to good health.
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Additional Drug Benefit List
Prescription drugs listed as commonly prescribed by physicians for patients' long-term use. Subject to review and change by the health plan involved. Also called drug maintenance list.
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Aftercare
Individualized patient services required after hospitalization or rehabilitation.
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Allocated Benefits
Payments authorized for specific purposes with a maximum specified for each. In hospital policies, for instance, there may be scheduled benefits for X-rays, drugs, dressings, and other specified expenses.
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Allowable Charge
The lesser of the actual charge, the customary charge and the prevailing charge. It is the amount on which Medicare will base its Part B payment.
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Allowable Costs
Charges which qualify as covered expenses.
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Ambulatory Care
Similar to outpatient treatment in that it is care which does not require hospitalization.
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Ambulatory Setting
Institutions such as surgery centers, clinics, or other outpatient facilities which provide health care on an outpatient basis.
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Ancillary
Additional services (other than room and board charges) such as X-rays, anesthesia, lab work, etc. Fees charged for ancillary care such as X-rays, anesthesia, and lab work. This term may also be used to describe the charge made by a pharmacy for prescriptions which exceed the healt
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Ancillary Benefits
Benefits for miscellaneous hospital charges.
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Assignment of Benefits
A method where the person receiving the medical benefits assigns the payment of those benefits to a physician or hospital.
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B
Benefit Levels
The maximum amount a person is entitled to receive for a particular service or services as spelled out in the contract with a health plan or insurer.
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Benefit Package
A description of what services the insurer or health plan offers to those covered under the terms of a health insurance contract.
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Benefit Period
Defines the period during which a Medicare beneficiary is eligible for Part A benefits. A benefit period is 90 days which begins the day the patient is admitted to a hospital and ends when the individual has not been hospitalized for a period of 60 consecutive days.
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Blanket Insurance
A contract of Health Insurance that covers all of a class of persons not individually identified in the contract.
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Blanket Medical Expense
A policy or provision in a Health Insurance contract that pays all medical costs, including hospitalization, drugs, and treatments, without limitation on any item except possibly for a maximum aggregate benefit under the policy. It is often written with an initial deductible amount
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C
Case Management
The assessment of a person's long term care needs and the appropriate recommendations for care, monitoring and follow-up as to the extent and quality of services to be provided.
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Case Manager
A person, usually an experienced professional, who coordinates the services necessary under the case management approach.
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Certificate of Authority (COA)
Issued by the state, it licenses the operation of an HMO (Health Maintenance Organization).
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COB
Coordination of Benefits. See Nonduplication of Benefits.
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Coinsurance Clause
A provision stating that the insured and the insurer will share all losses covered by the policy in a proportion agreed upon in advance, i.e., 80-20 would mean that the insurer would pay 80% and the insured would pay 20% of all losses. See also Percentage Participation.
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Comprehensive Major Medical
A plan of insurance which has a low deductible, high maximum benefits, and a coinsurance feature. It is a combination of basic coverage and major medical coverage which has virtually replaced separate hospital, surgical and medical policies with each having its own deductible requi
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Concurrent Review
A case management technique which allows insurers to monitor an insured's hospital stay and to know in advance if there are any changes in the expected period of confinement and the planned release date.
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Continuation
Allows terminated employees to continue their group health insurance coverage under certain conditions.
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Contract Year
This period runs from the effective date to the expiration date of the contract.
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Coordination of Benefits (COB)
A group policy provision which helps determine the primary carrier in situations where an insured is covered by more than one policy. This provision prevents an insured from receiving claims overpayments. (LI,H)
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Coordination of Benefits (COB)
See Nonduplication of Benefits.
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Copay
This is an arrangement where the covered person pays a specified amount for various services and the health care provider pays the remainder. The covered person usually must pay his or her share when the service is rendered. Similar to coinsurance, except that coinsurance is usuall
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Copay Provision
Often used with major medical policies. The copay provision states what percentage of a claim the company will pay and what percentage the insured will pay. For example, an 80 percent copay provision would provide that the insurer pay 80 percent of claims and the insured pay 20 per
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Copayment
See Copay.
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Corridor Deductible
A Major Medical deductible that provides for a deductible, or "corridor," after the full payment of basic hospital and medical expenses up to a stated amount. In the event of further expenses, payment is on the basis of participation or coinsurance, such as 80%-20% or 85%-15%, and
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Cosmetic Procedures
Procedures which improve the appearance, but are not medically necessary.
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Covered Expenses
Health care expenses incurred by an insured or covered person that qualify for reimbursement under the terms of a policy contract.
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Covered Person
A person who pays premiums into the contract for the benefits provided and who also meets eligibility requirements.
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Custodial Care
Care that is primarily for meeting personal needs such as help in bathing, dressing, eating or taking medicine. It can be provided by someone without professional medical skills or training but must be according to doctor's orders.
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D
Date of Service
The date that the health service was provided.
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Dental Insurance
A group Health Insurance contract that provides payment for certain enumerated dental services.
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Department of Health and Human Services
A federal department whose responsibility is primarily dealing with social service functions such as administration and supervision of the Medicare program.
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Dependent Coverage
Insurance coverage on the head of a family which is extended to his or her dependents, including only the lawful spouse and unmarried children who are not yet employed on a full-time basis. "Children" may be step, foster, and adopted, as well as natural. Certain age restrictions on
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Detoxification
The process an individual goes through when withdrawing from alcohol. Usually is done under guidance of medical personnel.
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Diagnosis
The process of identifying a disease.
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Diagnosis Related Groups (DRGs)
A method of classifying inpatient hospital services. It is used as a method of determining financing to reimburse various providers for services performed.
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Disability Benefits Law
A state law requiring an employer to provide disability benefits to covered employees for nonoccupational injuries, in contrast to Workers Compensation, which pays for occupational injuries. These laws are currently in effect in New York, New Jersey, Rhode Island, California, and H
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Discharge Planning
Determining what the patient's medical needs will be after discharge from a hospital or other inpatient treatment.
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Dismemberment
The loss of, or loss of use of, specified members of the body resulting from accidental bodily injury.
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Dismemberment Benefit
The benefits payable for various types of dismemberment. See also Accidental Death and Dismemberment and Multiple Indemnity.
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Drug Formulary
A schedule of prescription drugs approved for use which will be covered by the plan and dispensed through participating pharmacies.
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Drug Utilization Review (DUR)
A method for evaluating or reviewing the use of drugs in order to determine the appropriateness of the drug therapy.
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Duplicate Coverage Inquiry (DCI)
A request to determine whether or not other coverage exists. Used to apply the coordination of benefits provisions where two or more insurance companies are involved.
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Duplication of Benefits
A situation where identical or overlapping coverage exists between two or more insurance companies or service organizations.
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E
Eligibility Date
The date that a person is eligible for benefits.
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Eligibility Requirements
Requirements imposed for eligibility for coverage, usually in a group insurance or pension plan. (LI,H)
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Eligible Dependent
A dependent of an insured person who is eligible for coverage according to the requirements set forth in the contract.
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Eligible Expenses
Expenses as defined in the health plan as being eligible for coverage. This could involve specified health services fees or "customary and reasonable charges."
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Eligible Person
Similar to eligible employee except it could be a contract covering people who are not employees of a specified employer. An example might be members of an association, union, etc.
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Emergency
An injury or disease which happens suddenly and requires treatment within 24 hours.
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Emergency Accident Benefit
A group medical benefit which reimburses the insured for expenses incurred for emergency treatment of accidents.
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Emergi-Center
See Freestanding Emergency Medical Services Center.
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Enrollee
An eligible individual who is enrolled in a health plan _ does not include an eligible dependent.
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Enrolling Unit
The organization (such as an employer) that contracts for participation in a health insurance plan.
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Enrollment
Used to describe the total number of enrollees in a health plan. It may also be used to refer to the process of enrolling people in a health plan.
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Enrollment Period
The amount of time an employee has to sign up for a contributory health plan.
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Entire Contract Clause
A provision in an insurance contract stating that the entire agreement between the insured and the insurer is contained in the contract, including the application if it is attached, declarations, insuring agreements, exclusions, conditions and endorsements.
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Evidence of Coverage
See Certificate of Coverage.
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Experimental or Unproven Procedures
Any health care services, supplies, procedures, therapies, or devices that the health plan determines regarding coverage for a particular case to be either (1) not proven by scientific evidence to be effective, or (2) not accepted by health care professionals as being effective.
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Explanation of Benefits (EOB)
The statement sent to a participant in a health plan listing services, amounts paid by the plan, and total amount billed to the patient.
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Extended Care Facility
A facility such as a nursing home which is licensed to provide 24-hour nursing care service in accordance with state and local laws. Three levels of care may be provided--skilled, intermediate, custodial, or any combination.
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Extended Coverage
A provision in certain Health policies, usually Group, to allow the insured to receive benefits for specified losses sustained after the termination of coverage, such a maternity expense benefits incurred for a pregnancy in progress at the time of the termination.
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Extension of Benefits
A condition in the insurance policy which allows coverage to continue beyond the expiration date of the policy in the case of employees who are not actively at work or dependents who are hospitalized on that date. The extended coverage applies only where the employee or dependent is disabled as of that date and continues only until the employee returns to work or the dependent leaves the hospital.
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F
Fee Schedule
A list of maximum fees for providers who are on a fee-for-service basis.
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Free-Standing Emergency Medical Service Center
A facility whose primary purpose is the provision of care for emergency medical conditions. Also called emergi-center or urgi-center.
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Free-Standing Outpatient Surgical Center
A facility which only provides outpatient surgical services. Also called surgi-center.
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G
Generic Drug
A drug which is exactly the same as a brand name drug and which is allowed to be produced after the brand name drug's patent has expired. It is also called a "generic equivalent."
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Grievance Procedure
A procedure which allows a member of a health plan or a provider of benefits to express complaints and seek remedies.
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Group
Coverage of a number of individuals under one contract. The most common "group" is employees of the same employer.
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Group Certificate
The document provided to each member of a group plan. It shows the benefits provided under the group contract issued to the employer or other insured.
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H
Health Benefits Package
The coverages offered by a health plan to an individual or group.
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Health Insurance (HI)
Insurance against loss by sickness or bodily injury. The generic form for those forms of insurance that provide lump sum or periodic payments in the event of loss occasioned by bodily injury, sickness or disease, and medical expense. The term Health Insurance is now used to replace such terms as Accident Insurance, Sickness Insurance, Medical Expense Insurance, Accidental Death Insurance, and Dismemberment Insurance. The form is sometimes called Accident and Health, Accident and Sickness, Accident, or Disability Income Insurance.
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Health Maintenance Organization (HMO)
An HMO is a prepaid medical service plan which provides services to plan members. Medical providers contract with the HMO to provide medical services to plan members. Members must use contracted providers. The emphasis is on preventive medicine, and it is an alternative to employee benefit plans. Employers of more than 25 persons are required to offer the alternative of HMO to employees, but not if the cost exceeds that of present employee benefit plans.
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Health Plan
This refers to any kind of plan that covers health care services such as HMOs, insured plans, preferred provider organizations, etc.
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Health Services
The benefits covered under a health contract.
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Home Health Agency
A certified facility approved by a health plan to provide services under contract.
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Home Health Care
Care received at home as part-time skilled nursing care, speech therapy, physical or occupational therapy, part-time services of home health aides or help from homemakers or choreworkers.
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Home Health Services
Health care services provided by a licensed home health agency in the patient's home which is a covered expense under Part A of Medicare.
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Hospice
An organization which is primarily designed to provide pain relief, symptom management and supportive services for the terminally ill and their families. Hospice care is covered under Part A of Medicare.
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Hospital Benefits
Benefits payable for hospital room and board, plus miscellaneous charges resulting from hospitalization.
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I
Identification Card
A card given to each person covered under the plan which identifies him or her as being eligible for benefits.
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Intentional Injury
An injury resulting from an act, the doer of which had as his intent, inflicting injury. In an accident insurance contract, an intentionally self-inflicted injury is not covered (because it is not an accident). In general, intentional injuries inflicted on the insured are covered (assuming no collusion).
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Intermediate Care
A level of care associated with a skilled nursing facility which provides nursing care under the supervision of physicians or a registered nurse. The care provided is a step down from the degree of care described as skilled nursing care.
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Intermediate Care Facility
A facility licensed by the state, which provides nursing care to persons who do not require the degree of care which a hospital or skilled nursing facility provides.
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L
Legend Drug
A drug which has on its label "caution: federal law prohibits dispensing without a prescription."
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Length of Stay (LOS)
The total number of days a participant stays in a facility such as a hospital.
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M
Major Medical Insurance
A type of Health Insurance that provides benefits up to a high limit for most types of medical expenses incurred, subject to a large deductible. Such contracts may contain limits on specific types of charges, like room and board, and a percentage participation clause sometimes called a coinsurance clause. These policies usually pay covered expenses whether an individual is in or out of the hospital.
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Mandated Benefits
Benefits required by state or federal law.
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Maximum Out-of-Pocket Costs
The most a member will pay considering copayments, coinsurance, deductibles, etc.
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Medicaid
A medical benefits program administered by states and subsidized by the federal government. Under this plan, various medical expenses will be paid to those who qualify. It is technically referred to as Title XIX Benefits.
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Medical Supplies
Any items which are essential in carrying out the treatment of a patient's illness or injury.
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Medically Necessary
A service or treatment which is absolutely necessary in treating a patient and which could adversely affect the patient's condition if it were omitted.
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Medicare
The United States federal government plan for paying certain hospital and medical expenses for persons qualifying under the plan, usually those over 65. The hospital benefits are Part A, and the medical expense portion is Part B. Part A is compulsory social insurance; Part B is voluntary government-subsidized, government-operated insurance.
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Member
Anyone covered under a health plan (enrollee or eligible dependent).
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Member Certificate
Another term for certificate of coverage.
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Mental Health Services and Supplies
Items required for treatment of mental illness, including substance abuse and alcoholism.
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Miscellaneous Expenses
Ancillary expenses, usually hospital charges other than daily room and board. Examples would be X-rays, drugs, and lab fees. The total amount of such charges that will be reimbursed is limited in most basic hospitalization policies.
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N
National Drug Code (NDC)
A system for identifying drugs.
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National Health Insurance
Any system of socialized insurance benefits covering all or nearly all of the citizens of a country, established by its federal law, administered by its federal government, and supported or subsidized by taxation.
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Non-Occupational Policy
A policy or provision of a policy which excludes accidents occurring on the job, when such employment is covered by workers compensation.
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Nonduplication of Benefits
A provision in some Health Insurance policies specifying that benefits will not be paid for amounts reimbursed by others. In Group Insurance, this is usually called coordination of benefits (COB).
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Nonparticipating Provider
(1) A provider who has not signed a contract with a health plan. (2) A medical or health care provider who is not certified to participate in the Medicare program.
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Nonparticipating Provider Indemnity Benefits
Coverage where services provided by nonparticipating providers are reimbursed under an indemnity basis.
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Nursing Home
A licensed facility which provides general nursing care to those who are chronically ill or unable to take care of necessary daily living needs. May also be referred to as a Long Term Care facility.
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O
Occupational Disease
Impairment of health caused by continued exposure to conditions inherent in a person's occupation or a disease caused by an employment or resulting from the nature of an employment.
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Office Visit
Services provided in the physician's office.
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Open Access
Allows a participant to see another participating provider of services without a referral. Also called open panel.
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Open Panel
See Open Access.
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Out-of-Pocket Costs
The amounts the covered person must pay out of his or her own pocket. This includes such things as coinsurance, deductibles, etc.
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Out-of-Pocket Limit
The maximum coinsurnace an individual will be required to pay, after which the insurer will pay 100% of covered expenses up to the policy limit.
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Outpatient
A patient who is not a bed patient in the hospital in which he or she is receiving treatment.
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Over-The-Counter Drugs (OTC)
A drug that can be purchased without a prescription.
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P
Participating Provider
A health care provider approved by Medicare to participate in the program and receive benefit payments directly from carriers or fiscal intermediaries.
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Peer Review
Review of health care provided by a medical staff with training equal to the staff which provided the treatment.
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Peer Review Organization (PRO)
Groups of physicians who are paid by the federal government to conduct pre-admission, continued stay and services reviews provided to Medicare patients by Medicare approved hospitals.
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Permanent and Total Disability
Total disability from which the insured does not recover. When used as a definition in a policy (usually a life insurance policy rider), "permanent" is presumed after a stated period of time, commonly six months.
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Permanent Total Disability
A condition where the injured party is not able to work at any gainful employment for the remaining lifetime. (WC,H)
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Physical Therapist
A trained medical person who provides rehabilitative services and therapy to help restore bodily functions such as walking, speech, the use of limbs, etc.
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Physician's Current Procedural Terminology (CPT)
This terminology includes medical services and procedures performed by physicians and other providers of health care. The health care industry uses it as a standard for describing services and procedures.
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Place of Service
This designates where the actual health services are being performed, whether it be home, hospital, office, clinic, etc.
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Point-of-Service Plan.
This plan allows a choice of whether to receive services from a participating or nonparticipating provider.
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Practical Nurse
A licensed individual who provides custodial type care such as help in walking, bathing, feeding, etc. Practical nurses do not administer medication or perform other medically related services.
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Pre-Admission Authorization
A cost containment feature of many group medical policies whereby the insured must contact the insurer prior to a hospitalization and receive authorization for the admission.
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Pre-Admission Certification
Before being admitted as an inpatient in a hospital, certain criteria are used to determine whether the inpatient care is necessary.
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Preexisting Condition
A physical condition that existed prior to the effective date of a policy. In many Health policies these are not covered until after a stated period of time has elapsed.
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Preferred Provider Organization (PPO)
An organization of hospitals and physicans who provide, for a set fee, services to insurance company clients. These providers are listed as preferred and the insured may select from any number of hospitals and physicians without being limited as with an HMO. Coverage is 100%, with a minimal copayment for each office visit or hospital stay. Contrast with Health Maintenance Organization. (LI,H)***
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Prescription Medication
A drug which can be dispensed only by prescription and which has been approved by the Food and Drug Administration.
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Preventive Care
This type of care is best exemplified by routine physical examinations and immunizations. The emphasis is on preventing illnesses before they occur.
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Primary Care
Basic health care provided by doctors who are in the practice of family care, pediatrics, and internal medicine.
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Primary Care Network (PCN)
This is a group of primary care physicians who provide care to those members of a particular health plan.
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Primary Care Physician
Some health insurance plans require members to select and seek treatment from a primary physican who either renders treatment or refers the member to an appropriate specialist within the approved health care network.
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Primary Coverage
This is the coverage which pays expenses first, without consideration whether or not there is any other coverage. See also Coordination of Benefits.
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Prior Authorization
A cost containment measure which provides full payment of health benefits only when the hospitalization or medical treatment has been approved in advance.
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Professional Review Organization
An organization of physicians which reviews services to determine if they are medically necessary.
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Proration of Benefits
The adjustment of Health Insurance policy benefits by reason of the existence of other insurance covering the same contingency.
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Provider
Any individual or group of individuals that provide a health care service such as physicians, hospitals, etc.
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R
Reasonable and Customary Charges
The charge for medical services which refers to the amount approved by the Medicare Carrier for payment. Customary charges are those which are most often made by a provider for services rendered in that particular area.
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Recidivism
This term refers to how often a patient returns to an inpatient hospital status for the same reason.
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Recurring Clause
Health Insurance policy provision defining the duration of a period of time during which the recurrence of a condition will be considered a continuation of a prior period of disability or confinement.
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Referral
Occurs when a physician or other health plan provider receives permission to consult another physician or hospital.
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Referral Provider
The person or provider to whom a participating provider has referred a member of the plan.
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Registered Nurse (RN)
A licensed professional with a four-year nursing degree. Able to provide all levels of nursing care including the adminstration of medication.
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Rehabilitation Clause
A clause in a Health Insurance policy, particularly a Disability Income policy, that is intended to assist the disabled policyholder in vocational rehabilitation.
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Restoration of Benefits
A provision in many Major Medical Plans which restores a person's lifetime maximum benefit amount in small increments after a claim has been paid. Usually, only a small amount ($1,000 to $3,000) may be restored annually.
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S
Schedule (Surgical)
A list of specified amounts payable for surgical procedures, dismemberments, ancillary expenses, and the like in hospital and medical reimbursement policies.
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Second Surgical Opinion
A cost containment technique to help patients and insurance companies determine whether a recommended procedure is necessary, or whether an alternative method of treatment could accomplish the same result. Some health policies require a second surgical opinion before specified procedures will be covered, and many policies pay for the second opinion.
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Secondary Care
Medical services provided by physicians who do not have first contact with patients. Examples would be specialists such as urologists, cardiologists, etc. See also Primary Care and Tertiary Care.
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Secondary Coverage
Coverage which provides payment for charges not covered by the primary policy or plan. See also Coordination of Benefits.
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Sickness
Includes physical illness, disease, pregnancy, but does not include mental illness.
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Skilled Nursing Care
Daily nursing and rehabilitative care that is performed only by or under the supervision of skilled professional or technical personnel. Skilled care includes administering medication, medical diagnosis and minor surgery.
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Skilled Nursing Facility (SNF)
A facility designed to qualify for treatment to Medicare eligible people. Included is treatment for rehabilitation and other care such as 24-hour nursing coverage, physical, occupational, and speech therapies, etc.
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Surgi-Center
A separate facility (from a hospital) that provides outpatient surgical services.
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T
Terminally Ill
A term which refers to the status of a person who will normally die within 6 months of a specific illness or sickness. Often refers to the terminally ill requirement for hospice care.
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Therapeutic Alternatives
Alternate drug products which may be different in chemical content, but provide the same effect when administered to patients.
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Therapeutic Equivalence
Different drugs which will control a symptom or illness exactly the same as other drugs used to control that illness.
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Third Party Administrator (TPA)
A firm which provides administrative services for employers and other associations having group insurance policies. The TPA in addition to being the liaison between the employer and the insurer is also involved with certifying eligibility, preparing reports required by the state and processing claims. TPA's are being used more and more with the increase in employer self-funded plans.
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Title XIX Benefits
See Medicaid.
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Total Disability
A degree of disability from injury or sickness that prevents the insured from performing the duties of any occupation from remuneration or profit. The definition in any given case depends on the wording in a covering policy.
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Treatment Facility
Any facility, either residential or nonresidential, which is authorized to provide treatment for mental illness or substance abuse.
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Triage
A method of ranking sick or injured people according to the severity of their sickness or injury in order to ensure that medical and nursing staff facilities are used most efficiently.
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U
Uniform Billing Code of 1992 (UB-92)
This code is scheduled to be implemented on October 1, 1993. It's a federal directive which states how a hospital must provide their patients with bills, itemizing all services included and billed on each invoice.
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Urgi-Center
An emergency medical service center which is separate from any other hospital or medical facility.
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Usual, Customary, and Reasonable (UCR)
See Reasonable and Customary.
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Utilization
This refers to how much a covered group uses a particular health plan or program.
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Utilization and Review Committee
A committee composed of medical personnel whose purpose it is to monitor the health care services and supplies provided to Medicare patients.
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Utilization Management
This procedure or process utilizes a review coordinator to evaluate the necessity and appropriateness of various health care services.
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Utilization Review
A cost control mechanism by which the appropriateness, necessity, and quality of health care is monitored by both insurers and employers.
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V
Vision Care Coverage
A health care plan usually offered only on a group basis which covers routine eye examinations, and which may cover all or part of the cost of eyeglasses and lenses.
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