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The terminology and information provided below is only a general guideline. Your company may have its own unique processes, procedures, plan definitions and/or terminology which differ from those detailed below. In the event there is a difference in definition, terminology, processes or procedures, the information included in your specific plan document and/or Summary Plan Description (SPD) will govern.
In the event you have questions or need additional information regarding definitions and/or terminology specific to your plan, please contact your company's Human Resource department, Employee Relations Benefit department, or Fiserv Health - Kansas for additional information or instructions.
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
Accident
An unexpected occurrence causing loss or injury that is not the fault of the person injured. Bodily injury is caused by an external source.
Account Manager
The service representative who manages a client's account, including many aspects of client services.
Activities of Daily Living (ADLs)
Activities performed as part of a person's daily routine of self care, e.g., bathing, dressing, eating.
Acts of Third Parties
This provision is most often referred to as subrogation and the statement is a subrogation statement. The acts of third parties provision applies when an employee (or dependent) appears to have suffered an injury or illness because of an act or omission by another person.
ADA
American Dental Association codes are used in billing for dental services.
Administrative Costs
The costs incurred by a carrier for administrative services such as claims processing, billing, enrollment and overhead costs. These costs may be expressed as a percentage of premiums or on a per-member, per month basis.
Adjustment Disorder
Maladaptive reactions to identifiable psychosocial stressors occurring within a short time after onset of the stressor. They are manifested by either impairment in social or occupational functioning, or by symptoms (depression, anxiety, etc.) that are in excess of a normal and expected reaction to the stressor.
Administration Services Only (ASO)
Management services provided by a third party for an employer group that is financially at risk for the cost of health care services. These services may include claim payments, medical management services and/or network access. This is a common arrangement when an employer sponsors a self-funded health benefit program.
Admission
When a registered patient is admitted for at least 24 hours to a hospital, skilled nursing facility or other health care facility.
Aftercare
Services following hospitalization or rehabilitation individualized for each patient's needs.
Alcoholism
A primary, chronic disease with genetic, psychosocial and environmental factors influencing its development and manifestations. The disease is often progressive and can be fatal. It is characterized by continuous or periodic impaired control over drinking, preoccupation with the drug alcohol, use of alcohol despite adverse consequences, and distortions in thinking-the most notable is denial.
Allied Health Personnel
Specially trained and licensed health workers other than physicians, dentists, optometrists, chiropractors, podiatrists, mental health professionals and nurses. This term is sometimes used synonymously with paramedical personnel, all non-physician health workers, or heath workers who do not usually engage in independent practice.
Alternate Care
Non-inpatient care received in a less intensive setting than a hospital or other in-patient facility (e.g., a skilled nursing facility or day-surgery center).
Alternative Medicine
Therapeutic interventions that typically place nature's healing power, and technique and technology second. This is considered a "non-traditional" approach to medical care, and is not usually taught in medical schools or necessarily available at hospitals in the United States . Examples of alternative medicine are acupuncture, spiritual healing and herbal remedies.
Ambulatory Care
Healthcare services that do not require inpatient hospitalization.
Ambulatory Setting
An institutional health setting in which health services are provided on an outpatient basis, such as a day surgery center, clinic or other outpatient facility. Ambulatory care settings also may provide mobile services (e.g., mobile mammography, MRI).
Amendment
A formal document that revises a health plan's provisions.
Ancillary Care
Additional services performed prior to and/or secondary to a significant procedure such as lab work and X-ray.
Ancillary Charge
The fee associated with additional services performed prior to and/or secondary to a significant procedure, such as lab work and X-ray.
Anesthetist
A specially trained individual or nurse who administers anesthesia.
Anesthesiologist
A physician (an M.D. or D.O.) specializing in anesthesiology.
Annual Deductible
Refers to the amount of covered expenses a patient must pay during each benefit year before the plan will consider major medical expenses for reimbursement.
Annual Maximum
Annual maximums apply to one benefit year only. When a new benefit year begins, the accumulation begins again with $0 for the new benefit year.
Appeal
A specific request to reverse a denial, restriction or adverse determination of benefit reimbursement.
Application
A signed statement of facts made by a person applying for insurance. An insurance company uses the application to decide whether to issue a policy. The application becomes part of the insurance contract when the policy is issued.
Assignment of Benefits
Claim payment that is sent to the doctor or facility when the claimant has signed authorization to allow us to pay the doctor or facility.
Authorization
Consent for patient hospital stay, surgery or other ancillary services.
Average Cost Per Claim
The average dollar amount paid for administrative and/or medical services rendered for a type of service (e.g., admissions, physician services, outpatient claims). The formula is: dollar amount divided by number of services rendered.
Average Length of Stay (ALOS)
The average number of days in an inpatient facility for each admission. The formula is: number of inpatient days divided by the number of admissions.
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Balance Billing
An arrangement whereby a provider may bill a covered person for the difference between the billed charges and the amount reimbursed by the health plan. This may or may not be appropriate, depending upon the contractual arrangements among the health care provider and carrier, and/or any government regulations, such as Medicare.
Base Benefit
Reimbursements or payments for medical or dental expenses generally paid at 100 percent with no deductible. Often a base benefit will have a specified dollar limit at which point the benefit rate might be reduced. For example, a plan might indicate that X-ray and lab charges are covered at 100 percent up to $300 per benefit year. When the $300 limit is reached, additional benefits will be paid at a lower benefit rate.
Behavioral Health Care
Assessment and treatment of mental and/or psychoactive substance abuse disorders.
Beneficiary
A person designated by an insuring organization or Medicare as eligible to receive insurance benefits.
Benefit Administration
The process of processing claims according to the plan's benefits (based on the plan document information) and releasing payment to providers according to the plan.
Benefit Deductible
Deductible that applies to a specific plan benefit other than the plan deductible.
Benefit Level
The limit or degree of services a person is entitled to receive based on the Summary Plan Description (SPD).
Benefit Package
The coverage/reimbursement for health care services an insurer, government agency, or health care plan offers to a group or individual under a contract's terms.
Benefit Year
The time period during which deductibles, annual maximums and out-of-pocket expenses accumulate. For some plans the benefit year follows the calendar year (from Jan. 1 to Dec. 31) however, the benefit year can be based on any dates the plan chooses. Although the benefit year can be the same period as the plan year, it does not have to be. For example, the plan year might be from April 1 to March 31 while the benefit year is from Jan. 1 to Dec. 31.
Benefits
The reimbursement of medical or dental claims submitted for payment under the health benefit plan. The package offered in a contractual agreement that determines what covered services are provided by the plan.
Biofeedback
A process that uses instrumentation to give a person immediate and continuing signals of change in his bodily function of which he is usually unaware.
Birthday Rule
A method used to determine the primary carrier when coordinating benefits for dependent children. The birthday rule states that the plan of the parent who is born earlier in the year pays first. For example, if the mother's birthday was Jan. 1 and the father's was March 2, the mother's plan would be considered primary. If both parents have the same birthday, the plan of the person who has been covered longer pays first. If the parents are divorced, the order of benefit determination depends upon the divorce decree and which parent has custody.
Board Certified
A physician who has completed an approved residency, passed an examination given by a medical specialty board, and who has been certified as a specialist in that medical area.
Board Eligible
A physician who is eligible to take the specialty board examination by virtue of having graduated from an approved medical school, completed a specific type and length of training, and practiced for a specified amount of time.
Bundling
Combining service costs that might otherwise be billed separately. This includes providers billing for health care services that have been combined according to industry standards or commonly accepted coding practices.
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Cafeteria Plan
An employee benefit plan that allows employees to choose any or all of the benefits offered. This pertains to Flex Spending Benefits for Health Care and Dependent Care expenses.
Calendar Year
The inclusive period of time from Jan. 1 of any year through Dec. 31 of the same year. This may pertain to deductible amounts, out-of-pocket provisions and maximum amounts.
Capitation (Cap)
A stipulated dollar amount established to cover the cost of health care delivered to a person. The term often applies to a negotiated per capita rate to be prepaid to a health care provider. It is often coupled with mechanisms that set an upper limit on risk assumed by a provider. The provider is responsible for delivering, or arranging for the delivery of, all health services required by the covered person under the carrier provider contract's conditions.
Carrier
An entity that may underwrite, administer or sell a range of health benefit programs. The term may refer to an insurer or a managed health plan.
Carryover Deductible
Some health benefit plans state that any amount of a deductible satisfied within a specified time period of the benefit year will be used to satisfy that portion of the following year's deductible. For example, (in this example the benefit year runs from Jan. 1 to Dec. 31, any deductible amount satisfied within the last three months of the year is eligible for carry-over), a member satisfies $200 of the $250 annual deductible in December. When the new benefit year begins in January, the member will have $50 of the annual deductible remaining to satisfy for that benefit year.
Carryover Out-of-Pocket
Similar to "carryover deductible." Any amounts applied toward the out-of-pocket maximum by expenses incurred during the last quarter of the benefit year are also used to satisfy the next year's out-of-pocket maximum.
Carry Over Provision
In major medical policies, this allows an insured party who has submitted no claims during the year to apply any medical expenses incurred in the last three months of the year toward the new calendar year's deductible.
Carve Out COB
A situation when the benefit is calculated as usual and the other carrier's payment is subtracted from the allowable benefit. The paid amount is the difference between our payment and the other coverage payment.
Case Management
The process of identifying patients with specific health care needs and working with them and their physicians to determine and coordinate a treatment plan that promotes the best health outcomes with efficient use of health care resources.
Case Manager
A clinical professional such as a nurse, doctor or social worker who works with patients, health care providers, and insurers to coordinate a plan of medically necessary and appropriate health care.
Caudal Anesthesia
Anesthesia in the lower half of the body produced by injection of a local anesthetic solution to block nerve or nerves in the lowest spinal cord area.
Centers of Excellence
A network of credentialed health care facilities selected for specific services based on stringent criteria including outcomes and efficiency. For example, an organ transplant managed care program may require members to access transplant services through a centers of excellence network.
Centers for Medicare and Medicaid Services (CMS)
(formerly the Health Care Financing Administration) A Federal agency within the U.S. Department of Health and Human Services. Programs for which CMS is responsible include Medicare, Medicaid, State Children's Health Insurance Program and HIPAA.
Civilian Health and Medical Program of the Uniformed Services (CHAMPUS)
Part of the Uniformed Services Health Benefits Program that supplements the medical care available for families of active, deceased and retired military personnel.
Claim
Any itemized bill submitted for payment at the request of the enrollee, physician, hospital or other provider.
Claim Examiner
Fiserv Health - Kansas employee who processes client claims. The Claims Analyst is responsible for determining how to process the claim according to the plan provisions and industry guidelines.
Claim Number
A unique identifying number assigned to each claim processed.
Client
A company that has contracted with Fiserv Health - Kansas to handle their claims administration.
COB Savings
The amount of money the plan saves because another insurance carrier has paid partial medical benefits.
COBRA
Consolidated Omnibus Budget Reconciliation Act. Applicable to Employers who had 20 or more employees (full time and part time) on 50% of business days during the preceding calendar year. A federal law that allows the continuation of health care benefits for employees whose employment has been terminated. Employers are required to notify employees of these benefit continuation options, or the employer will face penalties and fines. The enrollee pays the premiums (cost of coverage).
Cognitive Impairment
A person who is impaired in memory, reasoning or orientation; or an impairment that requires a person to be supervised to protect himself or herself or others from harm.
Coinsurance
The amount for which the enrollee is responsible after the plan has paid an expense. This amount is usually a percentage of the total amount charged. The enrollee and the plan share the total cost of the service. For example, a plan may pay 80 percent of a service and the enrollee pays 20 percent, after meeting the deductible.
Coinsurance Clause
A provision that states the insured and the insurer will share all claims covered by the policy in a proportion agreed upon in advance, i.e., 80-20 would mean that the insurer would pay 80 percent and the insured would pay 20 percent of the plan's reasonable and customary allowance of all eligible claims.
Coinsurance Deductible
The deductible that applies to the plan's benefits. This amount must be met before the plan pays benefits. For example: on an 80/20 plan with a $100 deductible, the member needs to pay the first $100 of the medical expense(s), and then the plan would pay 80 percent of the plan's reasonable and customary allowance of the remaining or additional medical expense(s). The member would pay 20 percent of any other medical claims thereafter until the out-of-pocket maximum was met for the plan year. When that maximum is reached, the plan may pay a higher benefit.
Common Accident
An accident that involves more than one family member. Many plans allow for this type of situation. Usually the plan states only one member is required to satisfy the deductible for benefits to begin paying at the first coinsurance level.
Comprehensive Major Medical
Medical insurance designated to pay benefits for a broad range of both basic and catastrophic illnesses and injuries. Also known as major medical.
Confinement
An uninterrupted patient stay for a defined period of time in a hospital, skilled nursing facility or other approved health care facility or program, followed by discharge from the same facility or program.
Continuing Claim
A claim with same diagnosis as one already processed, or interim billing that needs to connection to the already processed claim.
Contract Year
The 12-month period following the effective date or subsequent renewal date of a client contract.
Contribution, Flexible Spending
A pre-tax dollar amount, determined by the flex participant, which is accumulated for medical or dependent care.
Contribution, Medical
The amount an employee pays for the cost of health care coverage. Usually, the employee and employer share the total cost.
Conversion Factor
A contractual dollar amount a PPO physician receives for a particular procedure. Conversion factors are established in a contract between a physician and PPO, and are used (along with unit values) to calculate benefits on PPO claims.
Coordination of Benefits
The process of determining benefits used when more than one health insurance carrier may be responsible for payment.
Co-Payment
A specified flat dollar amount a member pays for a specific service, usually when seeing a PPO physician. For example, if the office visit co-payment is $10 and the office visit is $70, the member would pay $10 to the physician at the time of service and the plan would pay $60, less the PPO discount. This is only true if the plan pays 100 percent benefit. Some plans may only pay 90 percent of the charge. Also referred to as a front-end deductible.
Cosmetic Procedures
Procedures that improve physical appearance, but do not correct or materially improve a physiological function.
Cost Drivers
Business expense categories (e.g., pharmacy) and/or the specific diagnosis (e.g., diabetes) that account for a significant percentage of medical expenses.
Covered Expense
Charges for services rendered or supplies furnished by a contracted health provider which qualify as expenses eligible for reimbursement under a health plan.
Coverage
Scope of protection provided under a contract of insurance.
CRNA (Certified Registered Nurse Anesthetist)
A trained nurse who is licensed to give anesthetics. Benefits for CRNA services are generally covered under the anesthesia provision of a medical plan.
Current Procedural Technology (CPT-4)/(CPT code)
Every medical procedure (e.g., surgery, office visit, lab work, etc.) has a five-digit code called a CPT code or procedure code. The first digit of a CPT code represents the type of service rendered:
1, 2, 3, 4 ,5, or 6: surgery
7: radiology
8: pathology
9: medical
0: anesthesia
Though not common, CPT codes starting with 9 may also be for surgery, X-ray or lab charges. For example, the CPT code for a cardiac catherization is 93501. Though the procedure begins with a 9, which ordinarily represents a medical service, cardiac catherization is a surgery charge.
Custodial Care
Medical or non-medical services not designed to cure an illness or injury, provided during periods when the patient's medical condition is not changing, or does not require continued administration by medical personnel. For example, assistance in the activities of daily living.
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Date of Service (DOS)
The date a covered employee or dependent received a medical or dental service. For example, if a covered employee visited the doctor on 5/8/98 , the date of service would be 5/8/98 .
Day Maximum
A limit on the number of days for which a plan will provide benefits for a particular service. For example, a plan may cover stays in skilled nursing facilities up to 60 days per benefit year.
Days, Visits, Treatments (DVT)
The number of services performed for a particular medical procedure. Some benefits may have a DVT limit. For example, a plan may cover up to 20 chiropractic visits per benefit year.
Deductible
The amount of expenses the patient must incur and pay before the plan will begin to provide benefits for certain services. For example, if a benefit is subject to a $150 deductible and the expense for a medical service is $200, the patient is responsible for $150 of the charge and the plan would consider the remaining $50.
DEFRA
Deficit Reduction Act, effective Jan. 1, 1985 . This federal law has a number of implications, including a provision that requires companies to give employees' spouses over age 65 the opportunity to enroll under the employers' group health plans.
Dependent
A covered employee's spouse and unmarried children from birth to the limiting age specified in the plan. Dependent children must be primarily dependent upon the covered employee for support and maintenance. The term "children" shall include natural children, adopted children or children placed with a covered employee in anticipation of adoption and stepchildren who reside with the employee.
Dependent Care Spending Account
Accounts in which pre-taxed funds are contributed from the employee's income to cover un-reimbursed dependent care expenses.
Depression
A lowering or decrease of functional activity. A mental state of depressed mood characterized by feelings of sadness, despair and discouragement. Depression ranges from normal feelings of the blues through dysthymia to major depression. It in many ways resembles the grief and mourning that follow bereavement. There are often feelings of low self-esteem, guilt and self-reproach, withdrawal from interpersonal contact, and somatic symptoms such as eating and sleep disturbances.
Detoxification
The process an individual goes through when withdrawing from alcohol or drugs. The process usually occurs under the guidance of medical personnel.
Diagnosis
What the medical professional determines as the cause of an illness or injury of a patient. An example of a diagnosis would be measles, hepatitis, etc.
Diagnosis Code (ICD-9)
The International Classification of Diseases, Ninth revision. The universal coding method used to indicate a diagnosis or medical condition.
Diagnosis Related Grouping (DRG)
A billing method that hospitals in some states are required to use and all other hospitals may choose to use. With this method, a hospital will charge a flat rate based on diagnosis, rather than billing each separate service rendered.
Disability
Any condition resulting in limitations that interfere with a person's ability to perform his/her customary work, or that results in substantial limitations in one or more major life activities.
Disability Benefit
An amount paid, in lieu of salary, to an individual who is disabled. Individuals must qualify for such benefits per the plan's requirements.
Disease
An interruption, cessation or disorder of physical or mental functions.
Duplication of Benefits
Overlapping or identical coverage of an insured person under two or more health plans. This usually is the result of a person taking coverage through both his own employer and his spouse's employer.
Durable Medical Equipment (DME)
Medical equipment which can withstand repeated use; is not disposable; is used to serve a medical purpose; is generally not useful in the absence of a sickness or injury; and is appropriate for home use. Examples of DME are hospital beds, wheelchairs and oxygen equipment.
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Educational Institution
An accredited organization with the primary function of developing individual knowledge or skill.
Effective Date
The date on which a person's coverage goes into effect and/or the date the plan's benefits went into effect with the current insurance administrator.
Electronic Data Interchange (EDI)
The computer to computer exchange of information between organizations. The data may be either HIPAA standardized format or proprietary format.
Eligibility
A person or expense that qualifies for benefits under the plan. Each plan determines eligibility by following federal, and sometimes state, guidelines such as ERISA, HIPAA and COBRA, among others.
Eligible
Qualified or acceptable. The word eligible can be applied as follows:
- When referring to a patient, the person is qualified to receive benefits under the plan.
- When referring to a charge, the expense is qualified or acceptable to be paid under the plan.
- When referring to a provider, the provider has met the qualifications to provide service under the plan.
Eligible Expense
Charges for services rendered or supplies furnished by a contracted health provider which qualify as expenses eligible for reimbursement under a health plan.
Emergency
A serious medical condition or symptom resulting from an injury, sickness or mental illness that occurs suddenly and requires immediate care and treatment. An emergency is also defined as being "life threatening." Some plans will not pay for emergency room treatment if the visit was not for a "life threatening" condition.
Employee
The person employed by the company whose benefits we administer. For example, if John Doe works for the Power Plant, he is their employee. Fiserv Health - Kansas refers to these employees as "members."
Employee Assistance Program (EAP)
Services designed to assist employees, their family members and employers in finding solutions for workplace and personal problems. EAP's also can provide voluntary or mandatory access to behavioral health benefits through an integrated behavioral health program.
Employee Retirement Income Security Act (ERISA)
This act, also called the Pension Reform Act, regulates the majority of the nation's private pension and welfare group benefit plans. It sets regulations regarding participation, crediting of service, vesting, communication and disclosure, funding and conduct. ERISA also exempts most large self-funded plans from state regulation and from any reform activities undertaken at the state level. It also includes claim-processing requirements. For example, under this act, the plan must respond to requests for information within 30 days. If the plan does not respond within this time, the plan may have to pay a fine. When a claim is denied, the plan must notify the employee of the denial in writing and explain the reason for that denial. If the employee does not agree with the benefits paid or denied on a claim, that employee has the right to have the claim reviewed. If the employee does not agree with the review, he has the right to sue the plan.
End-Stage Renal Disease
A patient with inadequate renal function to support life. Individuals with end-stage disease must rely on kidney dialysis or peritoneal dialysis to survive. End-stage renal disease may be caused by a number of problems, including diabetes, sickle cell disease, hypertension and congenital renal disease (polycystic kidney disease).
Enrollee
The employee that elects to have coverage under the health benefit plan his or her company offers. For example, John Doe of the Power Plant elects to be covered under the health benefit plan the Power Plant offers. He is the enrollee in the health benefit plan.
EOMB
Explanation of Medicare Benefits. This document explains the Medicare payment on medical services. Also known as MEOB.
Exclusions
Benefits, conditions or expenses not covered by the plan. Exclusions are listed in the Plan Document (link to plan document section).
Explanation of Benefits (EOB)
A statement that explains to the provider and member how a claim was processed and where the dollars submitted on the claim were applied. [23.0] (view a sample EOB)
Extended Care Facility
A nursing home or nursing center that is licensed to operate in accordance with all applicable state and local laws.
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Family Deductible
The maximum amount a family, as a unit, is expected to pay in a plan year. When the maximum is met by any combination of family members, no other deductible needs to be met for that plan year. For example, if the family deductible amount is $300 and the individual deductible amount is $150.00, a family member could accumulate $100, the spouse another $150 (meeting their individual maximum) and a child an additional $50, to meet the plan year's maximum family deductible. No other family member needs to meet the individual amount of $150 when the family maximum has been met for the plan year.
Fee Schedule
A list of codes and related services with pre-established payment amounts, which could be percentages of billed charges, flat rates or maximum allowable amounts.
First-Dollar Coverage
Feature of a health plan in which the plan does not require its members to pay any deductibles or co-payments before benefits are received.
Flexible Spending Benefits
Flexible spending allows employees to pay for un-reimbursed healthcare expenses such as deductibles, co-insurance payments, routine vision or dependent care expenses with pre-tax dollars. Because flexible benefit plans involve pre-tax salary, both the employee and employer realize tax savings.
Flex Year
Either a plan year or calendar year, usually a 12-month time period.
Fully Insured
The accounts/employer groups that assume only the financial risk for the payment of monthly employee premiums, and where the carrier assumes full risk for the actual medical expenses incurred. Fully insured accounts are subject to all state and federal regulations.
Full-time Student
Dependent children exceeding the age limit defined in the plan document who attend an accredited institution on a full-time basis. They are primarily dependent upon the covered enrollee for support and maintenance, unmarried and under the requirement age per plan language.
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Generic Drug
A drug that is exactly the same as a brand name drug and is allowed to be produced after the brand name drug's patent has expired. It is also called a "generic equivalent."
Global Services
Professional and technical components are percentages of the global service. Values listed for global services include reimbursement for the professional and technical components. Where codes are for "professional only" and "technical only," the total of the separate codes should not exceed the global code, regardless of the site(s) where services were rendered.
Grace Period
The specified period after a premium payment is due, in which the policyholder may make such payment, and during which the protection of the policy continues. The grace period for payment of medical insurance premiums is 30 days.
Group
A client for which Fiserv Health supplies claim processing, customer service and other benefit administration functions.
Group Contract
A contract of insurance made with an employer or other entity that covers a group of persons identified as employees by reference to their relationship to the entity.
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HCFA 1500
The Health Care Finance Administration's standard form physicians use to bill third-party administrators or insurance companies.
Health Care Financing Administration (HCFA)
As of July 1, 2001 , the Health Care Financing Administration ( HCFA ) is now known as The Centers for Medicare & Medicaid Services (CMS).
Health Care Financing Administration Common Procedure Code System (HCPCS)
An alternate procedure coding system providers sometimes use for miscellaneous services such as injections, prosthetics or orthotic services. These codes consist of a letter (A-Z) followed by four numbers. Not all-miscellaneous services are considered eligible under Medicare and other programs.
Health Care Spending Account
The account in which pre-tax funds are contributed from the employee's income to cover unreimbursed health care expenses. Also called flexible spending and cafeteria plan.
Health Insurance
Coverage to protect against financial losses resulting from a covered sickness or covered accidental bodily injury.
Health Insurance Association of America (HIAA)
One of several different companies that compile lists of physician charges upon which usual and customary schedules are based.
Health Maintenance Organization (HMO)
An association of health care professionals and facilities that provides a specified package of health care for a fixed sum of money, paid in advance for a specified period of time. An enrollee that has an HMO plan must use the participating providers to receive benefits for a service.
HIC #
The Social Security number under which the individual is entitled to Medicare coverage; if not entitled under the individual's own work record, the HIC # will be the entitled individual's Social Security number.
HIPAA
Health Insurance Portability and Accountability Act of 1996. This act sets federal requirements for group health plans that let individuals carry over credit for coverage from one carrier to another. This may reduce or eliminate the member's pre-existing condition limitations under a new plan. The Administrative Simplification section of HIPAA protects the individually identifiable health information of plan participants.
Home Health Agency (HHA)
A facility or program licensed, certified or otherwise authorized according to state and federal laws to provide home-based health care services.
Home Health Care
Care received at home, including part-time skilled nursing care, speech therapy, physical or occupational therapy, part-time home health aide services, or help from homemakers or choreworkers.
Hospice
A licensed or certified facility or program engaged in providing care of the terminally ill.
Hospital Miscellaneous Services
Any services other than room and board and general nursing services provided by a hospital during hospital confinement. Included are such items as: X- ray examinations, laboratory tests, medicines, surgical dressings, anesthetics (including the administration of), and operating room use.
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ICD-9
See Diagnosis Codes or International Classification of Diseases.
Inclusive Date
The ending date of a medical or dental service. For instance, if a patient entered the hospital on 5/2/98 and left the hospital on 5/5/98 , 5/5/98 would be the inclusive date.
Incurred Date
The beginning date of a medical or dental service. For instance, if a patient entered a hospital on 2/18/98 and left the hospital on 2/20/98 , 2/18/98 would be the incurred date.
Individual Deductible
The amount that each individual covered under the plan must meet before the plan will pay benefits for that person. For example, if the plan requires an individual deductible of $150, each individual covered under the plan must pay $150 before the plan will begin providing major medical benefits, unless the family deductible has been met.
Ineligible
A person or expense that does not qualify for benefits under the plan.
Injury
Bodily damage other than sickness, including all related conditions and recurrent symptoms.
Inpatient
An inpatient hospital service rendered while a patient is in a hospital for 24 hours or more.
Insurance
A system under which individuals, businesses, and other organizations or entities, in exchange for payment of a sum of money (called a premium), are guaranteed compensation for losses resulting from certain perils under specified conditions in a contract.
Insurance Commissioner
A state's insurance regulatory official. Third-party administrators are not regulated by the Insurance Commissioner, although some may choose to follow state guidelines.
Intermediate Care Facility (ICF)
A facility providing a level of care less than the degree of care and treatment a hospital or skilled nursing facility (SNF) is designed to provide, but greater than the level of room and board.
International Classification of Diseases (ICD-9)
This book lists the codes assigned to each disease or diagnosis, numerically (in Volume 1) and alphabetically in (Volume 2). Both medical professionals and benefit industry professionals, like Claims Analysts use ICD codes, sometimes called diagnosis codes.
Itemized Bill
A form that includes information from a provider that is necessary to process a claim. Information on an itemized bill includes the ICD-9 code, charges, CPT code, description of services, date of service, employee's name, patient's name, patient's account number, provider's tax identification number, and the provider's name and address.
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Large Case Management (LCM)
The medical management of patients with high dollar medical claim costs. A medical professional interacts with the patient and his/her physicians to help coordinate appropriate and cost-effective health care treatment plans.
Late Enrollment
Enrollment which takes place after the period of open enrollment or the original enrollment period.
Length of Stay (LOS)
The number of days a covered person stayed in an inpatient facility for each admission.
LGHP
Large Group Health Plan. A large group consists of more than 100 employees.
Lifetime Maximum
Applies to the entire time an employee is covered under the client's plan. When an employee reaches his lifetime maximum, the plan will no longer pay benefits for the applicable service. Sometimes plans will set lifetime maximums not per service but for all services.
Limitations
Any provision other than an exclusion that restricts coverage of a benefit. A particular benefit may have a specified limit that applies.
Location
The distinction of employees or benefits within a group. Each location could be for different physical locations, job function or simply a different benefit plan.
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Major Medical Benefit
When the plan pays less than 100 percent for a service and the patient is responsible for coinsurance and a deductible.
Managed Care
A system of health care delivery that influences utilization, quality of care and cost of services, and that measures performance. The goal is a system that delivers value by providing access to quality, cost-effective health care. Also known as managed health care.
Massachusetts Surcharge Payer
This legislation imposes surcharges on a variety of health care provider services. The surcharges collected are used to provide access to health care for low income uninsured and underinsured residents of Massachusetts.
Maximums
A dollar or frequency limit established for a benefit. Any expense that exceeds this limit is not covered by the plan.
Medical Data Research (MDR)
MDR is a national database of prevailing fees that is referenced by zip code and CPT code. It includes prevailing charge data arrayed in percentiles for more than 95 percent of all currently used CPT procedure codes in surgical, medical radiology and laboratory procedures. The database includes guidelines for professional procedures and services.
Medicaid
A federal program administered and operated individually by participating state and territorial governments that provides medical benefits to eligible low-income people needing health care. The federal and state governments share the program's costs.
Medical Benefits
Includes expenses for doctors, hospitals, medications and rehabilitation. Cost statutes place maximum limits on the benefits.
Medically Necessary
Health care services and supplies deemed medically appropriate, cost efficient, consistent with the diagnosis, non-experimental, and required for reasons other than comfort or convenience. This term, when used in a plan document, refers only to coverage, and may not necessarily be the same definition used by Medical Personnel.
Medicare
A government subsidized and operated medical plan for people who are aged 65 and older; those who are totally disabled or suffering from renal failure are also eligible for Medicare. In addition to being eligible for Medicare, many employees 65 or older have the option of continuing with their group health benefit plan, regardless of whether they are actively employed. When this occurs, benefits must be coordinated to ensure that the individual is not reimbursed for more than 100 percent of medical and dental expenses.
Medicare is divided into two parts, Part A and Part B. FICA funds Medicare Part A by taking deductions from employees' paychecks. Part A is free to people age 65 and older who have contributed to FICA and who have applied for Medicare within the prescribed time frame. Medicare Part B is not free but may be purchased by any U.S. citizen age 65 and older.
Medicare Assignment
Providers may either accept or decline Medicare benefit assignment.
Providers who accept Medicare benefit assignment do so knowing that, by law, they cannot charge the patient any more than the Medicare-approved amount - an amount usually less than the regular charge. The advantage of a provider accepting Medicare assignment is that she receives payment directly from Medicare.
Providers who do not accept Medicare benefit assignment do not have to charge the Medicare-approved amount. Instead, these providers may charge a certain percentage over the Medicare amount. Doing so is referred to as "limiting charges." However, by limiting charges, providers will not receive a check from Medicare, but instead, the check will go directly to the patient. The provider then bills the patient for the service. The advantage to a provider in not accepting Medicare assignment is they do not have to lower their fees to the same extent.
The Medicare EOB (EOMB) indicates whether the provider accepts assignment.
Medicare Beneficiary
Anyone entitled to Medicare benefits based on designation by the Social Security Administration.
Medicare Benefit Exclusions
Any items not covered by Medicare Part A or B. These include:
- Additional charge for private room (unless medically necessary)
- Custodial care - eye exams (except when performed for a medical condition) and glasses
- First three pints of blood
- Foot care and orthopedic shoes
- Hearing aids
- Most drugs taken at home
- Most immunizations
- Normal dental work and dentures
- Personal comfort items
- Private nurse
- Routine physical exams
- Services covered by Workers Compensation
- Services outside the United States (with some exceptions for Canada )
Medicare Carriers
Private insurance companies that contract with the federal government to process Medicare claims and make payments for services and supplies covered by Medicare Part B. Doctors are required by law to send claims to the carrier for the area where the service was provided. Medicare carriers can answer questions about Medicare coverage and Medicare Part B claims.
Medicare Intermediaries/Carriers
Part A Medicare claims are filed automatically with an intermediary who has a contract with the Federal Government to adjudicate Part A claims. Carriers are private insurance companies that contract with the Federal Government to process Medicare B claims.
Medicare Part A
Deductible:
Deductible may change annually or remain the same.
Duration:
90 days for each benefit period plus a lifetime reserve of 60 days (to be used only once).
Benefit Period:
Begins the first day of hospitalization or admission to an extended care facility and ends when the patient has been out of a hospital or Skilled Nursing Facility for 60 consecutive days.
Lifetime Reserve:
60 days, not renewable. During this time, the patient must pay a set amount. Medicare will then pay the remainder.
Psychiatric Limitations:
190 days per lifetime with possible other limitations.
Benefits Provided:
Semi-private room and board
Operating and recovery rooms
Drugs and biologicals
Lab tests
Radiology and pathology services
Medical supplies Appliances and supplies
Blood, after first three pints
Speech and physical therapy - Private room, if necessary
End-stage kidney disease service
Post-hospital care up to 100 days
Medicare Part B
Deductible:
Deductible may change annually or remain the same.
Coinsurance:
80 percent
Benefits Provided:
Physician and surgeon
Dental surgery or oral surgeon treatment for fractured jaw
Unlimited home health care services
Doctor's office services:
Ambulance
Blood transfusions (after first 3 pints)
Certain dentist's services
Certain inpatient services
Certain optometrists' services
Chiropractic manipulations (if medically prescribed)
Diagnostic x-ray and lab, surgical dressings, etc. *
Home dialysis supplies, etc.
Medical equipment
Out of hospital treatment for mental disorder
Outpatient hospital, diagnostic and treatment services
Outpatient physical therapy, up to $500/year
Outpatient speech therapy
Outpatient surgery
Outpatient therapy
Oxygen therapy
Prosthetic devices - braces, artificial legs, etc.
Medicare+Choice - Part C
Must at least cover items and services normally covered under the Medicare fee-for-service, and may offer supplemental health care benefits that HCFA approves and the beneficiary has the option to purchase.
Medicare Supplement Insurance
Insurance coverage sold on an individual or group basis that helps fill gaps in the protection provided by the Medicare program. Medicare supplements cannot duplicate any benefits provided by Medicare, but may pay part or all of Medicare's deductibles and co-payments, and may cover some services and expenses not covered by Medicare.
Medigap Insurance
Policies sold by private insurance companies designed to help pay health care expenses either not covered or not fully covered by Medicare.
Member
Any person covered on the health benefit plan. This includes the dependents, spouse and enrollee.
Mental Health Provider
A psychiatrist, licensed consulting psychologist, social worker, hospital or other facility duly licensed and qualified to provide mental health services under the law of the jurisdiction in which treatment is received. Some plans do not recognize a social worker as covered for mental health benefits.
Modifier
A two digit numeric code or two character alphabetic code used after a standard CPT code or HCPCS code that indicates additional information about the procedure.
Modified No Fault Insurance
Under modified no-fault insurance, the right to commence a lawsuit is restricted, but not eliminated. Actions can be maintained if the claim exceeds either the "monetary" or "verbal" threshold. Monetary thresholds are usually expressed as dollars of medical costs, while verbal thresholds may be expressed as definitions, describing the seriousness of injuries. All claims falling below the threshold are paid under the injured person's automobile insurance policy. Only states with the restriction on the right to sue are strict no-fault states.
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Narcotics
Originally, narcotics were agents that caused drowsiness or induced sleep; now, narcotics are regarded as any derivative, natural or synthetic, of opium or morphine or any substance that has their effects. Narcotics have potent analgesic effects associated with significant changes in mood and behavior, and with the potential for dependence and tolerance following repeated administration.
Negotiated Fees (also known as PPO allowances)
Managed care plans and physicians mutually agree on a set fee for each service. This negotiated rate is usually based on services defined by the CPT codes, generally at a discount from the provider's usual charge.
No-Fault Insurance
A type of auto insurance that insures injured auto accident victims. With no-fault insurance, each party involved in the auto accident files the injury claim with his own auto insurance carrier. The party who was at fault cannot be sued for injuring the other party unless certain monetary thresholds are met or exceeded.
Non-Compliance Penalty
A reduction in benefits due to a patient's negligence to comply with procedures required by the utilization review organization with which the patient's employer has contracted. The following instances result in a non-compliance penalty:
- The employee did not call the utilization review organization to notify or seek approval for an emergency or elective hospital admission or certain outpatient procedures at all.
- The employee did not call the utilization review organization to notify or seek approval for an emergency or elective hospital admission or certain outpatient procedures within the time frame specified in the plan.
- The employee did not obtain a second surgical opinion when one was required by the utilization review organization.
Non-Participating Provider (non-par or non-ppo)
A health care provider who has not contracted with the carrier or health plan to be a participating health care provider. A non-par provider can bill the patient up to the limit typically agreed to by participating providers. Also known as out-of-network providers.
Non-Retained
Flex contribution dollars and/or expense amounts manually entered for each contribution or expense cycle (expenses change per contribution/expense cycle).
NYHCRA
The New York Health Care Reform Act. This legislation deregulates hospital pricing and replaces it with open market negotiations between purchasers and hospital services providers. In addition, NYHCRA imposes new surcharges and assessments on a variety of health care provider services. The surcharges and assessments collected are used to continue the financing of bad debt, graduate medical education (GME) and other health care initiatives.
Beginning in January 1997, a surcharge was assessed to all inpatient, outpatient and emergency hospital services, diagnostic treatment centers providing comprehensive primary health services or ambulatory surgical services, and free-standing clinical laboratories.
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Occurrence
An event that results in a loss covered by the benefit plan.
Office Visit
A physician or nursing service provided in an office or clinic setting.
Open Enrollment
A period of time in which eligible members may elect to enroll in or transfer between health care plans.
Other Plan Provisions Section
This section of a plan document includes, but is not limited to, the following:
- Assignment of benefits
- Acts of third parties
- Recovery of excess payments
- Right to receive and release information
Out-of-Area (OOA)
Coverage for treatment obtained by a covered person temporarily outside the network services area.
Out-of-Network (OON)
Coverage for treatment obtained from a non-participating provider. Typically, it requires payment of a deductible and higher co-payments and co-insurance than for treatment from a participating provider.
Out-of-Pocket
The amount enrollees or patients have paid from their own pocket for a specified period. A plan may have an Out-of-Pocket maximum. When that maximum has been met, the plan must pay benefits at 100 percent.
Outpatient
When a patient visits a provider and the visit is less than 24 hours, the services he receives during that time are generally considered outpatient services.
Over the Counter Drugs (OTC)
A drug product available without a prescription under federal or state law.
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Participants
Covered employees and their dependents. The plan document's (link to plan document section) eligibility and participation section describes who is eligible to participate, how to enroll in the plan, when coverage begins and ends, and circumstances under which coverage may be extended.
Participating Provider
A provider who has contracted with a health plan to provide medical services to members. The provider may be a hospital, pharmacy, other facility or a physician who has contractually accepted the terms and conditions set forth by the health plan.
Patient-Controlled Analgesia (PCA)
Patient directed pain control through computer-controlled pumps. The pump is attached to an intravenous line on the patient's arm. When the patient is in pain, he pushes a button that releases a dose of pain medication.
Peer Review Organizations (PROs)
Groups of practicing doctors and other health care professionals paid by the federal government to monitor the quality of care provided to Medicare patients.
Pend
A process on the Fiserv Health - Kansas system that allows you to send a letter requesting additional information on a claim, keeping the claim open until the information is received. Pending a claim does not update accumulation history or allow a check to be sent.
Per Cause Benefit
A benefit that accumulates claim charges relating to the same problem or cause. Usually these benefits have a specific maximum that limits the amount we can pay.
Per Cause Deductible
An amount that must be paid each time a specific condition occurs.
Per Cause Maximum
The maximum benefit that will be paid on expenses incurred relating to the same problem or cause. For example, an accident benefit may have a per-cause maximum.
Per Diem
An all-inclusive per-day rate for a specific service or bed type. Per diem rates usually are negotiated with hospitals for inpatient services or with ancillary providers for per-day services.
Performance Guarantee
An agreement between the client and Fiserv Health - Kansas to administer benefits within a specified number of days at or above a specific quality standard.
Pharmacy Benefit Manager (PBM)
Entities that administers a managed pharmacy program. Pharmacy programs provide prescription drug identification cards which are presented to a participating pharmacy.
Physician
Any doctor of medicine (M.D.) or doctor of osteopathy (D.O.) who is duly licensed and qualified under the law of the jurisdiction in which treatment is received.
Physician's Desk Reference (PDR)
A reference book published annually by the Medical Economics Company, Inc. This book contains detailed information on pharmaceutical products and their uses.
PIP
Personal Injury Protection. A term frequently used in relation to no-fault insurance to describe no-fault benefits for medical treatment received as a result of an automobile accident.
Place of Service
A code that is used while processing a claim on the Fiserv Health - Kansas system that indicates where the service was performed.
Plan
Defines a set of benefits given to each member covered under the group.
Plan Document
A legal contract that contains detailed information about the benefits provided by the plan. Each plan document is unique in terms of the specific services covered or excluded, or the rates at which benefits are provided for those services. Plan documents (link to plan documents section) throughout the health care industry contain similar information. Standard plan documents include, but are not limited to:
- Introduction
- Eligibility and Participation
- Health Care Management Program
- Preferred Provider Organization (PPO)
- Medical Benefits
- Coordination of Benefits
- Other Important Plan Provisions
- Continuation of Coverage
- Schedule of Benefits
These sections will include the following:
- The employer's name
- The effective date of the plan
- The dates of the benefit and plan years
- Who is eligible
- Who pays for the benefits
- Enrollment requirements
- When coverage begins, ends or may be extended
- The review organization with whom the plan contracted (if any) and an explanation of the review procedure(s)
- Deductibles, maximums, co-payments and coinsurance
- Services covered/not covered by the plan and at what rate the benefits are provided for the covered services
- Calculation used to coordinate benefits
- Basic conditions that charges must meet to be considered for reimbursement/payment (for services deemed medically necessary, and equal to or less than the U&C fee)
- How to file a claim
- Terms used in the plan document
- ERISA rights
Plan Limitations
Plan limitations are similar to day maximums except that they do not limit the number of services or visits for which the plan will provide benefits. Plan limitations limit the circumstances under which the plan will provide benefits. For example, a plan may choose to cover cosmetic surgery only after a disfiguring accident. Plan limitations are generally included in the explanations of covered expenses in the Medical Benefits section of a plan document (link to plan document section).
Plan Participant
The enrollee or employee of the group plan.
Plan Year
The 12-month fiscal period in which financial records are kept. The plan year may be, but is not required to be, the same 12-month period as the benefit year.
Pledge
The total amount of pre-tax dollars the participant sets aside by flex type for a plan or calendar year. Flex participants may submit expense claims for reimbursement based on the dollars contributed.
Policy
The legal document issued by the insurance company to the policyholder, which outlines the insurance's conditions and terms. Also called the policy contract.
Policy Term
The period of time for which an insurance policy provides coverage.
Pre-Admission Certification
The process by which a health care professional evaluates an attending physician's request for a patient's admission to a hospital to determine if inpatient care is necessary.
Pre-certification
The process of notifying and obtaining approval from a hospital's admission area or the identified outpatient service before the service is rendered. The service will be certified as appropriate for reimbursement by the plan. Most plans require pre-certification to prevent a reduction in benefits.
Pre-determination
To determine the amount the plan will reimburse for a service, a covered employee may choose to submit a claim before he actually receives the service. Such claims are called pre-determination claims because no benefits will be paid. Pre-determination claims lack dates of service, otherwise they appear the same as regular claims.
Pre-existing Conditions
A medical condition that existed prior to an enrollee or member's effective date. If a plan has a pre-existing condition clause, benefits may be denied or reduced for all services related to the medical condition for a specified period of time.
Preferred Provider Organization (PPO)
A network of physicians and facilities with which an organization has contracted to offer medical care at reduced rates.
Prescription Drug/Prescription Medication
A Food and Drug Administration-approved drug or medicine which, under federal law, is required to bear the legend: "Caution: federal law prohibits dispensing without prescription." These include injectable insulin; hypodermic needles or syringes, but only when dispensed upon a written prescription of a licensed physician. Such drugs are medically necessary in the treatment of a sickness or injury.
Prescription Drug Card Plan
A member in the card program presents a prescription to a participating pharmacy. By using an on-line computer network the pharmacist can confirm the member's eligibility and benefits available. The member typically pays a fixed co-payment for brand name or generic drugs. The plans also typically contain a Mail Order program for routine, maintenance drugs.
Preventive Care
Comprehensive care emphasizing priorities for prevention, early detection and early treatment of conditions, generally including routine physical examination, immunization and well-person care.
Primary Care
Basic or general health care traditionally provided by family practice, pediatrics and internal medicine practitioners. See secondary care and tertiary care.
Primary Care Physician (PCP)
A "generalist" physician, such as a family practitioner or pediatrician, who supervises, coordinates and provides medical care to plan members. The PCP is responsible for referrals, procedures and hospitalization. In some HMO plans, a PCP is assigned or chosen by a member, who then must utilize this PCP for all medical care unless a referral is received.
Primary versus Secondary Payer
To coordinate benefits accurately, Claims Analysts must determine which coverage is primary (pays first) and which coverage is secondary (pays last).
Determining primary coverage for the covered employee and spouse is relatively easy. Generally, our client's plans are primary for their covered employees. If the employee's spouse has separate coverage, the spouse's coverage is usually primary when the claim is for expenses incurred by the spouse. In that case, our client's plan would be secondary coverage.
For primary carrier for children, refer to the birthday rule.
Prior Authorization
Authorization which may be required by members for scheduling outpatient services and for elective inpatient hospital admissions. The objective is to provide an opportunity for evaluation of the medical services to make a determination of medical necessity.
Prior Notification
The practice of a patient notifying the plan's review organization of medical services (specified in the plan); unlike pre-certification, no approval is necessary. For non-emergency services, the patient must call before receiving those services; for emergency services the patient must call after receiving those services. The patient's plan will specify the time frame within which the patient must call.
Procedure Code
Also referred to as CPT code. Indicates what procedure was performed.
Protected Health Information (PHI)
Any Individually identifiable health information related to physical or mental health that is generated by an individual seeking healthcare services. This information, created or received by a health plan or health care provider can be in electronic, oral or written format.
Professional Component
This component of global services represents the value of the physician's services. It encompasses examination of the patient; when indicated, the performance and/or supervision of the procedure; the procedure's interpretation and written report; and when appropriate, consultation with referring physicians.
Professional Consultation Services via Telecommunications
The use of audio visual communications equipment to permit real time communications among the patient, the presenting practitioner and the consultant for clinical assessment by the consultant.
Proposal
An act of putting forward or stating something for consideration. At Fiserv Health - Kansas, it is a document that indicates suggested benefits and services Fiserv Health - Kansas will administer for the potential client. The proposal will include the costs of such benefits and services.
Provider Identification Number
A number that identifies a provider in the claims system. This number can be a Social Security number or a Tax ID number assigned by the Federal Government. The Federal Government uses this number for tax purposes. See also Tax Identification Number.
Provider (Provider of Service)
A person or facility that renders medical, dental, mental/nervous or substance abuse services to an individual. Generally a client's plan specifies certain types of providers whose services are not covered or specifies requirements to which a provider must adhere in order for that provider's services to be covered.
Provisions
Services, benefits or expenses covered or provided by the plan.
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Qualifying Circumstances
Anesthesia services may be provided under particularly difficult circumstances, depending on the patient's condition or unusual risk factors. These circumstances are billed as separate anesthesia procedures or service.
Qualifying Event
Conditions that require an employer to provide continued coverage. The length of time employers must offer continued coverage is determined by the qualifying event. Qualifying events and the length of time coverage can be continued for each reason are listed below:
Death of covered employee (coverage for dependents)
36 months
Termination of employment or reduction in hours
18 months
Divorce or legal separation from covered employee
36 months
Employee becomes eligible for Medicare (coverage for dependents)
36 months
Dependent no longer meets eligibility requirements
36 months
Employer files for Chapter 11 bankruptcy petition*
Surviving spouses and dependent children of retirees who die after the bankruptcy filing may elect up to 36 months of continuation coverage.
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Reasonable and Customary Charge
A charge for health care which is consistent with the prevailing rate or charge in a certain geographical area for identical or similar services.
Reasonable and Customary Fees (also known as Usual and Customary)
The average fee charged by a particular type of health care practitioner within a geographic area. The term is often used by medical plans as the amount of money they will approve for a specific test or procedure. If the fees are higher than the approved amount, the individual receiving the service is responsible for paying the difference. Sometimes, however, if an individual questions his or her physician about the fee, the provider will reduce the charge to the amount that the insurance company has defined as reasonable and customary.
Reciprocity
Allows a PPO member to use an affiliated PPO's network while out of their service area and receive in-network benefits.
Regional Anesthesia
Nerve or field-blocking anesthesia that produces insensibility over an area larger than that produced by local anesthesia.
Registered Nurse (RN)
A licensed professional with a four-year nursing degree able to provide all levels of nursing care, including the administration of medication.
Reimbursement
Payment of expenses actually incurred as a loss covered by the policy.
Reinsurance
Insurance coverage taken out by a health plan or self-funded employer to provide protection from losses resulting from claims greater than a specific dollar amount per member per year or for a total plan expenditures per year.
Relative Value Scale (RVS)
A chart containing the unit values for selected codes. Charts are specific to the geographic location. These unit values are used in conjunction with conversion factors for calculating benefits on PPO claims. Such groups as HIAA, McGraw Hill, and California Relative Value Studies produce relative value scales.
Renewal
A continuance of insurance under a policy beyond its original term by the insurer's acceptance of the premium for a new policy term.
Repriced Claim
The amount the PPO contract allows for a service.
Resource Based Relative Value Scale (RBRVS)
This classification system is used to determine how physicians will be compensated for services provided under Medicare benefits.
Retained Contribution
Flex contribution dollars and/or expense amounts maintained by the Fiserv Health - Kansas system because they are the same amounts for every contribution or expense cycle. (The expense stays the same.)
Revenue Code
Standard codes used by hospitals to categorize and bill services rendered. They are found on UB-92 bills.
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Schedule
Shows the specific dollar amount to be paid or allowed for a specific service according to MDR tables. Also known as a fee schedule.
Schedule of Medical Benefits
All medical plans have this outline of the plan's benefits. This schedule provides information on covered benefits, benefit rates, deductibles and maximums.
Second Surgical Opinion (SSOP)
Some health care management programs require patients to seek a second surgical opinion about the necessity of the surgery. Some plans may always require a second surgical opinion; others may only require one for certain types of surgery.
Secondary Care
Services provided by medical specialists such as cardiologists, urologists and dermatologists, who generally do not have first contact with patients.
Secondary Procedure
Also referred to as "add-on" codes, these procedures are usually not billed alone. They are generally performed at the same session or on the same day as the primary procedure. The secondary procedures are not included in the primary procedure, but are commonly related to or similar to the primary procedure. They may have distinct ICD-9 codes.
Section 125 Plan
A term used to refer to flexible benefit plans. The reference comes from the section of the IRS code which defines such plans and stipulates that employee contributions to such plans may be made with pre-tax dollars.
Self-Funding
A type of health benefit plan where contributions made by the employer and employees are put into an account. When a health benefit plan member incurs medical expenses, this account is used to pay for those medical expenses. The group creates self-funded plans, and these plans may offer any combination of benefits to their employees.
Skilled Nursing Facility (SNF)
Offers specialized attention to patients who have long-term illnesses, such as cancer. At skilled nursing facilities, RNs are on duty at all times to provide the extra attention these patients require. These nursing centers are similar to inpatient hospital facilities, except that patients require more attention and generally require a longer stay. A skilled nursing facility may be a stand-alone facility or part of a hospital.
Spinal Anesthesia
Anesthesia produced by an injection of an anesthetic solution into the spinal cord.
Standard COB
In general, a type of COB (link to coordination of benefits definition) where the secondary carrier pays what the primary carrier did not pay, up to 100 percent of the eligible charge.
State Insurance Counseling and Assistance Program
These offices provide general information about Medicare, Medicaid, managed care plans, and the various Medicare supplement programs, including Medigap and long-term care insurance.
Stop Loss Insurance
Insurance coverage taken out by a health plan or self-funded employer to provide protection from losses resulting from claims greater than a specific dollar amount per member per year or for a total plan expenditures per year.
Subrogation
A procedure where an insurance company or third-party administrator recovers money from a third party when a medical expense was another person's fault. Examples may be an auto accident injury or an accident on public property for which a lawsuit has been filed.
Supplemental Accident Benefit
A benefit that is paid at a higher percentage (usually 100 percent) up to a specified maximum amount for covered expenses related to an accidental injury.
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Tax Identification Number (TIN)
The nine-digit number assigned to a corporation or partnership by the IRS for income reporting purposes. The digit format is 00-0000000. Much like a Social Security number, it is used to report business income.
Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA)
This act defines the Medicare program's primary and secondary coverage responsibilities, and the provisions for use by health plans in their contracts with the HCFA (Health Care Financing Administration).
Technical Component
The portion of a radiology charge that covers equipment expense. This component includes charges for personnel supervision, materials, film, space, specialized technical equipment and other facility charges.
Telemedicine
The use of medical information exchanged from one site to another via electronic communications for providing patients with health care services.
Termination
The date on which a plan participant's coverage or employment ends. Termination of coverage can occur for several reasons:
- The employee elected to discontinue coverage
- Termination of employment
- The employee's hours were reduced causing ineligibility
- There was a divorce from a covered spouse
- A dependent child was married, reached an ineligible age or otherwise lost eligibility
- The covered person failed to pay the premium
- The plan/employer terminates the administration agreement
Coverage may terminate the day employment terminates or at the end of the month in which employment terminates, depending upon the plan.
Tertiary Care
Those health care services provided by highly specialized providers such as neurosurgeons, thoracic surgeons and intensive care units. These services often require highly sophisticated technologies and facilities.
Third Party Administrator
A third-party administrator, or TPA, is an independent organization that provides administrative services including claims processing, customer service, eligibility services, utilization review, PPO network management, and underwriting for other entities, such as insurance companies or employers. Self-insured employers will often contract with TPAs to handle their insurance claim functions. TPAs are organizations with the expertise and capability to handle all or a portion of the claims process. Some companies, such as insurance companies, hospitals or provider organizations may outsource only certain responsibilities to a TPA. TPAs are prominent players in the managed care industry.
Turnaround Time (TAT)
The measure of a process cycle from the date a transaction is received to the date completed. For claims processing, TAT is the number of calendar days from the date a claim is received until the date processing is finished or the claim is paid.
Turn Around Time Performance Guarantee
An agreement between the client and Fiserv Health - Kansas to administer benefits within a specified number of days and according to specified quality standards.
Twenty-four Hour Coverage
Protection provided for employees of a health plan who are not covered by a Worker's Compensation plan.
Type of Service
A code located on the HCFA form that indicates the type of service performed.
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UB 92
The current Uniform Billing form hospitals use.
Unbundling
Separately packaging costs or services that might otherwise be billed together. For claims processing, unbundling includes providers billing separately for health care services that should be combined according to industry standards or commonly accepted coding practices.
Upcoding
Use of a more complex CPT code to describe the medical service and fee than the service warrants.
Urgent Care
An alternative to hospital emergency department care for use in non-emergencies. Used when health conditions are urgent but not health or life threatening.
Usual and Customary (U&C, UCR, R&C and URC)
The amount charged by a percentile of physicians in a specified zip code area where a service is performed. The percentile of physicians on which the usual and customary charge is based will vary depending on the plan: the plan may select any percentile over 50 percent. Another term for this is Reasonable and Customary.
Utilization Management
The procedure or process that utilizes a review coordinator to evaluate the necessity and appropriateness of various health care services.
Utilization Review
The evaluation of medical necessity, appropriateness, and cost effectiveness of health care services, procedures and facilities. This may include pre-certification, pre-authorization, and concurrent and retrospective reviews. An outside company or the plan administrator may handle this review designed to help ensure that all covered persons receive necessary and appropriate health care, while avoiding unnecessary expenses for the plan sponsor.
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Workers' Compensation
The plan that covers employees in case of work-related injury or illness. All employers are required by law to provide employees with this coverage. If an employee is injured at work, Workers' Compensation, not the group health plan, pays expenses related to that injury. When a patient is eligible for Workers' Compensation, the group health plan does not provide benefits for expenses related to the injury or illness that made that patient eligible for Workers' Compensation.
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