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Allowable Charges: maximum fee that a third party will
reimburse a provider for a given service. An allowable charge may not be the same as either a reasonable
or customary charge.
Balance Billing: a provider's billing of a covered
person for charges above the amount reimbursed by the health plan (difference between billed charges
and the amount paid). This may or may not be appropriate, depending upon the contractual arrangements
between parties.
Board Certification: a credential granted to
a physician who has passes an examination given by a medical specialty board and who has been certified
as a specialist in that medical area.
Case Management: process whereby covered persons
with specific health care needs are identified and a plan designed to effectively utilize health care
resources is formulated and implemented to achieve the optimum patient outcomes in the most cost effective
manor.
Coinsurance: portion of covered health care
costs for which the covered person has a financial responsibility, usually according to a fixed percentage.
Often coinsurance applies after first meeting a deductible requirement.
Continuity of Care: the coordination of care
received by a patient over time and across multiple health-care providers.
Copay: cost-sharing arrangement in which the
insured person pays a specified share of the charge for a specific service, such as $10 for an office
visit. The covered person is usually responsible for payment at the time the health care is rendered.
In some instances, co-payments are two-tiered with a smaller payment due when utilizing services within
an approved network and a larger payment due for out-of-network.
Deductible: amount of eligible expense a covered
person must pay each year from his/her own pocket before the plan will make a payment for eligible expenses.
Fully Insured: a plan that is funded by an independent
insurance company, which assumes full responsibility for the medical expenses of its members.
Managed Care: system of health care delivery
that influences utilization and cost of services and measures performance. The goal is a system that
delivers value by giving the people access to high quality, cost- effective health care.
Medically Necessary: evaluation of health care
services to determine if they are medically appropriate and required to meet basic health needs. The
medical necessity must be consistent with the diagnosis of condition and rendered in a cost- effective
manner and consistent with national medical practice guidelines regarding type, frequency, and duration
of treatment
Non-Participating Provider: term used to describe
a provider that has not contracted with the carrier or health plan to be a participate provider of health
care
Participating Provider: provider who has contracted
with the health plan to deliver medical services to covered persons. The provider may be a hospital,
other facility or a physician who has contractually accepted the terms and conditions set forth by the
health plan.
Preferred Provider Organization (PPO): an organization
that contracts with select providers of medical care thereafter referring to as preferred providers.
Covered individuals are encouraged or required to utilize the preferred providers in order to gain better
benefits, higher levels of coverage or any coverage at all. PPO's seek to manage care to assure the
most efficient outcomes. Providers may be, but are not necessarily, paid on a discount fee-for-service
basis.
Primary Care: basic or general health care,
traditionally provided by family practice, pediatrics and internal medicine.
Self-Funded: where an employer funds the medical
plan directly by investing funds and assuming all or part of the employer's medical expenses.
Specialist: a physician that specialize in a
certain medical field, such as dermatology, orthopedics and cardiology
Utilization Management: process of integrating
review and case management of service in a cooperative effort with other parties, including patient,
employers, providers and payers.
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