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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.