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 the parties.
a credential granted to a physician who has passed an examination given by a medical specialty board and who has been certified as a specialist in that medical area.
process whereby covered persons with specific health care needs are identified and a plan designed to efficiently utilize health care resources is formulated and implemented to achieve the optimum patient outcome in the most cost-effective manner.
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.
cost-sharing arrangement in which the insured person pays a specified share of the charge for a specified 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, copayments are two-tiered with a smaller payment due when utilizing services within an approved network and a larger payment due for out-of-network.
process of review to approve a provider who applies to participate in a health plan. Specific criteria and prerequisites are applied in determining initial and ongoing participation in the health plan.
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 benefits.
a plan that is funded by an independent insurance company, which assumes full responsibility for the medical expenses of its members.
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 people access to high quality, cost-effective health care.
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 or condition and rendered in a cost-effective manner and consistent with national medical practice guidelines regarding type, frequency and duration of treatment.
term used to describe a provider that has not contracted with the carrier or health plan to be a participating provider of health care.
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 as 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 managed care to assure the most efficient outcomes. Providers may be, but are not necessarily, paid on a discount fee-for-service basis.
basic or general health care, traditionally provided by family practice, pediatrics and internal medicine.
Provider Allowable Charges±:
maximum fee that a third party will reimburse a provider for a given service. An allowable charge may not be the same amount as either a reasonable or customary charge.
where an employer funds the medical plan directly by investing funds and assuming all or part of the employees’ medical expenses.
a physician that specializes in a certain medical field, such as dermatology, orthopedics and cardiology.
health care services provided by specialized providers, such as neurosurgeons, thoracic surgeons and intensive care units. These services often require highly sophisticated technologies and facilities.
process of integrating review and case management of services in a cooperative effort with other parties, including patients, employers, providers and payers.