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Partial Disability
A condition in which, as a result of injury or sickness, the insured cannot
perform all of the duties of his occupation but can perform some. Exact definitions
vary from policy to policy.
Partial Hospitalization Services
Additional services provided to mental health or substance abuse patients
which provides outpatient treatment as an alternative or follow-up to inpatient
treatment.
Participant
An employee or former employee who is eligible to receive benefits from an
employee benefit plan or whose beneficiaries may be eligible to receive benefits
from the plan.
Participating Provider
A health care provider approved by Medicare to participate in the program
and receive benefit payments directly from carriers or fiscal intermediaries.
Peer Review
Review of health care provided by a medical staff with training equal to the
staff which provided the treatment.
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.
Percentage Participation
A provision in a Health Insurance contract which states that the insurer will
share losses in an agreed proportion with the insured. An example would be
an 80-20 participation where the insurer pays 80% and the insured pays the
20% of losses covered under the contract. Often erroneously referred to as
coinsurance.
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.
Place of Service
This designates where the actual health services are being performed, whether
it be home, hospital, office, clinic, etc.
Point-of-Service
(POS) Plan
A type of managed care plan combining features of health maintenance organizations
(HMOs) and preferred provider organizations (PPOs). You can decide whether
to go to a network provider and pay a flat dollar or to an out-of-network
provider and pay a deductible and/or a coinsurance charge.
Policy Term
The period for which an insurance policy provides coverage.
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.
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.
Pre-Admission Certification
Before being admitted as an inpatient in a hospital, certain criteria are
used to determine whether the inpatient care is necessary.
Preauthorization
Previous approval for specialist referral or non emergency health care services.
Pre-existing
Condition Pre-existing
Condition exclusion Premium
Preventive Care Primary Care Primary
Care Physician Primary Coverage Prior Authorization
Probationary Period
Professional Review
Organization Proration of Benefits
Prospective Payment
System Prospective Reimbursement
Provider
Qualified Medicare
Beneficiary (QMB) Qualifying Event Rating Process Reasonable and Customary
Charges Recipient Recurring Clause Referral Registered Nurse (RN)
Rehabilitation Clause
Reinstatement Relative Value Schedule
Relative Value Unit
Renewal Resource-based relative
value scale (RBRVS) Respite Care Restoration of Benefits
Retention Retrospective Rate
Derivation (RETRO) Return of Premium Risk Analysis
A health problem that existed or was treated before the effective date of your health insurance coverage. Most health insurance contracts have a pre-existing condition clause that describes conditions under which the health insurance company will cover medical expenses related to a pre-existing condition. For more information, see also,
Pre-existing Condition Exclusion.
-see Pre-existing Condition. In some cases, a health insurance company may exclude a patient’s pre-existing conditions from coverage under a new health insurance plan. This is more typical with individual and family health insurance plans and less common with group health insurance plans. HIPAA legislation imposes certain limitations on when a health insurance company can exclude coverage for a pre-existing condition.
PPO (Preferred Provider Organization)
A network of health care providers that have agreed to provide medical services
to a health plan's members at discounted costs. PPO members typically make
their own decisions about their health care rather than going through a primary
care physician like HMO member. The cost to use physicians within the PPO
network is less than using a non-network provider.
The amount you pay in exchange for health insurance coverage.
Prescription Medication
A drug which can be dispensed only by prescription and which has been approved
by the Food and Drug Administration.
This type of care is best exemplified by routine physical examinations and
immunizations. The emphasis is on preventing illnesses before they occur.
Basic health care provided by doctors who are in the practice of family care,
pediatrics, and internal medicine.
Under a health maintenance organization (HMO) or point-of-service (POS) plan,
a primary care physician is usually the first contact for health care. This
is often a family physician, internist, or pediatrician. A primary care physician
makes referrals to specialists if necessary.
This is the coverage which pays expenses first, without consideration whether
or not there is any other coverage. See also Coordination of Benefits.
A cost containment measure which provides full payment of health benefits
only when the hospitalization or medical treatment has been approved in advance.
A period of time between the effective date of a Health Insurance policy,
and the date coverage begins for all or certain physical conditions.
An organization of physicians which reviews services to determine if they
are medically necessary.
The adjustment of Health Insurance policy benefits by reason of the existence
of other insurance covering the same contingency.
A system of Medicare reimbursement for Part A benefits which bases most hospital
payments on the patient's diagnosis at the time of hospital admission.
A system where hospitals or other health care providers are paid annually
according to rate of payment which have been established ahead of time.
Any person (doctor or nurse) or institution (hospital, clinic, or laboratory)
that provides medical care.
This is a person whose income is below the federal poverty guidelines. In
these cases, the state is required to pay the Medicare Part B premiums, plus
any deductibles or copayments.
An occurrence (such as death, termination of employment, divorce, etc.) that
triggers an insured's protection under COBRA, which requires continuation
of benefits under a group insurance plan for former employees and their families
who would otherwise lose health care coverage.
Rapid Approval
Participating health insurance companies working exclusively with eHealthInsurance
Services, Inc. to provide instant, preliminary approval to individuals that
meet certain eligibility requirements. Individuals who have non-conforming
applications or applications that do not require additional medical information
will receive preliminary approval within 24 hours.
The steps used to determine a premium rate for a particular group based on
the amount of risk that group presents. Items that generally go into the rating
process include age, sex, type of industry, benefits, and administrative costs.
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.
Anyone designated by Medicaid as being eligible to receive Medicaid benefits.
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.
A formal process that authorizes an HMO member to get care from a specialist
or hospital. Most HMOs require patients to get a referral from their primary
care doctor before seeing a specialist.
A licensed professional with a four-year nursing degree. Able to provide all
levels of nursing care including the administration of medication.
A clause in a Health Insurance policy, particularly a Disability Income policy,
that is intended to assist the disabled policyholder in vocational rehabilitation.
Resumption of coverage under a policy that had lapsed.
A surgical schedule which basically compares the value of one surgical procedure
to another and establishes the surgical fee to be paid.
Sometimes used instead of dollar amounts in a surgical schedule, this number
is multiplied by a conversion factor to arrive at the surgical benefit to
be paid.
Continuance of coverage beyond original terms signified by acceptance of a
premium payment for a new term.
A scale of national uniform relative values for all physicians' services.
The relative value of each service must be the sum of relative value units
representing physician work, practice expenses net of malpractice expenses,
and the cost of professional liability insurance.
Normally associated with Hospice care, respite care is a benefit to family
members of a patient whereby the family is provided with a break or respite
from caring for the patient. The patient is confined to a nursing home for
needed care for a short period of time.
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.
The portion of the premium which is used by the insurance company for administrative
costs.
A rating system whereby the employer becomes responsible for a portion of
the group's health care costs. If health care costs are less than the portion
the employer agrees to assume, the insurance company may be required to refund
a portion of the premium.
A rider or provision in a Health Insurance policy agreeing to pay a benefit
equal to the sum of all the premiums paid, minus claims paid, if claims over
a stated period of time do not exceed a fixed percentage of the premiums paid.
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Rider
A document that modifies or amends an insurance contract
The process of determining what benefits to offer and premium to charge a
particular group.