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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.
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.
A health care provider approved by Medicare to participate in the program and receive benefit payments directly from carriers or fiscal intermediaries.
Review of health care provided by a medical staff with training equal to the staff which provided the treatment.
Peer Review Organization
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.
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.
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.
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.
The period for which an insurance policy provides coverage.
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.
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.
Before being admitted as an inpatient in a hospital, certain criteria are used to determine whether the inpatient care is necessary.
Previous approval for specialist referral or non emergency health care services.
Condition exclusion Premium
Preventive Care Primary Care Primary
Care Physician Primary Coverage Prior Authorization
Organization Proration of Benefits
System Prospective Reimbursement
Beneficiary (QMB) Qualifying Event Rating Process Reasonable and Customary
Charges Recipient Recurring Clause Referral Registered Nurse (RN)
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 patientís 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.
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.
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.
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. 3
A document that modifies or amends an insurance contract
The process of determining what benefits to offer and premium to charge a particular group.
Proration of Benefits
Reasonable and Customary
Registered Nurse (RN)
Relative Value Schedule
Relative Value Unit
value scale (RBRVS)
Restoration of Benefits
Return of Premium