HEALTHCARE PLAN GLOSSARY
APPEALS CONSIDERATION: Clinical review conducted by appropriate independent clinical peers, when a decision not to certify a requested admission, procedure, or service has been appealed. Sometimes referred to as “third level review.”
ATTENDING PHYSICIAN: The doctor of medicine or doctor of osteopathic medicine with primary responsibility for the care provided to a patient in a hospital or other health care facility.
BIRTHDAY RULE: A plan provision in which the plan of the parent with the earliest birth month and day provides primary benefits; under “fall-back”, if one plan has a “gender rule” provision, the plan with the parent that is male is primary.
BOARD-CERTIFIED: A label that indicates a physician has passed an examination given by a medical specialty board and has met other eligibility requirements that certify the physician as a specialist in that area.
CASE MANAGEMENT: A collaborative process which accesses, plans, implements, coordinates, monitors, and evaluates options and services to meet an individual’s health needs using communication and available resources to promote quality cost-effective outcomes.
CERTIFICATION: A determination by a Utilization Management Organization that an admission, extension of stay, or other health care service has been reviewed and, based on the information provided, meets the clinical requirements for medical necessity, appropriateness, level of care, or effectiveness under the auspices of the applicable health benefit plan.
COINSURANCE: The benefit percentage of covered expenses payable by the Plan for benefits that are provided under the Plan. The coinsurance a percentage is applied to covered expenses after the deductible(s) have been met, if applicable.
CLAIMS ADMINISTRATOR : Any entity that recommends or determines to pay claims to enrollees, physicians, hospitals, or others on behalf of the health benefit plan. Such payment determinations are made on the basis of contract provisions. Claims administrators may be insurance companies, self-insured employers, third party administrators, or other private contractors.
CLINICAL PEER: A physician or other health professional who holds an unrestricted license and is in the same or similar specialty as typically manages the medical condition, procedures, or treatment under review. Generally, as a peer in a similar specialty, the individual must be in the same profession, i.e., and the same licensure category as the ordering provider.
CLINICAL RATIONALE: A statement which provides additional clarification of the clinical basis for a non-certification determination. The clinical rationale should relate the non-certification determination to the patient’s condition or treatment plan, and should supply a sufficient basis for a decision to pursue an appeal.
CLINICAL REVIEW CRITERIA: The written screens, decision rules, medical protocols, or guidelines used by the Utilization Management Organization as an element in the evaluation of medical necessity and appropriateness of requested admissions, procedures, and services under the auspices of the applicable health benefit plan.
CONCURRENT REVIEW: Utilization management conducted during a patient’s hospital stay or course of treatment sometimes called “continued stay review.”
COPAY: A dollar amount which is applied per service rendered, i.e., per office visit, per confinement, per emergency room visit.
COSMETIC SURGERY: Surgery for the restoration, or reconstruction of body structures directed toward altering appearance.
COVERED EXPENSES: Medically necessary services, supplies or treatments that are recommended or provided by a physician, professional provider or covered facility for the treatment of an illness or injury and that are not specifically excluded from coverage herein. Covered expenses shall include specified preventive care services.
CREDITABLE COVERAGE: Creditable coverage generally includes period of coverage under an individual or group health plan not followed by a break in coverage of 63 days. Creditable coverage excludes liability, limited scope dental, vision, specified disease or other supplemental-type benefits.
DEDUCTIBLE: A fixed amount of health care dollars, which an individual must pay before health benefits begin.
DISCHARGE PLANNING: The process that assesses a patient’s needs in order to help arrange for the necessary services and resources to effect an appropriate and timely discharge.
EMERGENCY: The sudden onset of an illness or injury where the symptoms are of such severity that the absence of immediate medical attention could reasonably result in:
EXPEDITED APPEAL: A request by telephone for additional review of a determination not to certify imminent or ongoing services requiring a review conducted by a clinical peer who was not involved in the original decision not to certify.
FACILITY RENDERING SERVICE: The institution or organization in which the requested admission, procedure, or service is provided. Such facilities may include, but are not limited to: hospitals; outpatient surgical facilities; individual practitioner offices; rehabilitation centers; residential treatment centers; skilled nursing facilities; laboratories; and imaging centers.
FAMILY DEDUCTIBLE: Plans may also provide for a family deductible on a yearly basis. This type of provision may require individual family members to satisfy a deductible or the family, as a group, to satisfy a total amount. (E.g. upon satisfaction of deductibles by three family members in the same calendar year, no further deductibles are required in that calendar year.) The carry over provision rarely applies to the family deductible.
FULL-TIME STUDENT OR FULL-TIME STUDENT STATUS: An employee’s dependent child who is enrolled in and regularly attending secondary school, an accredited college, university, or institution of higher learning for the minimum number of credit hours required by that institution in order to maintain full-time student status.
GENDER RULE: COB provision for determining primary status; in Gender Rule, the male’s plan pays primary benefits on the eligible dependent before a female’s plan; under “fallback”, if either plan has a Gender Rule provision, the Gender Rule takes precedence; Gender Rule is a Traditional COB provision.
ILLNESS: A bodily disorder, disease, or physical sickness. Pregnancy of a covered employee or their covered spouse shall be considered an illness.
INITIAL CLINICAL REVIEW: Clinical review conducted by appropriate licensed or certified health professionals. Initial clinical review staff may approve requests for admissions, procedures, and services that meet clinical review criteria, but must refer requests that do not meet clinical review criteria to peer clinical review for certification or non-certification. Sometimes referred to as “first level review.”
INJURY: A physical harm or disability, which is the result of a specific incident, caused by external means. The physical harm or disability must have occurred at an identifiable time and place. Injury does not include illness or infection of a cut or wound, or self-inflicted injury.
ORDERING PROVIDER: The physician or other provider who specifically prescribes the health care service being reviewed.
PATIENT: The enrollee or covered person who files or for whom a claim for benefits has been filed.
PEER CLINICAL REVIEW: Clinical review conducted by appropriate health professionals when a request for an admission, procedure, or service was not approved during initial clinical review. Sometimes referred to as “second level review.”
PHYSICIAN: A Doctor of Medicine (M.D.) or a Doctor of Osteopathy (D.O.) who is practicing within the scope of his license, other than a close relative of the covered person.
PREEXISTING CONDITIONS: An illness or injury, which existed within three (3) months before the covered person’s enrollment date of coverage under this Plan. An illness or injury is considered to have existed when the covered person:
PREFERRED PROVIDER: A physician, hospital or other health care facility who has an agreement in effect with the Preferred Provider organization at the time services are rendered. Preferred providers agree to accept the negotiated rate as payment in full.
PREFERRED PROVIDER ORGANIZATION: An organization who selects and contracts with certain hospitals, physicians, and other health care providers to provide covered persons services, supplies and treatment at a negotiated rate.
PRIMARY PLAN: the group plan that pays benefits first.
PRINCIPAL REASONS: A clinical or non-clinical statement describing the general reason(s) for the non-certification determination (“lack of medical necessity” is not sufficient to meet this).
PROSPECTIVE REVIEW: Utilization management conducted prior to a patient’s admission, stay, or other service or course of treatment, sometimes called “pre-certification review.”
PROVIDER: A licensed health care facility, program, agency, or health professional that delivers health care services.
REASONABLE AND CUSTOMARY AMOUNT: The fee assessed by a provider of service for services, supplies or treatment which shall not exceed the general level of charges made by others rendering or furnishing such services, supplies or treatment within the area where the charge is incurred and is comparable in severity and nature to the illness or injury. Due consideration shall be given to any medical complications or unusual circumstances which require additional time, skill or experience. The customary and reasonable amount is determined from a statistical review and analysis of the charges for a given procedure in a given area. The term “area” as it would apply to any particular service, supply or treatment means a county or such greater area as is necessary to obtain a representative cross-section of the level of charges.
RETROSPECTIVE REVIEW: Review conducted after services have been provided to the patient.
REVIEW OF SERVICE REQUEST: Review of information submitted to the Utilization Management Organization for health care services that do not need medical necessity certification nor result in a non-certification. decision.
SECOND OPINION: Requirement of some health plans to obtain an opinion about the medical necessity and appropriateness of specified proposed services by a practitioner other than the one originally making the recommendation.
SECONDARY PLAN: The group plan that pays benefits only after the primary plan has paid.
STANDARD APPEAL: A request to review a determination not to certify an admission, extension of stay, or other health care service conducted by a peer reviewer who was not involved in any previous non-certification pertaining top the same episode of care.
UTILIZATION MANAGEMENT (UM): Evaluation of the medical necessity, appropriateness, and efficiency of the use of health care services, procedures, and facilities under the auspices of the applicable health benefit plan; sometimes called “utilization review.”
