| Word |
Definition |
| Benefits |
Amount of money payable by a health plan for the cost of covered services |
| Billed Charges |
A reimbursement arrangement whereby fees for healthcare services are based on what the provider usually charges all patients for the particular service. |
| Calendar Year |
The period of January 1 of any year through December 31 of the same year. |
| Case Management |
Manage the costs and quality of high cost services by monitoring and coordinating treatment for specific diagnoses |
| Certificate of Coverage (COC) |
A document provided to covered employees by the insurance carrier or managed care plan that outlines the benefits, covered services, and principal provisions of the group health plan provided under contract by the insurance carrier or managed care plan to the employer. |
| Clean Claim |
A medical claim that is submitted on a specified form by a certain date and contains necessary information as specified by the plan contract and generates no arguments or reasons for denial from the health plan. |
| Client Specific Contract |
A managed care contract which is secured as a result of a specific employer request. Occasionally, third party administrators or preferred provider organizations will market their services to employers, only to discover that the potential employer has objections to the TPAs existing medical network arrangements. As a condition of engaging the TPA to perform its functions, an employer, typically a large one, will insist that the TPA negotiate a contract with a medical network it deems appropriate for its employees. |
| Co-payment |
A cost sharing technique whereby a plan member or insured individual pays a specified amount of money directly to the provider out of his/her own pocket at the time services are rendered and the managed care plan or insurance carrier pays the remaining amount. |
| Covered Expenses |
Hospital, medical and miscellaneous healthcare expenses incurred by an insured person that entitles him/her to a payment of benefits under the terms of a health plan. |
| Covered Person |
A person who meets a health plan's eligibility requirements and for whom premium payments are paid for specified benefits of the contract between the insurance carrier and a contract holder. |
| Credentialing |
A process of checking a practitioner's references and documenting his/her credentials, including training, experience demonstrated ability, licensure verification, malpractice insurance, etc. Credentialing is carried out by both hospitals and managed care organizations to ensure that only qualified practitioners with current, demonstrated competence have practice privileges at the hospital or other type of health care facility, and that they practice within the range of their expertise and abilities. Often, managed care organizations defer to hospitals for credentialing of physicians and non-physician staff. Some plans, however, establish their own credentialing programs. Hospitals and managed care organizations both may be held liable for corporate negligence in their selection of practitioners who do not meet credentialing standards. TexNet credentials all its own physicians, hospitals and ancillaries. |
| Custodial Care |
Patient care that is not medically required but is necessary when the patient is unable to care for himself/herself. |
| Deductible |
The portion of health care expenses that a plan member or insured person must pay out of his/her own pocket before any insurance coverage applies or reimbursement of expenses begins. |
| Direct contract |
A managed care contract between TexNet and a specific employer, such as TISD or Wadley and a specific employer, such as Choctaw Electric Cooperative. |
| Drug Formulary |
A restricted list of prescription medications covered under a managed care plan, which are approved for use for specific treatments and dispensed through participating pharmacies to plan members. |
| Enrollee |
An individual who subscribes to or enrolls in a managed care plan on his/her own behalf (not a dependent) to receive health services under that plan. |
| Exclusions |
Specific conditions or circumstances listed in a group health contract or employee benefit plan for which the policy or plan will not provide benefit payments such as pre-existing conditions or cosmetic treatment not medically necessary. |
| Exclusive Contract |
A managed care contract between TexNet and another entity or Wadley and another entity, in which the entity has agreed to use TexNet providers or Wadley facility exclusively as "in network" for all healthcare needs. |
| Exclusive Provider Organization (EPO) |
A type of managed care plan that provides benefits only if care is rendered by providers with which the plan contracts with certain exceptions for emergency or out-of-area services. Employers agree not to enter into agreement with any other plan or insurance carrier for coverage for eligible employees. |
| Explanation of Benefits (EOB) |
A statement sent by a managed care plan or insurance company to a plan member who files a claim listing the services provided, the amount billed and the payment made or an explanation why a claim was not paid and information about the individual's rights of appeal. |
| Family Deductible |
A deductible that is satisfied by the combined expenses of all covered family members such as a program with a $100 deductible may charge either a maximum of three deductibles or $300 total even if it is a family of four or more. |
| Fee Schedule |
A comprehensive listing of accepted fees or established allowances that a health plan uses to reimburse a provider on a fee-for-service basis for specified medical procedures. |
| Fully insured plan (also called Group Health Insurance) |
An insurance contract for group benefits made with an employer or other entity under which a number of employees and their dependents, or members of a homogeneous group, such as a union, are insured under one single policy. The services included in a fully insured plan encompass physician, hospital and ancillary medical coverage, (sometimes with a preferred provider network), repricing, claims processing and payment services, utilization review services and reporting. The above services are financed in total by monthly premiums assessed to the company. Heritage Health Plans are fully insured plans that are marketed to employers in our area who wish to purchase group health coverage for their employees. |
| Gatekeeper |
A primary care physician (PCP) or nonphysician practitioner who is responsible for managing a plan member's medical treatment, including all referrals for specialty care, ancillary services, and hospital services through the duration of the contract. |
| In-Network Services |
Covered health care services received by a plan member from a participating provider of the health plan. |
| Managed Care |
A system of managing and financing health care delivery to ensure that services provided to managed care plan members are necessary, efficiently provided, and appropriately priced (e.g. PPOs, HMOs, etc.) |
| Member |
An individual who has enrolled in a health care plan as a subscriber or a dependent of a subscriber, and for whom the plan has accepted the responsibility for providing health services as specified in the health plan contract. |
| Out-of-Network Services (OON) |
Health care services received by a managed care plan member from a nonparticipating provider whereby the member pays completely for the services with no reimbursement or reimbursement is at a lower percentage. |
| Out-of-Pocket Limit |
The total amount of money that a plan member must pay out of his/her own pocket toward eligible expense for himself/herself and/or dependents such as deductibles, co-payments and coinsurance as defined in the health care contract. |
| Payor/Payer |
Any managed care organization, third-party administrator, employer, association, trust fund, insurance carrier, federal government, or other entity that is liable for health care coverage for plan members usually by entering into an agreement with managed care networks to provide certain financial incentives which encourages plan members to use participating providers. |
| Pre-existing Condition |
Any physical or mental health condition, including injury or disease, that occurred and has been diagnosed or treated within a specified period of time prior to enrollment in a health plan. |
| Preferred Provider |
Any physician, hospital or other health care provider who contracts with a particular managed care plan, such as a PPO, to provide health services to persons covered by the plan. |
| Preferred Provider Organization |
A type of managed care organization that offers a variety of health plans that are accountable to purchasers for cost, quality, access and other services associated with their network of providers. |
| Primary Care |
Basic, or first level, general health care traditionally provided by a primary care physician including family practice physicians, pediatricians, internists and sometimes obstetric/gynecology physician specialists and generally provided on an outpatient basis. |
| Reasonable and Customary Charge (R&C) |
A charge for health care services that is consistent with the going rate or charge within a certain geographical area for identical or similar services. A fee is considered reasonable if it is falls within the average commonly charged fee for a particular service within that specific community. |
| Referral |
A recommendation by a physician and/or managed care plan for a plan member to be evaluated and/or treated by a different physician (either another primary physician or a specialist) who may or may not be in a the plan's network. |
| Reinsurance |
A type of insurance purchase by primary insurers that provide health care coverage directly to policyholders form other secondary insurers called reinsurers to protect against part or all of the losses the primary insurer might incur in honoring the claims of the policyholders. |
| Rider |
A legal document that modifies or amends the coverage or original contract under an insurance policy (may waive a condition, increase or decrease a benefit). |
| Self-insured plan (also called Self-funded plan) |
A health care program in which employers (usually large companies with 500 or more employees) fund employee benefits plan from their own resources and directly pay claims instead of purchasing group insurance. An employer who self-funds covers specified health care costs of its own employees rather than insuring them. Self-funded plans may be self administered, or the employer may contract with a third party administrator (TPA) for administrative services only (ASO). Self-funded employers contract with managed care organizations or directly with providers for health care services for their employees. They may limit their liability with stop-loss insurance on an aggregate and/or individual basis. Self-funding employers are exempted by ERISA from state insurance laws, state-mandated requirements or employer health benefit programs, state taxes on insurance premiums, and participation in state risk pools or uncompensated care plans. An example of a self-insured group is the Wadley Employee Health Plan. TexNet is its medical network and CHEC is its third party administrator that processes claims. |
| Subrogation |
A legal right to recover from third parties the full amount or some proportion of benefits paid to an insured person (i.e., employee is in a car accident, receives medical treatment through his employment insurance benefit, and the other party [third party] was at fault. The employee's insurance company may file a claim with the negligent driver's insurance company for the value of services provided to the injured plan member.) |
| Third-Party Administrator (TPA) |
An independent firm that performs administrative services, such as premium collecting, claims processing, claims payment, membership services, and utilization review for employee health benefit plans and managed care plans. |
| Utilization Review (UR) |
A technique whereby trained health care professionals evaluate the appropriateness, quality, and medical necessity of services provided to plan members. |
| Wrap-around network |
A network which fills any gaps in network provider coverage. Medical networks, such as TexNet, which are NOT located in metropolitan areas can rarely cover all the necessary medical services required by their participants. Therefore, they will contract with larger, more comprehensive networks to ensure adequate coverage for all services. Typically, participants are contractually required to utilize local providers for all services that are available and prevail upon the wrap-around network only for those services that are not available in the immediate service area. NovaSys and Southwest Preferred Network are the wrap-around networks for TexNet. |
