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Glossary
A B C D E F G H I J K L M N O P Q R S T U V W X Y Z
Admitting Physician: A patient care arrangement in which the group designates a physician to admit a patient to the hospital and this physician is responsible for coordinating all diagnostic treatments and processes needed during that patient's hospital stay.
Affiliated Provider: A health care provider or facility that is part of the HMO's network usually having formal arrangements to provide services to the HMO member.
Allowed Amount: Maximum dollar amount assigned for a procedure based on various pricing mechanisms. Also known as a maximum allowable.
Allowable Charge: The maximum charge for which a third party will reimburse a provider for a given service. An allowable charge is not necessarily the same as either a reasonable, customary, maximum, actual, or prevailing charge. Medicare normally pays 80 percent of the charge and the beneficiary pays that remaining 20 percent. The allowable charge for a nonparticipating physician may bill beneficiaries for an additional amount above the allowed charge. These rates are published by the HCFA intermediary in each state.
Ancillary Services: Supplemental services provided to a person while being treated. Included are laboratory, radiology, physical therapy, etc.
Appeal: The request for a case review in the event of denial of continued confinement and/or services. An appeal may be requested by the participating provider(s) and/or the patient/member.
Authorization: A consent or endorsement by a primary care physician for patient referral to ancillary services and specialists.
Authorized Covered Services: Covered services which are pre-approved or pre-authorized by John Muir Medical Group or John Muir Physician Network from time to time.
Balance Billing: Physician charges in excess of Medicare-allowed amounts, for which Medicare patients are responsible, subject to a limit. Can also apply to other health insurance plans.
Benefit Limitations: Any provision, other than an exclusion, which restricts coverage in the Evidence of Coverage, regardless of medical necessity.
Benefit Package: A collection of specific services or benefits that the HMO is obligated to provide under terms of its contracts with subscriber groups or individuals.
Billed Claims: Fees submitted by a health care provider for services rendered to a covered person.
Capitation (CAP): Method of paying health care providers or insurers in which a fixed amount is paid per enrollee to cover a defined set of services over a specified period, regardless of actual services provided.
Case Management: Service performed by one member of a medical team or organization, usually a primary care physician. The case manager supervises the provisions of medical care for each patient under his/here care. Case management is widely used to ensure the delivery of coordinated and appropriate care. (See Gatekeeper)
Case Manager: An experienced professional (e.g. nurse, doctor, or social worker) who works with patient, providers and insurers to coordinate all services deemed necessary to provide the patient with a plan of medically necessary and appropriate health care.
Centers of Excellence: A network of health care facilities selected for specific services based on criteria such as experience, outcomes, quality, efficiency and effectiveness.
Claim: A demand to the insurer for the payment of benefits under the insurance contract.
Coinsurance: The portion of the cost for care received and for which an individual is financially responsible. Usually this is determined by a fixed percentage, as in major medical coverage. Often coinsurance applies after a specified deductible has been met.
Commercial Plan: Refers to the benefit package an insurance company/HMO/PPO offers to employers. This is distinguished from a senior plan, which is offered to Medicare beneficiaries.
Consolidated Omnibus Budget Reconciliation Act (COBRA): A federal law that, among other things, requires employers to offer continued health insurance coverage for a certain length of time to certain employees and their dependents whose group health insurance coverage has been terminated.
Coordination of Benefits (COB): The determination of which of two or more plans or other third party payors are primarily or secondarily responsible for covered services provided to an enrollee. Such coordination is intended to preclude the enrollee from receiving an aggregate of more than one hundred percent (100%) of covered charges from all coverage. When the primary and secondary benefits are coordinated, determination of liability will be in accordance with the usual procedures employed by the California Department of Insurance and applicable state and federal regulations.
Copayments (copay) and Deductibles: Charges for professional services which are to be paid by an enrollee directly to provider at the time covered services are rendered, as set forth in enrollee's evidence of coverage.
Covered Benefit: A medically necessary service that is specifically provided for under the provisions of an evidence of coverage. A covered benefit must always be medically necessary, but not every medically necessary service is a covered benefit. For example, some elements of custodial or maintenance care which are excluded from coverage may be medically necessary, but not covered.
Covered Services: Those medically necessary health care services, equipment and supplies which enrollee is entitled to receive under a plan's health benefits.
Credentialing: The process of determining eligibility for hospital or PHO of medical staff membership and privileges to be granted to physicians. Credentials and performance are periodically reviewed, which could result in a doctor's privileges being denied, modified, or withdrawn.
[back to top]Date of Service (DOS): The date on which health care services were provided to the covered person.
Deductible: The part of an individual's health care expenses that the patient must pay before coverage from the insurer begins.
Disallowance: When a payor declines to pay for all or part of a claim submitted for payment.
Discounted Fee-For-Service: Physician's services are provided as fee-for-service, but at a negotiated rate less than his/her usual fee.
Effective Date: The date on which the health plans agreement goes into effect.
Electronic Medical Record (EMR): A term for computer-based patient records which provide real-time access to patient medical records. On-line records allow for longitudinal data storage and access and result in more efficient care, improved communication among providers and health plans, and facilitate outcome measurement.
Eligibility: The qualifications an employee or dependent must meet for coverage under the contract or agreement.
Emergency: Unless otherwise defined by a plan in a service agreement, a medical condition manifesting itself by acute symptoms of sufficient severity such that a prudent layperson who possesses average knowledge of health and medicine could reasonably expect the absence of immediate medical attention to result in (a) placing the individual in serious jeopardy; (b) serious impairment to bodily functions; or (c) serious dysfunction of any bodily organ or part.
Encounter: Face to face meetings between a member and a health care provider where services are provided. The number of encounters per member per year is calculated as the total number of encounters per year divided by the total number of members per year.
Encounter Data: Data relating to treatment or service rendered by a provider to a patient, regardless of whether the provider was reimbursed on a capitated or fee-for-service basis. Used in determining the level of service.
Enrollee: A person who is enrolled in a plan, including enrolled dependents, and who is entitled to receive covered services.
Enrollment: The total number of members in a health plan. The term also refers to the process by which a health plan signs up groups and individuals for membership, or the number of employees who sign up from any one group.
Evidence of Coverage: The document issued by a Pplan to an enrollee that sets forth the plan's covered services, and which describes the costs, procedures, benefits, conditions, limitations, exclusions and other obligations to which enrollees are subject thereunder.
Exclusions: Charges, services, or supplies that are not covered benefit under a health plan.
Federally Qualified HMO: An HMO that meets certain federally stipulated provisions aimed at protecting consumers (e.g., providing a broad range of basic health services, assuring financial solvency, and monitoring the quality of care).
Fee Schedule: Maximum dollar or unit allowance for health services that apply under a specific contract.
Fee-For-Service (FFS): A term which refers to the method of reimbursing service providers on an individual fee basis after services are rendered rather than reimbursing providers on a prepaid basis such as capitation.
Gatekeeper: First contact physician in a managed care setting. This physician is responsible for determining the appropriate level and delivery of care for each patient. The gatekeeper administers the patient's treatment and authorizes referrals to specialists, diagnostic tests, and hospitalizations. (See Case Management.)
Grievance Process: The formal process by which a health plan member who feels that he/she has been treated unfairly or unjustly by the health plan with regard to denial of treatment can submit a complaint. The complaint is usually submitted in writing and may include a hearing by the health plan's grievance review committee.
Health Care Financing Administration (HCFA): Part of the U.S. Department of Health and Human Services. In addition to its many other functions, HCFA is the contracting agency for HMOs who seek direct contractors/provider status for provision of the Medicare benefit package.
Health Insurance Portability and Accountability Act of 1996 (HIPAA): Individual small group and large group insurance plans fall under established federal standards which prohibit discrimination based on health status and the renewability of insurance.
Health Maintenance Organization (HMO): A health insurer or provider that offers comprehensive services on a prepaid basis. The HMO contracts or directly employs physicians to serve as its network. Physicians are paid a salary, reduced fees, or capitated rate for services. Patient choice is limited to contracted physicians to a varying degree depending on the type of organization. Types of HMO models:
- Group Model - contract with medical groups for services.
- IPA Model - contract with an IPA that in turn contracts with individual physicians.
- Staff Model - a health care model that employs physicians to provide health care to its members. All premiums and other revenues accrue to the HMO which compensates physicians by salary and incentive programs.
- Direct Contract Model - contracts directly with individual physicians.
- Mixed Model - members get options ranging from staff to IPA models.
- Network Model HMO - contracts with more than one physician group, and may contract with single and multi-specialty groups.
- Open-Ended HMO - a product that allows members to use physicians outside the plan in exchange for additional personal liability in the form of a deductible, coinsurance, or copayment.
Health Plan Employer Data and Information Set (HEDIS): A set of standardized measures of health plan performance. HEDIS allows comparisons between plans on quality, access and patient satisfaction; membership and utilization; financial information; and health plan management. HEDIS was developed by employers, HMOs, and the National Committee for Quality Assurance (NCQA).
Hospitalist: Physicians stationed primarily in the hospital to handle all admissions from a specific practice or group. Physician who is responsible for coordinating all diagnostic treatments and processes during that patient's hospital stay.
Individual Plans: A type of insurance plan for individuals and their dependents who are not eligible for coverage through an employer group coverage.
Individual Practice Association (IPA Model: A health care model that contracts with an entity, which in turn contracts with physicians, to provide health care services in return for a negotiated fee. Physicians continue in their existing individual or group practices and are compensated on a per capita, fee schedule, or fee-for-service basis.
Integrated Delivery System (IDS): A generic term referring to a combination of providers to deliver health care in an integrated way. Some models of integration include physician-hospital organization, a management service organization, and group practice without walls, integrated provider organization and medical foundation. (See Organized Delivery Systems).
Joint Commission on Accreditation of Health Care Organizations (JCAHO): A private, not-for-profit organization that evaluates and accredits hospitals and other health care organizations providing home care, mental health care, ambulatory care, and long term care services.
Maximum Allowable Charge: The amount set by an insurance company as the highest amount that can be charged for a particular medical service.
Maximum Out-Of-Pocket Expenses: Limit on total number of copayments or limit on cost of deductibles and coinsurance under a benefit plan.
Medical Director(s): The physician(s) designated by John Muir Physician Network to be responsible for administering John Muir Physician Network's and the Muir Medical Group IPA's medical affairs and serving as the medical liaison between John Muir Physician Network and the plans.
Medical(ly) Necessity(ary): Unless otherwise defined by a plan in a service agreement, medical or surgical treatment which an enrollee requires, as determined by a participating provider in accordance with professionally recognized standards of practice at the time of treatment.
Medicare: The nation's largest health insurance program administered by the Health Care Financing Administration (HCFA) for people at least 65 years of age, those with permanent kidney failure, and certain disabled people. Medicare Part A (Hospital Insurance) provides mandatory coverage of inpatient hospital services, skilled nursing facilities, home health services, and hospice care. Medicare Part B (Supplementary Medical Insurance) covers physician fees, outpatient care, and medical equipment and supplies. Part B is optional and requires a monthly premium.
Medicare + Choice Organization or M+CO: A Plan that has entered into an agreement with Health Care Financing Authority of the United States Department of Health and Human Services ("HCFA") to provide Medicare beneficiaries health care services options.
Member: Any person eligible to receive reimbursement for healthcare services expenses pursuant to the terms and conditions of a health care plan. The term includes the subscriber and any enrolled dependents in the health care plan.
National Committee of Quality Assurance (NCQA): An independent non-profit organization that has worked with consumers, healthcare purchasers, state regulators and the managed care industry in developing standards that evaluate the structure and function of medical and quality management systems in managed care organizations. NCQA's standards for accreditation of managed care organizations evaluate a managed care plan's performance in the area of quality management and improvement, utilization management credentialing, member's rights and responsibilities, preventative health services, and medical record-keeping.
Non Covered Services: Those health care services, equipment and supplies that are not designated as benefits to enrollees under the terms of the enrollee's evidence of coverage.
Omnibus Budget Reconciliation Act (OBRA): Federal tax and budget conciliation acts affecting Medicare reimbursement and other areas.
Open Enrollment Period: The period of time stipulated in a group contract in which eligibles of the group can choose a health plan alternative for the coming benefit year. There is an open enrollment period as defined in the Federal HMO Regulations requiring HMOs who meet certain criteria to conduct annual open enrollments for periods of not less than 30 days (refer to 110.107 of the Federal HMO Regulations). This federally required open enrollment of individuals should not be confused with enrollment of individuals many HMOs pursue as a normal part of their marketing strategies.
Participating Hospital: A licensed hospital which has entered into an agreement with a plan or John Muir Physician Network to provide covered services to enrollees.
Participating Physician: A physician who is licensed to practice medicine or osteopathy in the State of California and who has entered into an agreement with John Muir Physician Network to provide Covered Services to enrollees.
Participating Provider: A participating physician, participating hospital, or other licensed, certified or registered health facility or provider which has entered into an agreement with a plan, John Muir Physician Network to provide covered services to enrollees.
Plan: An entity licensed as a health care service plan by the California Commissioner of Corporations pursuant to the Knox-Keene Act, or another third-party payor that has contracted with John Muir Physician Network to arrange for the provision of covered services to its enrollees pursuant to a service agreement.
Point of Service (POS): An insurance model which determines coverage by where care is provided at the time of delivery, rather than by enrollment. POS plans allow enrollees to choose between a network and out-of-network providers. Network or contracted providers are paid on a pre-paid, contractual basis and non-network providers are paid on a fee-for-service basis. Enrollees are given the option of choosing non-network physicians at the cost of higher copayments or deductibles.
Pre-existing Conditions: Used by health insurance companies to refer to medical conditions or diagnoses that existed at or prior to the date at which the individual applied for health insurance. Health plans usually charge an additional premium for pre-existing conditions and/or provide limited benefits for these conditions.
Preferred Provider Organization (PPO): A network of providers which allows the enrollee the option of pursuing care outside of the network, for higher fees. All physicians are paid on a fee-for-service basis. Network physicians are paid reduced fees in exchange for their preferred status.
Primary Physician or Primary Care Physician (PCP): A participating physician selected by an enrollee to provide primary care services. Primary physician or primary care physician may include (as determined by Muir Medical Group IPA) internists, pediatricians, family practitioners, general practitioners, obstetricians and gynecologists who agree to provide primary care services to enrollees.
Primary Care Services: Those covered services determined to be primary care services are determined by the John Muir Medical Group or Muir Medical Group IPA.
Quality: The features of a product or service that are assessed on its ability to satisfy the stated or implied needs of the user, or consumer.
Quality Assurance (QA) Program: An internal peer review process that audits the quality of care delivered. The programs typically include an educational mechanism to identify and prevent discrepancies in care.
Quality Management (QM): A formal set of activities to assure the quality of services provided. Quality management includes quality assessment and corrective actions taken to remedy any deficiencies identified through the assessment process.
Referral: A participating provider's direction of an enrollee to seek and obtain covered services from a health professional, a hospital, or any other provider of covered services.
Referral Provider: A provider (usually a specialty physician or health care facility) that renders a service to a patient who has been sent by a participating provider in a health plan.
Specialist Physician or Specialist: A participating physician who is professionally qualified to practice his or her designated specialty and whose agreement with John Muir Physician Network includes responsibility for providing covered services in his or her designated specialty.
Specialty Physicians: Those physicians practicing in areas other than general internal medicine, family practice or pediatrics.
Subscriber: The primary person eligible and enrolled in a health care plan. The term refers to the employee or the other person who has executed the health plan documents to obtain coverage, but does not generally include any dependents.
Termination of Benefits: The written process used to notify the patient and the providers that acute care is no longer necessary. Any further care that is provided would be the financial responsibility of the patient.
Usual, Customary, and Reasonable (UCR): A term used to refer to the commonly charged or prevailing fees for health services within a geographic area. A fee is considered to be reasonable if it falls within the parameters of the average or commonly charged fee for the particular service within that specific community.