Admitting Physician: The physician responsible for admitting a patient to a hospital. This physician is responsible for coordinating all diagnostic treatments and processes needed during the patient's hospital stay.
Affiliated Provider: A healthcare provider (doctor or other clinician), facility, or hospital that is part of the health plan’s network, usually having formal arrangements to provide services to any patient subscribing to the health plan.
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. For example, Medicare normally pays 80 percent of a charge and the beneficiary pays the remaining 20 percent. The allowable charge for a non-participating physician may be higher because he may bill Medicare beneficiaries for an additional amount above the allowed charge.
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 hospitalization 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 or health insurance plan for patient referral to ancillary services and specialists.
Authorized Covered Services: Covered services, which are pre-approved or pre-authorized.
Benefit Limitations: Any provision, other than an exclusion, which restricts insurance coverage, regardless of medical necessity.
Benefit Package: A collection of specific services or benefits that the health plan 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 in which a fixed amount is paid per enrollee or member 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 with HMO coverage. The case manager supervises the provisions of medical care for each patient under his/her care. Case management is widely used to ensure the delivery of coordinated and appropriate care.
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 and often applies after a specified deductible has been met.
Commercial Plan: Refers to the benefit package an insurance company offers to employers. This is distinguished from a senior plan, which is offered directly to seniors eligible for Medicare.
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 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 prevent the enrollee from receiving a total of more than one hundred percent (100%) of 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 the patient directly to provider at the time covered services are rendered.
Covered Benefit: A medically necessary service that is specifically provided for under the provisions of the health insurance plan. 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 — such as being in a nursing home —may be medically necessary, but not covered.
Covered Services: Those medically necessary healthcare services, equipment, and supplies, which a covered individual is entitled to receive under a plan's health benefits.
Credentialing: The process of determining eligibility for a hospital 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.
Deductible: The part of an individual's health care expenses that the patient must pay before coverage from the insurer begins.
Disallowance: When an insurance company or other payor declines to pay for all or part of a claim submitted for payment.
Electronic Medical Record or Electronic Health Record (EMR/EHR): Computer-based patient records which provide real-time, online access to patient medical records. Online records allow for long-term, centralized data access and storage, resulting in more efficient care, improved communication among providers and health plans, and facilitation of patient outcome measurements.
Eligibility: The qualifications an employee or dependent must meet for coverage under the insurance health plan.
Emergency: Unless otherwise defined by a plan in a service agreement, a medical condition manifesting itself by sudden 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 dispensed.
Evidence of Coverage: The document issued by a plan 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 benefits under a health plan.
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.
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 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 a capitated rate for services. Patient choice is limited to contracted physicians, though this can vary depending on the type of organization.
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 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.
Maximum Out-Of-Pocket Expenses: Limit on total number of copayments or limit on cost of deductibles and coinsurance under a benefit plan.
Medical(ly) Necessity(ary): Unless otherwise defined by a health plan in a service agreement, medical or surgical treatment which a patient 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 Centers for Medicare and Medicaid Services (CMS) for people at least 65 years of age, those with permanent kidney failure, and certain disabled people.
Member or Enrollee: Any person eligible to receive reimbursement for healthcare services and expenses according to the terms and conditions of a healthcare plan. The term includes the subscriber and any enrolled dependents in the healthcare plan.
National Committee of Quality Assurance (NCQA): An independent, non-profit organization that works with consumers, healthcare purchasers, state regulators, and the managed care industry to develop 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, preventive 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.
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 its patients.
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 or John Muir Physician Network to provide covered services to its patients.
Plan: An entity licensed as a healthcare service plan by the California Commissioner of Corporations per 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 or subscriber and dependents according to a service agreement.
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 patient, 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 physicians or primary care physicians 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.
Specialist Physician or Specialist: A participating doctor 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.
Subscriber: The primary person eligible and enrolled in a healthcare 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.
The Joint Commission (TJC): A private, not-for-profit organization that evaluates and accredits hospitals and other healthcare organizations providing home care, mental health care, ambulatory care, and long-term care services.
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.