Please note:
Your plan is fully described in your plan documents.
Should the definitions in this glossary and your
plan documents disagree, or should provisions
contained in your plan documents be omitted from
this glossary, your plan documents will always
govern.
|
| Acupuncture |
An alternative health
procedure based on ancient Chinese methods, gaining
acceptance in Western hospitals, involving insertion
of thin needles at specific pressure points in
the body. |
| Adjudication
|
Determination of the
amount of payment for a claim. |
| Administrative Costs
|
The costs assumed by
an insurance company or managed care plan for
administrative services such as claims processing,
billing and overhead costs. |
| Administrative Services
Only (ASO) |
An arrangement under
which an insurance carrier or an independent organization
will, for a fee, handle the administration of
claims, benefits and other administrative functions
for a self-insured group. This type of arrangement
usually requires the employer to be at risk for
the cost of health care services to be provided.
|
| Agent |
An individual licensed
by the State who sells insurance to a payer and
who provides service to the policyholder for the
insurer. Could be sole-proprietor, member of a
large firm or employee of the insurance company.
Paid by a fee/commission from insurer. |
| Allergy Treatment
|
Treatment of allergy,
which may involve allergy testing and physician's
services. |
| Allowable Charge
|
The maximum fee that
a third party will reimburse a provider for a
given service. An allowable charge may not be
the same amount as either a reasonable or customary
charge. |
| Alternate Care Facility |
A licensed residence,
other than a nursing facility, where care services
are delivered (i.e. hospice, assisted living,
Alzheimer's or Christian Science setting). |
| Ambulatory Setting
|
A type of health care
setting where health services are provided on
an outpatient basis. Ambulatory settings usually
include physicians' offices, clinics and surgery
centers. |
| Ambulatory Surgery
|
Surgical procedures
performed that do not require an overnight hospital
stay. |
| Ambulatory Services
|
Health services that
are provided on an outpatient basis, in contrast
to services provided in the home or to persons
who are inpatients in a hospital. |
| Ancillary Services
|
Hospital services other
than room and board, and professional services.
They may include X-ray, drug, laboratory or other
services. |
| Appeal(s) |
An individual's dispute
over the denial of a claim payment or the denial
of provision of a health care service, or a coverage
denial based on a contractual exclusion or limitation.
|
| Assignment |
Agreement by the provider
to accept any reimbursement from a third-party
payer as payment in full for the services rendered.
|
| Authorization
|
The approval of care,
for hospitalization, outpatient procedure, certain
specialty, etc., by a managed care or insurance
company for its member, subscriber, or insured.
|
| Average Length of Stay |
A measure used to determine
the average number of days patients spend in a
facility. |
| Bed Days/1000
|
The number of inpatient
days per 1000 health plan members. |
| Beneficiary |
A person who is eligible
to receive insurance benefits. |
| Benefit |
Payments provided for
covered services under the terms of the policy.
The benefits may be paid to the insured, or on
his behalf, to others. |
| Benefit Consultant
|
An individual or organization
hired by a group plan holder to review, analyze,
and make recommendations on benefit strategies,
including benefit plan design, carrier selection,
pricing, etc. An insurance professional who provides
information, advice and counseling for their clients.
|
| Benefit Period
|
The maximum length
of time for which benefits will be paid. |
| Birthing Center
|
A facility that allows
mothers to give birth in a home-like setting.
|
| Board Certified
|
A term used to describe
a physician who has passed an examination given
by a medical specialty board and who has been
certified as a specialist in that medical area.
|
| Board Eligible
|
A physician who has
graduated from an approved medical school and
is eligible to take a specialty board examination.
|
| Broker |
One who represents
a client in solicitation, negotiation or procurement
of contracts of insurance, and who may render
services incidental to those functions. By law,
the broker may also be an agent of the insurer
for certain purposes such as delivery of the policy
or collection of the premium. |
| Brand Name Drug(s)
|
Those drugs that are
marketed under a specific trade name by a pharmaceutical
manufacturer. In most cases, these drugs are still
under patent protection, meaning the manufacturer
is the sole source for the product. |
| Capitation |
A method of payment
for health services in which an individual or
institutional provider is paid a fixed, per capita
amount for each person served without regard to
the actual number or nature of services provided
to each person. Capitation is a common method
of paying physicians in health maintenance organizations.
|
| Case Management
|
A utilization management
program that assists the patient in determining
the most appropriate and cost effective treatment
plan. It is used for patients who have prolonged,
expensive or chronic conditions, helps determine
the treatment location (hospital, other institution
or home) and authorizes payment for such care
if it is not covered under the patient's benefit
agreement. The purpose of case management is to
provide optimum patient care in the most cost-effective
manner. |
| Certification
|
See pre-certification
|
| Chemotherapy
|
Treatment of malignant
disease by chemical or biological antineoplastic
agents. |
| Chiropractic (Care)
|
An alternative medicine
therapy administered by a provider such as a chiropractor,
osteopath or physical therapist. The provider
adjusts the spine and joints to treat pain and
improve general health. |
| Claim |
A request for payment
for benefits received or services rendered. A
billing record as generated and submitted by a
provider or subscriber using paper or electronic
media. |
| COBRA |
The federal law that
requires employers with more than 20 employees
to extend group health insurance coverage for
up to 36 months after a qualifying event (e.g.
termination of employment, reduction in hours,
divorce). The right to continue such coverage
ends when a qualified beneficiary becomes covered
under any other group health plan that does not
contain any pre-existing condition or other limitations.
|
| Coinsurance |
An arrangement under
which the covered person pays a fixed percentage
of the cost of medical care after the deductible
has been paid. For example, an insurance plan
might pay 80% of the allowable charge, with
the insured individual responsible for the remaining
20%, which is then referred to as the coinsurance
amount. |
| Coinsurance Maximum
|
The total amount of
coinsurance that an individual pays each year
before the carrier pays 100% of allowable
charges for covered services. Coinsurance amounts
differ with each contract. |
| Concurrent Review
|
The review and assessment
of an ongoing inpatient hospitalization to assure
it remains the most appropriate setting for the
care being rendered. |
| Consolidated Omnibus Budget Reconciliation Act of 1985 |
See "COBRA".
|
| Continuation
|
See "COBRA".
|
| Contraception
|
Deliberate prevention
of conception or impregnation using methods such
as oral drugs, injectable drugs, implants, diaphragms.
|
| Contract |
A legal agreement between
an individual or an employer group and a carrier
that describes the benefits and limitations of
the coverage. |
| Contract Holder
|
An individual entitled
to health benefits according to a Plan benefit
contract issued to him or to a group of which
he is a member. This definition excludes dependents.
Under a group plan, the contract holder is the
group. |
| Conversion(Option)
|
The exercise of an
option to purchase individual coverage by a person
who is leaving an employee group, typically at
retirement. |
| Coordination of Benefits |
The anti-duplication
provision to limit benefits for multiple group
health insurance in a particular case to 100%
of the covered charges and to designate the order
in which the multiple carriers are to pay benefits.
Under a COB provision, one Plan is determined
to be primary and its benefits are applied to
the claim. The unpaid balance is usually paid
by the secondary Plan to the limit of its liability.
|
| Copayment or Copay
|
A type of member cost
sharing that requires a flat amount per unit of
service or unit of time. This is usually a percentage
of the charges but may also be a dollar amount
for specified services. The most common percentage
copayment is 20%. A common copay is $5-$15
per visit. |
| Covered Medical Expense |
Those expenses payable
according to the terms of the subscriber's contract.
The charges for these services are still subject
to any cost sharing components or limits, such
as deductibles, coinsurance, copayments and maximums
included in the contract. |
| Covered Services
|
Hospital, medical and
other health care expenses incurred by the covered
person that entitle him/her to benefits under
a contract. The term defines the type and amount
of expense, which will be considered in the calculation
of benefits. |
| Credentialing
|
An examination of a
health care provider's credentials to determine
if they should be granted clinical privileges
at a health care facility or with a managed care
organization. |
| Custodial Care
|
Care provided primarily
to assist a patient in meeting the activities
of daily living, but not care requiring skilled
nursing services. |
| Customary and Reasonable
(C&R) |
The amount customarily
charged for the service by other physicians in
the area (often defined as a specific percentile
of all charges in the community), and the reasonable
cost of services for a given patient after medical
review of the case. |
| Day Treatment Center
|
An outpatient psychiatric
facility which is licensed to provide outpatient
care and treatment of mental or nervous disorders
or substance abuse under the supervision of physicians.
|
| Deductible |
An amount the covered
person must pay before payments for covered services
begin. The deductible is usually a fixed amount
or a percentage determined by the individual's
contract, and is calculated based on the lower
hospital/provider actual charges or payment benefit.
For example, an insurance plan might require the
insured to pay the first $250 of covered expense
during a calendar year. |
| Dental Care |
Under a medical plan,
dental care is dental treatment which due to the
nature of the procedure or patient's medical condition,
may be provided in a hospital setting. |
| Dependant |
Person (spouse or child)
other than the subscriber who is covered in the
subscriber's benefit certificate. |
| Diagnosis Code
|
A numerical classification
that describes diseases, injuries and causes of
death. International Morbidity Code, Manual of
the International Statistical Classification of
Diseases & Injuries and AMA Standard Nomenclature
of Disease are different diagnosis coding methods.
|
| Diagnosis Related
Groups (DRGs) |
A method of grouping
related diagnosis and their associated medical
or surgical treatment. A coding system used to
determine the amount that Medicare will reimburse
hospitals and other designated providers for the
delivery of inpatient services. HCFA uses these
groupings to establish the amount that it will
reimburse hospitals for the care given to Medicare
beneficiaries. Each DRG corresponds to a specific
patient condition. Each DRG has a pre-established
fixed amount that is paid for any patient in the
DRG category. |
| Diagnostic Tests
|
Tests and procedures
ordered by a physician to determine if the patient
has a certain condition or disease based upon
specific signs or symptoms demonstrated by the
patient. Such diagnostic tools include radiology,
ultrasound, nuclear medicine, laboratory, pathology
services or tests. |
| Discharge Planning
|
The process of assessing
a patient's treatment plan during hospitalization
to effect an appropriate and timely discharge.
The hospital and attending physician have major
responsibility for this function, with the Plan
promoting, monitoring and assisting the providers.
|
| Disease Management
Programs |
Interventions and educational
programs designed for individuals with chronic
diseases designed to prevent recurrence of symptoms,
maintain high quality of life and prevent future
need for medical resources by using an integrated,
comprehensive approach to health care. Pharmaceutical
care, continuous quality improvement, practice
guidelines and case management all play key roles
in this effort. |
| Drug Formulary
|
A listing of preferred
pharmaceutical products that health plans, working
with an expert panel of physicians and pharmacists,
have developed to encourage the dispensing of
quality, cost effective medications. Formularies
can be classified as: * Open, in which doctors
are encouraged to prescribe medications on the
formulary but which allow nonformulary drugs to
be covered without prior authorization; * Restricted,
in which only medications on the formulary list
are covered; * Managed, in which doctors are encouraged
to prescribe medications on the formulary, but
nonformulary drugs are covered with prior authorization.
|
| Durable Medical Equipment
|
Mechanical devices,
equipment and supplies which enable a person to
maintain functional ability. |
| Effective Date
|
The date on which the
coverage or a change in coverage of a contract
goes into effect at 12:01 a.m. |
| Emergency Care
|
Care for patients with
severe or life-threatening conditions that require
immediate medical attention. |
| Enrollee |
An individual who is
enrolled and eligible for coverage under a health
plan contract. Synonymous with member. |
| Exclusions |
Specific conditions
or circumstances that are not covered under the
contract. |
| Experimental Procedures
|
Services that are not
recognized under generally accepted medical standards
as safe and effective for treating a particular
condition. |
| Expiration Date
|
The date coverage expires.
|
| Explanation of Benefits
(EOB) |
A form sent to the
covered person after a claim for payment has been
processed by the carrier that explains the action
taken on that claim. This explanation might include
the amount that will be paid, the benefits available,
reasons for denying payment or the claims appeal
process. |
| Flexible Benefits
|
A generic name for
employee benefits programs which offer employees
a choice of benefit components. |
| Formulary |
See Drug Formulary.
|
| Gatekeeper |
Term given to a primary
care provider who coordinates all medical care
for a patient and determines whether services
such as tests or referral to a specialist are
necessary. |
| Generic Drug(s)
|
Safe, effective and,
equivalent to brand name medications that may
cost considerably less than the brand name medications.
Generic drugs must meet the same high standards
of quality as brand name drugs and are formulated
to have the same effect in the body as the brand
name version. Generic drugs often become available
when a brand name drug's patent expires. |
| Health Benefit Plan
|
A health insurance
product offered by a health plan company that
is defined by the benefit contract and represents
a set of covered services and a provider network.
|
| Health Maintenance
Organization (HMO) |
An organization that
provides a wide range of comprehensive health
care services for a specific group at a fixed
periodic payment or a pre-paid health care plan
under which people enroll by paying a set annual
fee. Members then receive all the medical services
they need through a group of affiliated doctors
and hospitals, often with no additional copayments
or fees. Members are generally limited to using
providers designated by the HMO. |
| Hearing Services
|
Testing and services
related to hearing. |
| HMO |
See Health Maintenance
Organization. |
| Home Health Care
|
Health services rendered
to an individual as needed in the home. Such services
are provided to aged, disabled, sick or convalescent
individuals who do not need institutional care.
|
| Home Infusion Therapy
|
The administration
of intravenous drug therapy in the home. Home
infusion therapy includes the following services:
solutions and pharmaceutical additives; pharmacy
compounding and dispensing services; durable medical
equipment; ancillary medical supplies; and, nursing
services. |
| Hospice |
A facility or service
that provides care for terminally ill patients
and support to their families, either directly
or on a consulting basis with the patient's physician.
Emphasis is on symptom control and support before
and after death. |
| Hospital |
An institution whose
primary function is to provide inpatient services,
diagnostic and therapeutic, for a variety of medical
conditions, both surgical and non-surgical. In
addition, most hospitals provide some outpatient
services, particularly emergency care. |
| ID Card/Identification
Card |
A card issued by a
carrier to a covered person, which allows the
individual to identify himself or his covered
dependents to a provider for health care services.
The card is subsequently used by the provider
to determine benefit levels and to prepare the
billing statement. |
| In Area Services
|
Medical services received
within a health plan's authorized service area
and administered by a health plan's participating
provider. |
| Indemnity |
(1) Benefits paid in
a predetermined amount in the event of a covered
loss. (2) A traditional carrier that reimburses
for medical services provided to patients based
on bills submitted after the services are rendered.
Also known as fee-for-service. |
| Immunizations
|
Specific types of injections
to prevent infectious diseases and viral infections.
|
| In-Network |
Refers to the use of
providers who participate in the carrier's provider
network. Many benefit plans encourage covered
persons to use participating (in-network) providers
to reduce the individual's out of pocket expense.
|
| Infertility |
Term used to describe
the inability to conceive or an inability to carry
a pregnancy to a live birth after a year or more
of regular sexual relations without the use of
contraception. Also includes the presence of a
condition recognized by a physician as the cause
of infertility. |
| Infusion Therapy
|
The administration
of intravenous drug therapy. Infusion therapy
includes the following services: solutions and
pharmaceutical additives; pharmacy compounding
and dispensing services; durable medical equipment;
ancillary medical supplies; and, nursing services.
|
| Inpatient |
Service provided while
the patient is admitted to the hospital for at
least a 24-hour period. |
| Investigation Procedures
|
Those that have progressed
to limited use on humans, but which are not widely
accepted as proven and effective within the organized
medical community. |
| Lifetime Maximum
|
Maximum amount that
Major Medical will pay toward a subscriber's claim
in a lifetime. The amount varies depending on
the type of coverage the subscriber carries. |
| Managed Care
|
Any form of health
plan that initiates selective contracting to channel
patients to a limited number of providers and
that requires utilization review to control unnecessary
use of health services. |
| Maternity Care
|
The care of women before
and during childbirth as well as the care of newborn
babies. |
| Medical Equipment
|
See Durable Medical
Equipment |
| Medically Necessary
|
Procedures, supplies,
equipment or services determined to be: appropriate
for the symptoms, diagnosis or treatment of a
medical condition, and provided for the diagnosis
or direct care and treatment of the medical condition;
and 3) within the standards of good medical practice
within the organized medical community; and 4)
not primarily for the convenience of the patient's
physician or other provider; and 5) the most appropriate
procedure, supply, equipment or service which
can be safely provided. |
| Member |
An individual or dependent
who is enrolled in and covered by a health care
plan. Also called enrollee or beneficiary. |
| Mental Health/Behavioral
Health |
Conditions that affect
thinking and the ability to figure things out
which affect perceptions, mood and behavior. Such
disorders are recognized primarily by symptoms
or signs that appear as distortions of normal
thinking, or distortions of the way things are
perceived (seeing or hearing things that are not
there). Disorders can also be recognized by moodiness,
sudden or extreme changes in mood, depression,
highly agitated or unusual behavior. |
| Mental Health Parity
Act |
A federal health benefits
law passed in 1996, effective January 1, 1998,
which restricts health plans from applying lower
annual and aggregate lifetime limits to mental
illness than limits imposed on medical illness.
The law exempts group health plans from complying
with its provisions if mental health parity results
in an increase in the cost under the plan or coverage
of at least one percent. The law applies to all
group health plans (insured and self-insured)
with over 50 employees. |
| Network |
The doctors, clinics,
hospitals and other medical providers that a carrier
contracts with to provide health care to its covered
persons. Individuals are generally limited to
network providers for full coverage of their health
costs. |
| Network Provider
|
See "Provider
Network". |
| Non-Participating
Provider |
A Medical provider
who has not contracted with a carrier or health
plan to be a participating provider. |
| Occupational Therapy
|
Treatment to restore
a physically disabled person's ability to perform
activities such as walking, eating, drinking,
toileting and bathing. |
| Out of Network
|
The use of health care
providers who have not contracted with the carrier
to provide services. HMO members are generally
not reimbursed if they go out-of-network except
in emergency situations. Covered persons of preferred
provider organizations and HMOs with point-of-service
options can go out-of-network, but must pay additional
costs including deductibles and co-insurance.
|
| Out of Pocket Maximum
|
Refers to the maximum
amount that a covered employee will have to pay
for expenses covered under the plan. It is a sum
of deductible and coinsurance amounts. |
| Outpatient |
A patient who is receiving
ambulatory care at a hospital or other health
facility without being admitted to the facility.
|
| Outpatient Surgery
|
Surgical procedures
performed that do not require an overnight stay
in the hospital or ambulatory surgery facility.
Such surgery can be performed in the hospital,
a surgery center, or physician office. |
| Partial Day Treatment
|
A program offered by
appropriately licensed psychiatric facilities
that includes either a day or evening treatment
program for mental health or substance abuse.
Such care is an alternative to inpatient treatment.
|
| Participating Provider
|
A physician, hospital,
pharmacy, laboratory or other appropriately licensed
provider of health care services or supplies,
that has entered into an agreement with a managed
care entity to provide such services or supplies
to a patient enrolled in a health benefit plan.
|
| PCP |
See Primary Care Physician.
|
| UniCare Pharmacy
Network |
A prescription drug
program that offers the following advantages:
* A network of participating pharmacies nationwide.
* A convenient mail-order option that saves time
and money. * Low copayments and no claim forms
when using a participating pharmacy. * Toll-free
customer service telephone numbers. |
| Physical Therapy
|
Treatment involving
physical movement to relieve pain, restore function
and prevent disability following disease, injury
or loss of limb. |
| Physician's Current
Procedural Terminology (CPT) |
A list of medical services
and procedures. Each service and/or procedure
is identified by its own unique five-digit code.
CPT has become the health care industry's standard
for reporting of physician procedures and services,
thereby providing an effective method of nationwide
communication. |
| Plan Benefit Maximum
|
Maximum amount the
carrier will pay toward an individual's coverage.
The amount varies depending on the type of coverage
the individual carries. |
| Point of Service
(POS) |
An option provided
by some HMOs that allows covered persons to go
outside the plan's provider network for care,
but requires they pay higher cost-sharing than
they would for network providers. |
| Pre-Admission Review
|
The assessment of medical
necessity and appropriateness of elective hospital
admissions before hospitalization has occurred.
|
| Pre-Authorization
|
A procedure used to
review and assess the medical necessity and appropriateness
of elective hospital admissions and non-emergency
outpatient services before the services are provided.
|
| Preventive Care
|
Proactive health care
designed to keep people from getting sick or hurt.
It includes immunizations and screenings. A key
part of preventive medicine is making sure patients
know how to improve their health by altering their
lifestyles. |
| Pre-Certification
|
Refers to certifying
the medical necessity and level of care in advance.
Pre-certification does not guarantee that contract
benefits will be available. |
| Pre-Certification
Review |
Utilization management
performed prior to a patient's admission, stay
or other service or course of treatment. Also
known as Prospective Review. |
| Pre-Existing Condition
|
A health condition
or medical problem that was diagnosed or treated
before enrollment in a new health plan or insurance
policy. Some pre-existing conditions may be excluded
from coverage. |
| Preferred Provider
|
A health care professional
and/or facility that contracts with a health plan
to provide medical services to covered individuals.
Also referred to as a Participating Provider.
|
| Preferred Provider
Organization (PPO) |
A delivery system where
providers are under contract to a carrier to provide
care at a discount or for a fixed fee, and the
carrier provides incentives to patients to use
the contracting providers. The PPO does not assume
insurance risk, and it does not facilitate the
sharing of risk by its covered persons. |
| Prescription
|
A written order or
refill notice issued by a licensed medical professional
for drugs which are only available through a pharmacy.
|
| Primary Care Physician
(PCP) |
A doctor designated
by an HMO or other managed health care company
to be the first physician a patient contacts for
any medical problem. The doctor acts as the patient's
regular physician and as a gate-keeper who determines
if the patient needs to see a specialist or requires
hospitalization. |
| Prior Authorization
|
The process of obtaining
pre-approval of coverage for a health care service
or medication. |
| Prosthetic Devices
|
A device which replaces
all or a portion of a part of the human body.
These devices are necessary because a part of
the body is permanently damaged, is absent or
is malfunctioning. |
| Provider |
A licensed health care
facility, program, agency or health professional
that delivers health care services. |
| Provider Network
|
That set of providers
with which a carrier has contracted to provide
services to the Accountable Health Plan's covered
persons. In the case of a "fee-for-service"
or non-network Health Benefit Plan, the Provider
Network will be deemed to be all licensed providers
of covered services. |
| Radiation Therapy
|
Treatment of disease
by x-ray, radium, cobalt or high energy particle
sources. |
| Reasonable and Customary
|
The amount customarily
charged for the service by other physicians in
the area (often defined as a specific percentile
of all charges in the community) and the reasonable
cost of services for a given patient after medical
review of the case. Also known as Usual and Customary
(U&C). |
| Referral |
A recommendation by
a physician or insurer that an individual receive
care from a different doctor or facility. |
| Respiratory Therapy
|
Treatment of illness
or disease that is accomplished by introducing
dry or moist gases into the lungs. |
| Retrospective Review
|
A review of claims
and medical records for medical necessity and
appropriateness after the episode of care is concluded
and before and/or after the claim is submitted
by the provider. |
| Second Opinion
|
The voluntary option
or mandatory requirement to visit another physician
or surgeon regarding diagnosis, course of treatment
or having specific types of elective surgery performed.
|
| Self Funding
|
When a business funds
a benefit plan from its own resources rather than
purchasing insurance. |
| Service Area
|
The geographic area
that an insurer, health plan or health care provider
services. |
| Skilled Nursing Facility
|
An institution (or
a distinct part of an institution) that is primarily
engaged in providing skilled nursing care and
related services for patients who require medical
care, nursing care or rehabilitation services.
|
| Speech Therapy
|
Treatment or the correction
of a speech impairment which resulted from birth,
or from disease, injury or prior medical treatment.
|
| Subrogation |
Means by which claims
are identified as the responsibility of another
insurer since treatment of the condition resulted
from the action of an outside party. Situations
include coverage under another health insurance
policy, Worker's Compensation, disability or medical
insurance under automobile policies. Subrogation
literally means the substitution of one person
for another. Under Subrogation, insurers assume,
by operation of law or contract, the rights of
the insured against the wrongdoer. Where legal,
a subrogation right can be asserted when it is
determined that an injury was caused by the negligence
of another party. This allows an insurance carrier
to recover medical expenses paid out as a result
of such negligence. Insurance payment must be
made before it can be subrogate. |
| Subscriber |
The individual in whose
name a contract is issued or the employee covered
under an employer's group health contract. |
| Substance Abuse/Chemical
Dependency |
Conditions that include,
but are not limited to (1) psychoactive substance
induced mental disorders; (2) psychoactive substance
use dependence; and (3) psychoactive substance
use abuse. Chemical dependency does not include
addition to, or dependency on, tobacco or food
substances (or dependency on items not ingested).
|
| Utilization Management
|
(1) A process that
evaluates health care on the basis of appropriateness,
necessity, and quality. For hospital review, it
can include pre-admission certification, concurrent
review with discharge planning, and retrospective
review. (2) One of the six categories of Standards
of Quality used by NCQA, which examines the consistency
and the reasonableness of the determinations of
necessary services. Also looks at how well the
plan responds to member and physician appeals.
Utilization Management at WellPoint is comprised
of the three following components: (i) Pre-Hospital
Review — For medical, surgical, obstetrical,
mental health and substance abuse admission requests,
the WellPoint companies evaluate whether hospitalization
is necessary; the proposed length of stay is appropriate;
another form of treatment is available and appropriate;
and/or if diversion to an alternate care facility
is possible. (ii) Continued Stay Review —
During a hospital stay, the WellPoint companies
continually monitor the patient's progress through
the attending physician to ensure adherence to
the treatment plan. The WellPoint companies review
requests for (and authorize, when appropriate)
extended lengths of stay. (iii) Alternate Medical
Care — In conjunction with Pre-Hospital Review
and Continued stay Review, the WellPoint companies
identify patients for whom early discharge to
home health care is appropriate. The program then
controls home health care utilization through
pre-authorization and ongoing evaluation and monitoring;
authorizes services and specific dollar amounts
by modality; works with the hospital discharge
planner to develop an appropriate treatment plan
and coordinates the patient's benefits. |
| Utilization Review
|
A review process designed
to evaluate the appropriateness of health care
services. |
| Usual,Customary and
Reasonable |
A "usual"
charge is the amount that is most consistently
charged by an individual physician for a given
service. A "customary" charge is the
amount that falls within a specified range of
usual charges for a given service billed by most
physicians with similar training and experience
within a given geographic area. A "reasonable"
charge is a charge that meets the Usual and Customary
criteria, or is otherwise reasonable in light
of the complexity of treatment of the particular
case. Under a UCR Program, the payment is the
lowest of the actual billed charge, the physician's
usual charge or the area customary charge for
any given covered service. |
| Urgent Care |
An unexpected illness
or injury that is not life threatening but requires
outpatient medical care that cannot be postponed.
An urgent situation requires prompt medical attention
to avoid complications and unnecessary suffering,
such as a high fever. Examples include skin rashes
or ear infections. |
| Well Baby/Well Child
Care |
Routine care, testing,
checkups and immunizations for a generally healthy
child from birth through the age of six. |
| Wellness Program
|
A health management
program which incorporates the components of disease
prevention, medical self-care, and health promotion.
It utilizes proven health behavior techniques
that focus on preventive illness and disability,
which respond positively to lifestyle related
interventions. Programs are designed to integrate
with existing health care benefits, e.g., flex
benefits, HMO, PPO; support the reduction in the
demand for health care resources; and address
the issues of dependent coverage and services
for high-risk employees. |
