Common Health Insurance Terminology (PQR)
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Partial Disability
A condition in which, as a result of injury or sickness, the insured cannot
perform all of the duties of his occupation but can perform some. Exact
definitions vary from policy to policy.
Partial Hospitalization Services
Additional services provided to mental health or substance abuse patients which
provides outpatient treatment as an alternative or follow-up to inpatient
treatment.
Participant
An employee or former employee who is eligible to receive benefits from an
employee benefit plan or whose beneficiaries may be eligible to receive benefits
from the plan.
Participating Provider
A health care provider approved by Medicare to participate in the program and
receive benefit payments directly from carriers or fiscal intermediaries.
Peer Review
Review of health care provided by a medical staff with training equal to the
staff which provided the treatment.
Peer Review
Organization (PRO)
Groups of physicians who are paid by the federal government to conduct
pre-admission, continued stay and services reviews provided to Medicare patients
by Medicare approved hospitals.
Percentage
Participation
A provision in a Health Insurance contract which states that the insurer will
share losses in an agreed proportion with the insured. An example would be an
80-20 participation where the insurer pays 80% and the insured pays the 20% of
losses covered under the contract. Often erroneously referred to as coinsurance.
Physical Therapist
A trained medical person who provides rehabilitative services and therapy to
help restore bodily functions such as walking, speech, the use of limbs, etc.
Place of Service
This designates where the actual health services are being performed, whether it
be home, hospital, office, clinic, etc.
Point-of-Service (POS)
Plan
A type of managed care plan combining features of health maintenance
organizations (HMOs) and preferred provider organizations (PPOs). You can decide
whether to go to a network provider and pay a flat dollar or to an
out-of-network provider and pay a deductible and/or a coinsurance charge.
Policy Term
The period for which an insurance policy provides coverage.
Practical Nurse
A licensed individual who provides custodial type care such as help in walking,
bathing, feeding, etc. Practical nurses do not administer medication or perform
other medically related services.
Pre-Admission
Authorization
A cost containment feature of many group medical policies whereby the insured
must contact the insurer prior to a hospitalization and receive authorization
for the admission.
Pre-Admission
Certification
Before being admitted as an inpatient in a hospital, certain criteria are used
to determine whether the inpatient care is necessary.
Preauthorization
Previous approval for specialist referral or non emergency health care services.
Pre-existing Condition Pre-existing Condition exclusion Premium Preventive Care Primary Care Primary Care Physician Primary Coverage Prior Authorization Probationary Period Professional Review Organization Proration of Benefits Prospective Payment System Prospective Reimbursement Provider Qualified Medicare Beneficiary (QMB) Qualifying Event Rating Process Reasonable and Customary Charges Recipient Recurring Clause Referral Registered Nurse (RN) Rehabilitation Clause Reinstatement Relative Value Schedule Relative Value Unit Renewal Resource-based relative value scale (RBRVS) Respite Care Restoration of Benefits Retention Retrospective Rate Derivation (RETRO) Return of Premium Risk Analysis John K. Arnold Phone: 407-592-0311 (Best number to reach me) Let me know how I can
help you.
A health problem that existed or was treated before the date your insurance
became effective. Most health insurance contacts have a pre-existing condition
clause that describes under what conditions they will cover medical expenses
related to a pre-existing condition.
Generally, a "pre-existing condition exclusion" is a limitation or
exclusion of health benefits based on the fact that a physical or mental
condition was present before the first day of coverage. HIPAA limits the extent
to which a group health plan or issuer can apply a preexisting condition
exclusion, and, as stated above, prohibits issuers of individual health
insurance from applying a preexisting condition exclusion to an "eligible
individual."
During the preexisting condition exclusion period, the group health plan or
issuer may opt not to cover or pay for treatment of a medical condition based on
the fact that the condition was present prior to your enrollment date under the
new plan or policy. (The plan or issuer must, however, pay for any unrelated
covered services or conditions that arise once coverage has begun.) The
enrollment date is the first day of coverage, or if there is a waiting period
before coverage takes effect, the first day of the waiting period.
A group health plan can apply a pre-existing condition exclusion for no more
than 12 months (18 months for a late enrollee) after your enrollment date and
the preexisting condition exclusion period must be reduced by your prior
creditable coverage.
A group health plan cannot apply a pre-existing condition exclusion to an
individual who had creditable coverage (without a break of 63 or more days) of
12 months (18 months for a late enrollee).
PPO (Preferred Provider Organization)
A network of health care providers that have agreed to provide medical services
to a health plan's members at discounted costs. PPO members typically make their
own decisions about their health care rather than going through a primary care
physician like HMO member. The cost to use physicians within the PPO network is
less than using a non-network provider.
The amount you pay in exchange for health insurance coverage.
Prescription Medication
A drug which can be dispensed only by prescription and which has been approved
by the Food and Drug Administration.
This type of care is best exemplified by routine physical examinations and
immunizations. The emphasis is on preventing illnesses before they occur.
Basic health care provided by doctors who are in the practice of family care,
pediatrics, and internal medicine.
Under a health maintenance organization (HMO) or point-of-service (POS) plan, a
primary care physician is usually the first contact for health care. This is
often a family physician, internist, or pediatrician. A primary care physician
makes referrals to specialists if necessary.
This is the coverage which pays expenses first, without consideration whether or
not there is any other coverage. See also Coordination of Benefits.
A cost containment measure which provides full payment of health benefits only
when the hospitalization or medical treatment has been approved in advance.
A period of time between the effective date of a Health Insurance policy, and
the date coverage begins for all or certain physical conditions.
An organization of physicians which reviews services to determine if they are
medically necessary.
The adjustment of Health Insurance policy benefits by reason of the existence of
other insurance covering the same contingency.
A system of Medicare reimbursement for Part A benefits which bases most hospital
payments on the patient's diagnosis at the time of hospital admission.
A system where hospitals or other health care providers are paid annually
according to rate of payment which have been established ahead of time.
Any person (doctor or nurse) or institution (hospital, clinic, or laboratory)
that provides medical care.
This is a person whose income is below the federal poverty guidelines. In these
cases, the state is required to pay the Medicare Part B premiums, plus any
deductibles or copayments.
An occurrence (such as death, termination of employment, divorce, etc.) that
triggers an insured's protection under COBRA, which requires continuation of
benefits under a group insurance plan for former employees and their families
who would otherwise lose health care coverage.
Rapid Approval
Participating health insurance companies working exclusively with
eHealthInsurance Services, Inc. to provide instant, preliminary approval to
individuals that meet certain eligibility requirements. Individuals who have
non-conforming applications or applications that do not require additional
medical information will receive preliminary approval within 24 hours.
The steps used to determine a premium rate for a particular group based on the
amount of risk that group presents. Items that generally go into the rating
process include age, sex, type of industry, benefits, and administrative costs.
The charge for medical services which refers to the amount approved by the
Medicare Carrier for payment. Customary charges are those which are most often
made by a provider for services rendered in that particular area.
Anyone designated by Medicaid as being eligible to receive Medicaid benefits.
Health Insurance policy provision defining the duration of a period of time
during which the recurrence of a condition will be considered a continuation of
a prior period of disability or confinement.
A formal process that authorizes an HMO member to get care from a specialist or
hospital. Most HMOs require patients to get a referral from their primary care
doctor before seeing a specialist.
A licensed professional with a four-year nursing degree. Able to provide all
levels of nursing care including the administration of medication.
A clause in a Health Insurance policy, particularly a Disability Income policy,
that is intended to assist the disabled policyholder in vocational
rehabilitation.
Resumption of coverage under a policy that had lapsed.
A surgical schedule which basically compares the value of one surgical procedure
to another and establishes the surgical fee to be paid.
Sometimes used instead of dollar amounts in a surgical schedule, this number is
multiplied by a conversion factor to arrive at the surgical benefit to be paid.
Continuance of coverage beyond original terms signified by acceptance of a
premium payment for a new term.
A scale of national uniform relative values for all physicians' services. The
relative value of each service must be the sum of relative value units
representing physician work, practice expenses net of malpractice expenses, and
the cost of professional liability insurance.
Normally associated with Hospice care, respite care is a benefit to family
members of a patient whereby the family is provided with a break or respite from
caring for the patient. The patient is confined to a nursing home for needed
care for a short period of time.
A provision in many Major Medical Plans which restores a person's lifetime
maximum benefit amount in small increments after a claim has been paid. Usually,
only a small amount ($1,000 to $3,000) may be restored annually.
The portion of the premium which is used by the insurance company for
administrative costs.
A rating system whereby the employer becomes responsible for a portion of the
group's health care costs. If health care costs are less than the portion the
employer agrees to assume, the insurance company may be required to refund a
portion of the premium.
A rider or provision in a Health Insurance policy agreeing to pay a benefit
equal to the sum of all the premiums paid, minus claims paid, if claims over a
stated period of time do not exceed a fixed percentage of the premiums paid. 3
Rider
A document that modifies or amends an insurance contract
The process of determining what benefits to offer and premium to charge a
particular group.
Florida Health Insurance
Group, Employee Benefits & Individual Health Insurance Specialist
Website Address www.floridahealthinsurance.com
E-Mail:
John K Arnold
Phone: 407-830-0259
Fax: 407-386-7053
If outside the US, it is best to e-mail as we can respond more
quickly. Thanks.