Basic Health Insurance Terms

Question 1

Accidental Dental

Answer 1

accidental injury to sound and natural teeth directly related to the injury. Services must be rendered within 12 months of the accident (may also state: and the contract must have been in effect at the time of injury and remains in effect throughout time services are rendered.) Sound natural teeth are defined as natural teeth that are free of active clinical BAD decay, have at least 50% bony support and are functional in the arch.

Question 2

Acute Care

Answer 2

A level of care that can be rendered only in a hospital

Question 3

Adjudication

Answer 3

procedures followed to fully process claims

Question 4

Adjustment

Answer 4

correction to claim

Question 5

Administrative Services Only (ASO)

Answer 5

Service that requires third party to deliver administrative services to employer group.

• This requires employers to be at risk for the cost of health care services provided
• Common in self-funded (like BCBS)
• We administer self-funded portion, arrangement transfers entire risk to employer, making employer liable for all
• administrative fee plus additional charges for extra services

Question 6

Aggregate

Answer 6

a combined total (Ex: physical, occupational and speech therapy has an aggregate limit of 60 visits, therefore, 60 visits can be used for one or any combination between the three but cannot exceed 60 visits)

Question 7

Allowed Charge

Answer 7

the contracted rate that the provider and insurance agreed upon

Question 8

Appeal

Answer 8

arguing against the adverse decision made by the insurance (typically medical, typically done by the provider)

Question 9

Application

Answer 9

A legal document indicating a person wants to enter into a contract with insurance coverage

Question 10

Applied Behavior Analysis (ABA) Therapy

Answer 10

Charges for AVA therapy for treatment of Autism Spectrum Disorder (ASD)

Question 11

AWP (Average Wholesale Price)

Answer 11

The amount that the pharmacy pays for medications before marking them up.

Question 12

Balance Billing

Answer 12

The difference between the dollar amount charged by the provider for a service and fee schedule allowance for the services, generally applies to OON services (Ex: A provider bills for $500, we allow $300. If the provider bills the member the disallowed $200.)

Question 13

Benefit

Answer 13

covered service under contract or dollar amount paid for the covered service

Question 14

Blended Plan

Answer 14

a plan that has copays, coinsurance, and a deductible

Question 15

Capitation

Answer 15

The provider is paid a fixed dollar amount in advance regardless of the number of services they provide to a member, payment is established on a per member, per month basis

Question 16

Carryover Deductible

Answer 16

expenses that were incurred during the last three months of the year which were applied to that year’s deductible, may be carried over to the following year and applied to the deductible for the new year

Question 17

Claim

Answer 17

a request for payment for hospital, medical and/or surgical services rendered

Question 18

Coinsurance

Answer 18

a portion or percentage of covered health care costs the subscriber is responsible to pay

Question 19

Contract

Answer 19

legal agreement between subscriber and insurance plan, provides information

Question 20

Controlled Access

Answer 20

limits members to providers that are only participating in the geographical area where the product is sold

Question 21

Coordination of Benefits (COB)

Answer 21

A procedure that coordinates the payment of health care benefits between two or more health insurance companies. The purpose is to guarantee that the insured is paid no more than the total charges when duplicate coverage exists, thereby eliminating overpayment and duplication of benefits.

Question 22

Copay

Answer 22

dollar amount or percentage that a subscriber pays at the time medical services are rendered

Question 23

Cost Sharing

Answer 23

shared cost between the member and the health insurance company

Question 24

Covering Providers

Answer 24

A provider the member sees in place of their PCP or requested specialist, seen when a member’s PCP or requested specialist is unavailable

• Must be the same specialty
• Listed with the insurance as covering provider
• Accepts same co-pay as PCP or specialist
• Can write referrals and prescriptions

Question 25

CPT Code

Answer 25

identifies medical services and procedures//what we did (Ex: 99214 is an office visit CPT)

Question 26

Date of Service (DOS)

Answer 26

dates health services are provided

Question 27

Deductible

Answer 27

dollar amount, patient’s responsibility, must be met before insurance plan will provide benefits for covered services

Question 28

Effective Date

Answer 28

date insurance begins

Question 29

Eligible

Answer 29

one who is qualified for coverage

Question 30

Embedded Deductible

Answer 30

once any individual has met the individual deductible, subsequent medical costs will be covered for that individual, even if the family deductible has not been satisfied.

Question 31

Exclusion

Answer 31

a provision in the contract stating situations or conditions under which coverage is not afforded (Ex: no fault, workers’ compensation, cosmetic, experimental, etc.)

Question 32

Explanation of Benefits (EOB)

Answer 32

a statement sent to a subscriber that gives a detailed explanation of what action was taken on a claim

Question 33

Fee Schedule

Answer 33

accepted charges or established allowances (set amount that insurance company will pay for specific procedures) what the provider has agreed to accept in full from the insurance company

Question 34

General Anesthesia

Answer 34

a controlled state of unconsciousness, accompanied by a partial or complete loss of protective reflexes, including loss of ability to independently maintain airway and respond purposefully to physical stimulation or verbal command, produced by a pharmacologic or non-pharmacologic method or combination thereof.

Question 35

Group

Answer 35

body of subscribers eligible for group insurance with common identifying attribute (Ex: employment, union, association)

Question 36

ICD10 Code

Answer 36

identifies diseases and injuries, diagnosis or what’s wrong (Diagnosis Codes)

Question 37

ID Card

Answer 37

evidence of membership

Question 38

ID Number

Answer 38

number assigned to each subscriber by an insurance plan/references pertinent info concerning subscriber

Question 39

In Area

Answer 39

treatment obtained within plan’s operating service area (Ex: the operating are includes 8 counties of WNY (Allegheny, Cattaraugus, Chautauqua, Erie, Genesee, Niagara, Orleans, Wyoming)

Question 40

In Network (Participating Providers)

Answer 40

participating in the subscriber’s network of health care or referral obtained, in the network we are contracted with

Question 41

Inpatient Admission

Answer 41

at least 24 hours in a hospital

Question 42

Insurance

Answer 42

the act, system or business of insuring property, life, one’s person etc. against loss or harm, insurance company agrees to pay a provider on behalf of the insured for services rendered

Question 43

Limitation

Answer 43

benefits for which coverage is limited to specifics i.e. dollar amounts, number of visits, number of days of a hospital stay, etc.

Question 44

Local Anesthesia

Answer 44

the loss of pain sensation over a specific area of the anatomy without loss of consciousness

Question 45

Managed Care

Answer 45

A system of health care delivery that influences the utilization and cost of services, and measures performance. The goal is a system that delivers value by giving people access to quality, cost – effective health care//PCP coordinates care, tied to a certain network of doctors/specific area, makes providers accountable for the quality and cost of medical care

Question 46

Mandated Benefits

Answer 46

benefits which health plans are required by state or federal law to provide to policy holders and eligible dependents

Question 47

Marketplace (On Exchange)

Answer 47

public exchange (website) set up through NYS that sells insurance directly to individuals and small businesses

Question 48

Maxillary

Answer 48

The upper jaw

Question 49

Medically Necessary

Answer 49

service or treatment which is appropriate and consistent with diagnosis, according to accepted standards of practice in medical community of the area in which the health services are rendered//could not have been omitted without adversely affecting the members condition or quality of medical care rendered

Question 50

Members

Answer 50

a person eligible to receive or is receiving benefits from a health insurance program

Question 51

Network

Answer 51

group of health care providers contracted by insurance company to provide care to group of plan members

Question 52

Non-Intravenous Conscious Sedation

Answer 52

a medically controlled state of depressed consciousness while
maintaining the patient’s airway, protective reflexes and the ability to respond to stimulation or verbal commands. It includes administration of sedative and/or analgesic agent(s) by a route other than IV. (PO, PR, Intranasal, IM) and appropriate monitoring

Question 53

Occupational Therapy

Answer 53

Treatment or services rendered by a registered occupational therapist in a home setting or at a facility or institution who’s primary purpose is to provide medical care for an illness or injury. It is a treatment to improve motor skills, balance, and coordination. It helps kids and adults who struggle with everyday tasks like writing or getting dressed.

Question 54

Off-Exchange

Answer 54

private market sells insurance directly to individuals or through brokers

Question 55

Open Access

Answer 55

ability to see a provider in area/out of area/par or non-par

Question 56

Orthodontist

Answer 56

dentist whose practice includes the diagnosis, preventions, interceptions and treatment of all forms of malocclusion of the teeth and associated alterations in their surrounding structures

Question 57

Orthotic

Answer 57

medical equipment that is used to strengthen or support a weakened body part i.e. a knee, back or ankle brace, a shoe insert

Question 58

Out of Network (Non – Participating Providers)

Answer 58

not participating or proper referral not obtained, not in the network we are contracted with

Question 59

Out of Pocket (OOP) Maximum

Answer 59

amount subscriber must pay out of pocket before the plan pays 100%

Question 60

Outpatient

Answer 60

hospital entry without being admitted, anything under 24 hours. A patient who is receiving ambulatory care at a hospital or other health facility without being admitted to the facility

Question 61

Periodontics/Pediatric Dentist

Answer 61

dentist whose practice includes the teaching of comprehensive, preventive and therapeutic oral health care for children from birth through adolescence

Question 62

Physician

Answer 62

doctor licensed and qualified by law to practice medicine (provider)

Question 63

Physical Therapy

Answer 63

In physical therapy, trained professionals evaluate and treat abnormal physical function related to, for example, an injury, disability, disease or condition.

Question 64

Place of Service (POS)

Answer 64

location where health services are provided

Question 65

Pre/Prior Authorization

Answer 65

authorization for services, care that must be approved by the insurance company before the services are rendered to ensure that the proposed care is medically necessary and appropriate (Ex: inpatient stay at hospital, inpatient/outpatient services)

Question 66

Pre-certification

Answer 66

a review of certain services, by Blue Shield that must be conducted prior to rec care for those services. This is done to ensure that the proposed care is medically necessary and appropriate. Failure to obtain this review may result in a reduction of benefits, penalties or denial of services

Question 67

Pre-existing Condition

Answer 67

any illness, injury or condition for which treatment was received within six months prior to the contract effective date

Question 68

Premium

Answer 68

money paid to insurance plan for providing coverage under a contract, paid by group and/or subscriber

Question 69

Preventive/Routine Care

Answer 69

emphasizes priorities for prevention, early detection and early treatment of conditions, generally includes routine physical examination, immunization and well person care (Ex: colonoscopy, mammogram)

Question 70

Primary Care Physician (PCP)

Answer 70

physician that manages and coordinates subscriber’s health care, assumes responsibility for a patients treatment of illness and ongoing health maintenance

• General Practitioner
• Family Practitioner
• Pediatrician
• Internal Medicine

Question 71

Professional Component (PC)

Answer 71

the charge for professional services provided by the physician in association with the performance of a procedure

Question 72

Prosthetic

Answer 72

medical equipment that preplaces a lost body part, i.e. eye, breasts, leg, hand, etc.

Question 73

Provider

Answer 73

an individual or group that provides health care services, i.e. Hospitals, Physicians, Nurses, Laboratories, Physical Therapists

Question 74

Referral

Answer 74

written or verbal requirement for seeking authorization for care, typically a specialist, usually for a specific amount of time/number of visits// a recommendation or request from a physician for a member to receive care from another provider or facility, types – in network, out of network

Question 75

Regional Anesthesia

Answer 75

a term used for local anesthesia

Question 76

Rejection

Answer 76

insurance company refuses to accept claim

Question 77

Reimbursement

Answer 77

the dollar amount that is paid to the provider

Question 78

Rider

Answer 78

legal document added to a contract that adds, expands, or limits benefits (commercial only)

• Add (Ex: elective cosmetic surgery)
• Expand – (Ex: dependents through age 30 (only in NYS))
• Eliminate – Ex: elective abortion, contraceptives)
• State Mandated Riders
• Emergency Medical and Ambulance Service Rider
• Enteral Formulas and Solid Food Products Endorsement to Prescription Drug Riders
• Equipment & Supplies for the Treatment of Diabetes and Diabetes Self-Management Education
• HMO Chiropractic Care Rider
• Infertility Benefits Amendment
• Mammography Screening Rider
• Mental Health Rider

Question 79

Root Canal Treatment

Answer 79

a root canal is a treatment used to repair and save a tooth that is badly decayed or becomes infected. During the root canal procedure, the nerve and pulp are removed and the inside of the tooth is cleaned and sealed. Without treatment, the tissue surrounding the tooth will become infected and abscesses may form

Question 80

Skilled Nursing Facility (SNF)

Answer 80

an institution that is primarily engaged in providing skilled nursing care and related services for patients who require medical or nursing care, or rehabilitation services

Question 81

Specialist

Answer 81

studies and specializes in a specific field of medicine (Ex: allergist, surgeon, cardiologist)

Question 82

Speech Therapy

Answer 82

Speech therapy is the assessment and treatment of communication problems and speech disorders. It is performed by speech-language pathologists (SLPs), which are often referred to as speech therapists. Speech therapy techniques are used to improve communication. These include articulation therapy, language intervention activities, and others depending on the type of speech or language disorder.

Question 83

Stop Loss

Answer 83

amount insurance company will pay before reimbursement for additional benefits are considered to increase to 100% of the fee schedule for health care services received during remainder of that calendar year

Question 84

Subscriber

Answer 84

individual to whom a plan enters a contract

Question 85

Taxonomy Code

Answer 85

national specialty codes used by providers to indicate their
specialty at the claim level

Question 86

Technical Component (TC)

Answer 86

the charge for that portion of a procedure that includes the fees for the technical or non-physician personnel, supplies, utilities and equipment

Question 87

Temporomandibular Joint (TMJ)

Answer 87

the connecting hinge mechanism between the mandible (lower jaw) and base of the skull (temporal bone)

Question 88

True Family Deductible

Answer 88

no matter the family member, the full deductible must be met before the insurance plan will provide benefits for covered services

Question 89

Type of Service (TOS)

Answer 89

refers to services provided, surgery, anesthesia, x-ray, on claims, indicates the service category under which a service is classified (what happened on the DOS)

Question 90

Urgent Care

Answer 90

care that requires prompt attention but is not life threatening (Ex: earache, rash etc.)

Question 91

Usual and Customary

Answer 91

common charges for healthcare in a specific geographical area
Vendor – an outside agency contracted with the insurance company that administers and/or performs certain services on our behalf, such as claims processing or utilization review (Ex: Integra, Davis Vision)

Question 92

Voucher

Answer 92

statement sent to a provider that gives detailed explanations of what actions were taken on a claim and what their payment was for each claim (bulk check vs. Payment per claim)

Question 93

Well Care

Answer 93

usually for children, a non-sick visit to a physician

Question 94

Withhold

Answer 94

an amount of money held back from a provider payment as part of a risk arrangement. Based on the performance versus the medical loss ratio, the withhold is either returned or not, in whole or part. This is an incentive for appropriate utilization and quality of care.