Glossary of Terms

To find the definition of a term, click on the corresponding first letter of the term above.

ACCIDENTAL INJURY - An objectively demonstrable impairment of bodily function or damage to part of the body caused by trauma from a sudden, unforeseen outside force or object, occurring at an identifiable time and place, and without a person's foresight or expectation.

 

ACTUARIES - Insurance professionals who perform the mathematical analysis necessary for setting insurance premium rates.

 

ACUTE CARE - Inpatient treatment in a hospital or other facility provider for medical and/or surgical conditions that require sustained medical intervention by a physician and skilled nursing care to safeguard a patient's life and health. The immediate medical goal of acute care is to stabilize the patient's condition, rather than upgrade or restore his or her abilities.

 

ALCOHOLISM - A behavioral or physical disorder manifested by repeated excessive consumption of alcohol to the extent that it interferes with a person's health or social or economic functioning.

 

ALCOHOLISM OR SUBSTANCE ABUSE TREATMENT FACILITY - A facility provider that is primarily engaged in providing detoxification and rehabilitative care for alcoholism or substance abuse or addiction.

 

AMBULATORY SURGICAL FACILITY - A facility provider, with an organized staff of physicians, which: (1) has permanent facilities and equipment for the primary purpose of performing surgical procedures on an outpatient basis; (2) provides treatment by or under the supervision of physicians and provides skilled nursing care when the patient is in the facility; (3) does not provide inpatient accommodations appropriate for a stay of longer than 12 hours; and, (4) is not primarily a facility used as an office or clinic for the private practice of a physician or other professional provider.

 

ANCILLARY SERVICES - Auxiliary or supplementary services, such as diagnostic services, home health services, physical therapy, and occupational therapy, used to support diagnosis and treatment of a patient's condition.

 

ANTITRUST LAWS - Legislation designed to protect commerce from unlawful restraint of trade, price discrimination, price fixing, reduced competition, and monopolies. See also Sherman Antitrust Act, Clayton Act, and Federal Trade Commission Act.

 

ARTIFICIAL ORGANS - Permanently attached or implanted man-made devices that replace all or part of a diseased or nonfunctioning body organ, including but not limited to, artificial hearts and pancreases.

 

BENEFIT PERIOD - The specified period of time during which an insured may receive covered services.

 

BLUECARD - A program that enables Blue Cross of Idaho to process claims for most covered services received by insureds outside of Blue Cross of Idaho's service area while capturing the local Blue Cross and/or Blue Shield Plan's provider discounts.

 

BRAND - A name, number, term, sign, symbol, design, or combination of these elements that an organization uses to identify one or more products.

 

BROKER - A salesperson who has obtained a state license to sell and service contracts of multiple health plans or insurers, and who is ordinarily considered to be an agent of the buyer, not the health plan or insurer.

 

CARVE-OUT - Specialty health service that an insurer or managed care plan obtains for its members by contracting with a company that specializes in that service. See also Carve-Out Companies.

 

CARVE-OUT COMPANIES - Organizations that have specialized provider networks and are paid on a capitation or other basis for a specific service, such as mental health, chiropractic, and dental. See also Carve-Out.

 

CASE MANAGEMENT - A process of identifying plan members with special health care needs, developing a health-care strategy that meets those needs, and coordinating and monitoring the care, with the ultimate goal of achieving the optimum health care outcome in an efficient and cost-effective manner.

 

CERTIFICATE OF AUTHORITY - The license issued by a state to an insurance company, which allows it to conduct business in that state.

 

CERTIFIED REGISTERED NURSE ANESTHETIST - An individual registered as a certified registered nurse anesthetist by the state where the service was rendered and performing within the scope of registration.

 

CERTIFIED SOCIAL WORKER - (with Private Practice Endorsement) - an individual licensed by the state where the service was rendered to provide diagnosis and treatment of mental or nervous conditions and performing within the scope of license.

 

CHILDREN'S HEALTH INSURANCE PROGRAM (CHIP) - A program, established by the Balanced Budget Act, designed to provide health assistance to uninsured, low-income children either through separate programs or through expanded eligibility under state Medicaid programs.

 

CHIROPRACTIC CARE - Services rendered, referred or prescribed by a chiropractic physician when practicing within the scope of license.

 

CHIROPRACTIC PHYSICIAN - An individual licensed to practice chiropractic care by the state where the service was rendered.

 

CLAIM - An itemized statement of health care services and their costs provided by a hospital, physician's office, or other facility or professional provider.

 

CLAIM FORM - An application for payment of benefits under a health plan.

 

CLAYTON ACT - A federal act which forbids certain actions believed to lead to monopolies, including (1) charging different prices to different purchasers of the same product without justifying the price difference, and (2) giving a distributor the right to sell a product only if the distributor agrees not to sell competitors' products. The Clayton Act applies to insurance companies only to the extent that state laws do not regulate such activities. See also Antitrust Laws.

 

CLINICAL PSYCHOLOGIST - An individual licensed to practice clinical psychology by the state where the service was rendered.

 

COINSURANCE - The percentage of the maximum allowance or the actual charge, whichever is less, an insured is responsible to pay out-of-pocket for covered services after satisfaction of any applicable deductibles or copayments, or both.

 

COMPREHENSIVE LIFETIME BENEFIT LIMIT - The greatest aggregate amount payable by an insurer on behalf of an insured for all covered services during all periods in which the insured has been continuously enrolled or covered under any agreement, certificate, contract or policy with that insurer. Payments applied toward specific lifetime benefit limits also apply toward the all-inclusive comprehensive lifetime benefit limit.

 

CONGENITAL ANOMALIES - A physical deformity present at or before birth that is significantly different from normal form or function, whether caused by a hereditary or developmental defect.

 

CONSOLIDATED OMNIBUS BUDGET RECONCILIATION ACT (COBRA) - A federal act which requires each group health plan to allow employees and certain dependents to continue their group coverage for a stated period of time following a qualifying event that causes the loss of group health coverage. Qualifying events include reduced work hours, death or divorce of a covered employee, and termination of employment.

 

CONTINUOUS CRISIS CARE - Hospice nursing care provided during periods of crisis in order to maintain a terminally ill insured at home. A period of crisis is one in which the insured’s symptom management demands predominantly skilled nursing care services.

 

CONTRACTING PROVIDER - A provider that has entered into an agreement with an insurer regarding payment for covered services rendered or provided to an insured.

 

COPAYMENT - A designated dollar and/or percentage amount separate from coinsurance that an insured is financially responsible for and must pay to a provider at the time certain covered services are rendered or provided.

 

COVERED PROVIDER - A provider from whom an insured must receive covered services in order to receive benefits.

 

COVERED SERVICE - A service, supply or procedure specified under an insured's policy for which benefits will be provided to an insured when rendered by a covered provider.

 

CREDENTIALING - The process of obtaining, reviewing, and verifying a provider's credentials -- the documentation related to licenses, certifications, training and other qualifications -- for the purpose of determining whether the provider meets the insurer's or managed care organization's pre-established criteria for participation in the network.

 

CUSTODIAL CARE - Care designed principally to assist a person in engaging in the activities of daily living; or services which constitute personal care, such as help in walking and getting in and out of bed; assistance in bathing, dressing, eating and using the toilet; preparation of special diets, and supervision of medication, which can usually be self-administered and which does not entail or require the continuous attention of trained medical or other paramedical personnel. Custodial care is normally, but not necessarily, provided in a nursing home, convalescent home, rest home or similar institution.

 

DEDUCTIBLE - The amount an insured is responsible to pay out-of-pocket before an insurer begins to pay benefits for covered services. The amount credited to the deductible is based on the maximum allowance or the actual charge, whichever is less.

 

DENTIST - An individual licensed to practice dentistry by the state where the service was rendered.

 

DENTISTRY OR DENTAL TREATMENT - The treatment of teeth and supporting structures, including but not limited to, replacement of teeth.

 

DIAGNOSTIC SERVICE - A test or procedure performed on the order of a physician or other professional provider because of specific symptoms, in order to identify a particular condition, disease, illness or accidental injury. Diagnostic services include, but are not limited to: (1) radiology services, (2) laboratory and pathology services, and (3) cardiographic, encephalographic and radioisotope tests.

 

DISEASE - Any alteration in the body or any of its organs or parts that interrupts or disturbs the performance of vital functions, thereby causing or threatening pain, weakness or dysfunction. A disease can exist with or without a person's awareness of it, and can be of known or unknown cause.

 

DISEASE MANAGEMENT - A coordinated system of preventive, diagnostic, and therapeutic measures intended to provide cost-effective, quality health care for a patient population who have or are at risk for a specific chronic illness or medical condition. Also known as disease state management.

 

DRUG UTILIZATION REVIEW - A review program that evaluates whether drugs are being used safely, effectively, and appropriately.

 

DURABLE MEDICAL EQUIPMENT - Items which can withstand repeated use, are primarily used to serve a therapeutic purpose, are generally not useful to a person in the absence of accidental injury, disease or illness and are appropriate for use in the patient's home.

 

DURABLE MEDICAL EQUIPMENT SUPPLIER - A business that sells or rents durable medical equipment.

 

EFFECTIVE DATE - The date when coverage for an insured begins under a policy.

 

ELECTRONIC DATA INTERCHANGE (EDI) - The application-to-application interchange of business data between organizations using a standard data format.

 

ELIGIBLE DEPENDENT - A person eligible for enrollment under an enrollee's coverage as specified in the Eligibility and Enrollment section of a specified policy.

 

ELIGIBLE PERSON - A person entitled to apply to be an enrollee as specified in the Eligibility and Enrollment section of a specified policy.

 

EMERGENCY ADMISSION REVIEW - An evaluation conducted by an insurer to determine the medical necessity of an insured's emergency inpatient admission or unscheduled maternity admission, and the attendant course of treatment.

 

EMERGENCY INPATIENT ADMISSION - An inpatient admission to a hospital or other inpatient facility due to the sudden, acute onset of a medical condition or an accidental injury which requires immediate inpatient medical treatment to preserve life or prevent severe, irreparable harm to a patient.

 

EMERGENCY MEDICAL CONDITION - A medical condition in which sudden and unexpected symptoms are sufficiently severe to necessitate immediate medical care. Emergency medical conditions may include, but are not limited to, heart attacks, cerebrovascular accidents, poisonings, loss of consciousness or respiration, and convulsions.

 

EMPLOYEE ASSISTANCE PROGRAM (EAP) - A mental health counseling program provided to employees and designed to identify an individual's or family's problem(s) and provide the short-term counseling necessary to achieve resolution of his/her/their identified problem(s).

 

EMPLOYEE RETIREMENT INCOME SECURITY ACT (ERISA) - A broad-reaching law that establishes the rights of pension plan participants, standards for the investment of pension plan assets, and requirements for the disclosure of plan provisions and funding.

 

ENROLLEE - An eligible person who has satisfied an insurer's eligibility requirements and has enrolled for coverage.

 

ENROLLMENT DATE - The date of enrollment of an individual under a policy or, if earlier, the first day of the probationary period for such enrollment.

 

EXPERIMENTAL AND/OR INVESTIGATIONAL - The use of any treatment, procedure, facility, equipment, drug, device or supply that: (1) is not yet generally recognized by physicians practicing within a given state as accepted medical practice, or (2) requires federal or other governmental approval, for other than experimental and/or investigational purposes, and such approval has not been granted at the time the treatment, procedure, facility, equipment, drug, device or supply is used.

 

FAMILY COVERAGE - The enrollment of an enrollee and two or more eligible dependents under a policy.

 

FEDERAL TRADE COMMISSION ACT - A federal act which established the Federal Trade Commission (FTC) and gave the FTC power to work with the Department of Justice to enforce the Clayton Act. The primary function of the FTC is to regulate unfair competition and deceptive business practices, which are presented broadly in the Act. As a result, the FTC also pursues violators of the Sherman Antitrust Act.

 

FEE-FOR-SERVICE (FFS) PAYMENT SYSTEM - A system in which the insurer will either reimburse the insured or pay the provider directly for each covered medical expense after the expense has been incurred.

 

FORMULARY - A listing of drugs, classified by therapeutic category or disease class, that are considered preferred therapy for a given population and that are to be used by an insurer's providers in prescribing medications.

 

FREESTANDING DIALYSIS FACILITY - A facility provider that is primarily engaged in providing dialysis treatment, maintenance or training to patients on an outpatient or home care basis.

 

GENERIC DRUG - Unbranded pharmaceutical drugs that meet the same standards for safety, purity, strength, and quality as brand name drugs but typically provide substantial dollar savings versus branded counterparts. AB rated generic drugs are chemically and therapeutically equivalent to corresponding brand name drugs.

 

GENERIC DRUG SUBSTITUTION - The dispensing of a drug that is the generic equivalent of a drug listed on a pharmacy benefit management plan's formulary.

 

GROUP - A sole proprietorship, partnership, association, corporation or other entity that has made application for group coverage and has agreed to comply with all the terms and requirements of a specified policy.

 

GUARANTEE ISSUE - An insurance policy provision under which all eligible persons who apply for insurance coverage and who meet certain conditions are automatically issued an insurance policy.

 

HEALTH BENEFIT PLAN - Any hospital or medical policy or certificate, any subscriber policy provided by a hospital or professional service corporation, or managed care organization subscriber policy. Health benefit plan does not include policies or certificates of insurance for specific disease, hospital confinement indemnity, accident-only, credit, dental, vision, Medicare supplement, long-term care or disability income insurance, student health benefits-only coverage issued as a supplement to liability insurance, Workers' Compensation or similar insurance, automobile medical payment insurance, or nonrenewable short-term coverage issued for a period of twelve (12) months or less.

 

HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA) - A federal act that protects people who change jobs, are self-employed, or who have preexisting medical conditions. HIPAA standardizes an approach to the continuation of health care benefits for individuals and members of small group health plans and establishes parity between the benefits extended to these individuals and those benefits offered to employees in large group plans. The act also contains provisions designed to ensure that prospective or current enrollees in a group health plan are not discriminated against based on health status.

 

HEALTH MAINTENANCE ORGANIZATION (HMO) - A health care system that assumes or shares both the financial risks and the delivery risks associated with providing comprehensive medical services to a voluntarily enrolled population in a particular geographic area, often in return for a fixed, prepaid fee.

 

HOLD HARMLESS PROVISION - A contract clause which prohibits providers from seeking compensation from patients for charges which exceed the insurer's maximum allowance for a covered service, excluding deductibles, coinsurance, and copayments.

 

HOME HEALTH AGENCY - Any agency or organization that is duly licensed by the appropriate licensing authority to provide skilled nursing care services and other therapeutic services in the state or locality in which it operates.

 

HOME HEALTH AIDE - An individual employed by a contracting hospice, under the direct supervision of a licensed registered nurse (R.N.), who performs, and trains others to perform, intermittent custodial care services which include, but are not limited to, assistance in bathing, checking vital signs, and changing dressings.

 

HOME INTRAVENOUS THERAPY COMPANY - A provider that is principally engaged in providing skilled nursing care services, medical supplies and equipment for certain covered home infusion therapy services to patients in their homes or other locations outside of a hospital.

 

HOSPICE - A public agency or private organization designated specifically to provide services for care and management of terminally ill patients, primarily in the home.

 

HOSPICE NURSING CARE - Skilled nursing care services and home health aide services provided as a part of a hospice plan of treatment.

 

HOSPICE PLAN OF TREATMENT - A written plan of care established and periodically reviewed by the attending physician that describes the services and supplies for the medically necessary palliative care and treatment to be provided to a patient by a hospice.

 

HOSPICE THERAPY SERVICES - Hospice therapy services include: (1) hospice physical therapy - the treatment by physical means, hydrotherapy, heat or similar modalities, physical agents, biomechanical and neurophysiological principles, and devices to relieve pain, to enable a patient to maintain basic functional skills and to manage symptoms; (2) respiration therapy, and (3) speech therapy.

 

ILLNESS - A deviation from the healthy and normal condition of any bodily function or tissue. An illness can exist with or without a person's awareness of it, and can be of known or unknown cause.

 

INDEPENDENT PRODUCER - Agents that represent the products of several health plans or insurers.

 

IN-NETWORK SERVICES - Covered services provided by a contracting provider.

 

INPATIENT - A patient who is admitted as a bed patient in a hospital or other facility provider and for whom a room and board charge is made.

 

INSURED - An enrollee or an enrolled eligible dependent.

 

LARGE EMPLOYER - Any person, firm, corporation, partnership or association that is actively engaged in business that, on at least fifty percent (50%) of its working days during the preceding calendar year, employed no less than fifty-one (51) eligible employees, the majority of whom were employed within a given state. In determining the number of eligible employees, companies that are affiliated companies, or that are eligible to file a combined tax return for purposes of state taxation, are considered one (1) employer.

 

LICENSED GENERAL HOSPITAL - A short term, acute care, general hospital that: (1) is an institution duly licensed in and by the state in which it is located and is lawfully entitled to operate as a general, acute care hospital; (2) for compensation from or on behalf of its patients, is primarily engaged in providing inpatient diagnostic and therapeutic services for the diagnosis, treatment and care of injured and sick persons by or under the supervision of physicians; (3) has organized, functioning departments of medicine and surgery; (4) provides 24-hour nursing service by or under the supervision of licensed registered nurses; and (5) is not predominantly a skilled nursing facility, nursing home, custodial care home, health resort, spa or sanatorium, place for rest, place for the aged, place for the treatment or rehabilitative care of mental or nervous conditions, place for the treatment or rehabilitative care of alcoholism or substance abuse or addiction, or place for hospice care.

 

LICENSED PHARMACIST - An individual licensed to practice pharmacy by the state where the service was rendered.

 

LICENSED PROFESSIONAL COUNSELOR (with Private Practice Endorsement) - An individual licensed by the state where the service was rendered to provide diagnosis and treatment of mental or nervous conditions and performing within the scope of license.

 

LIFETIME BENEFIT LIMIT - The greatest aggregate amount payable by an insurer on behalf of an insured for certain specified covered services during all periods in which the insured is continuously enrolled or covered under any agreement, certificate, contract or policy with the insurer. Payments applied toward specific lifetime benefit limits shall also apply toward the all-inclusive comprehensive lifetime benefit limit.

 

MANAGED CARE - The integration of both the financing and delivery of health care within a system that seeks to manage the quality, accessibility, and cost of that care.

 

MANAGED CARE ORGANIZATION - Any entity that utilizes certain concepts or techniques to manage the quality, accessibility, and cost of health care. Also known as a managed care plan.

 

MAXIMUM ALLOWANCE - The maximum allowance is the lesser of the billed charge or the amount established by Blue Cross of Idaho as the highest level of compensation for a covered service. If covered services are rendered outside the state of Idaho, the maximum allowance is the lesser of the billed charge or the amount established by a Blue Cross Blue Shield Association affiliate in the location of the covered services. The maximum allowance is determined using many factors, including pre-negotiated payment amounts; diagnostic related groupings (DRGs); a resource based relative value scale (RBRVS); the provider’s charge(s); the charge(s) of providers with similar training and experience within a particular geographic area; Medicare reimbursement amounts; and/or the cost of rendering the covered service.

 

MCCARRAN-FERGUSON ACT - A federal act that placed the primary responsibility for regulating health insurance companies and HMOs that service private sector (commercial) plan members at the state level.

 

MEDICAID - A jointly funded federal and state program that provides hospital expense and medical expense coverage to the low-income population and certain aged and disabled individuals.

 

MEDICAL SAVINGS ACCOUNT - A trust that individuals or employees of small businesses may establish to pay for out-of-pocket medical expenses.

 

MEDICALLY NECESSARY - The services or supplies provided by a hospital, physician, or other provider that are required to identify or treat a patient's condition, disease, illness or accidental injury and which are: (1) consistent with the symptoms or diagnosis and treatment of the patient's condition, disease, illness or accidental injury; (2) in accordance with commonly accepted standards of good medical practice in the state in which the services are rendered; (3) not primarily for the convenience of the patient or the patient's provider; and (4) the standard and most economical supply or level of service consistent with quality health care.

 

MEDICARE - A federal government sponsored medical insurance plan primarily for elderly and disabled persons.

 

MEDICARE PART A - The part of Medicare that provides basic hospital insurance coverage automatically for most eligible persons.

 

MEDICARE PART B - A voluntary program that is part of Medicare and provides benefits to cover the costs of physicians' services.

 

MEDICARE PART C - The part of Medicare that expands the list of different types of entities allowed to offer health plans to Medicare beneficiaries. Also known as Medicare Advantage.

 

MEDICARE ADVANTAGE - See Medicare Part C.

 

MEDICARE SUPPLEMENT - A private medical insurance plan that supplements Medicare coverage. Also known as a Medigap policy.

 

MEDIGAP POLICY - See Medicare Supplement.

 

MENTAL OR NERVOUS CONDITIONS - Means and includes mental disorders, mental illnesses, psychiatric illnesses, mental conditions and psychiatric conditions. This includes, but is not limited to, the following conditions: psychoses, neurotic disorders, schizophrenic disorders, affective disorders, personality disorders and psychological or behavioral abnormalities associated with transient or permanent dysfunction of the brain or related neurohormonal systems.

 

NETWORK - The group of physicians, hospitals and other providers that an insurer has contracted with to deliver medical services to its members for a specified product or line of business.

 

NONCONTRACTING PROVIDER - A provider that has not entered into an agreement with a specified insurer pertaining to payment for covered services rendered or provided to an insured under the program in which the insured is enrolled.

 

OPTOMETRIST - An individual licensed to practice optometry by the state where the service was rendered.

 

ORGAN PROCUREMENT - Diagnostic and medical services to evaluate or identify an acceptable donor for a recipient and a donor's surgical and hospital services directly related to the removal of an organ or tissue for such purpose. Transportation for a donor or for a donated organ or tissue is not an organ procurement service.

 

OUT-OF-NETWORK SERVICES - All covered services that are not in-network services.

 

OUT-OF-POCKET MAXIMUM - The maximum dollar amount of coinsurance paid by an insured in a calendar year after meeting the deductible before specified covered services are paid at 100% of the maximum allowance. See Total Out-of-pocket Maximum.

 

OUTPATIENT - A patient who receives services or supplies while not an inpatient.

 

OUTPATIENT DIABETIC EDUCATION - Specialized education services for insureds who are either newly diagnosed with diabetes or have had a recent complication of diabetes. Outpatient diabetes education includes instruction in the basic skills of diabetes management through books/educational material as well as an individual or group consultation with a certified diabetes educator, nurse or dietitian.

 

PAIN REHABILITATION - An intensive inpatient program administered by qualified health care professionals, under the orders of an attending physician, to a patient who is suffering chronic, intractable pain, regardless of its origin, which has failed to respond to medical or surgical treatment. Pain rehabilitation is intended to teach the patient how to control and cope with pain and regain normal function.

 

PHARMACY BENEFIT MANAGEMENT (PBM) PLAN - A type of specialty service organization that seeks to contain the costs, while promoting safer and more efficient use of prescription drugs or pharmaceuticals. Also known as a prescription benefit management plan.

 

PHYSICAL REHABILITATION - Medically necessary non-acute therapy rendered by qualified health care professionals, intended to restore a patient's physical health and well-being as close as reasonably possible to the level that existed immediately prior to the occurrence of a condition, disease, illness or accidental injury.

 

PHYSICAL REHABILITATION PLAN OF TREATMENT - A written plan established and periodically reviewed by an attending physician, which describes the services and supplies for the physical rehabilitation care and treatment to be provided to a patient.

 

PHYSICAL THERAPIST - An individual licensed to practice physical therapy by the state where the service was rendered.

 

PHYSICIAN - A doctor of medicine (M.D.) or doctor of osteopathy (D.O.) licensed to practice medicine by the state where the service was rendered.

 

PODIATRIST - An individual licensed to practice podiatry by the state where the service was rendered.

 

POINT-OF-SERVICE (POS) PRODUCT - A health care option that allows members of a managed care plan to choose at the time medical services are needed whether they will go to a provider within the plan's network or seek medical care outside the network.

 

POLICY - A policy of insurance between an insurer and a person or entity.

 

POLICY DATE - The date specified in a policy on which coverage under the policy commences for the insured.

 

PREADMISSION REVIEW - An evaluation conducted by an insurer to determine the medical necessity of an insured's inpatient admission and attendant course of treatment.

 

PREADMISSION TESTING - Tests and studies required in connection with a patient's inpatient admission to a hospital that are rendered or accepted by the hospital on an outpatient basis prior to a scheduled inpatient admission to the hospital. Preadmission testing does not include tests or studies performed to establish a diagnosis.

 

PREEXISTING CONDITION - A condition (whether physical or mental), regardless of the cause of the condition, for which medical advice, diagnosis, care or treatment was recommended or received during the six (6) months immediately preceding the enrollment date. Under HIPAA guidelines, a pregnancy existing on the enrollment date is not a preexisting condition under group coverage. Pregnancy can be considered a preexisting condition under individual coverage. Genetic information is not considered a preexisting condition in the absence of a diagnosis of the condition related to such information.

 

PREFERRED PROVIDER ORGANIZATION (PPO) - A health care benefit arrangement designed to supply services at a discounted cost by providing incentives for members to use designated health care providers (who contract with the PPO at a discount), but which also provides coverage for services rendered by health care providers who are not part of the PPO network.

 

PREMIUM - A prepaid payment or series of payments made to a health plan by purchasers, and often plan members, for medical benefits.

 

PREMIUM TAXES - State income taxes levied on insurance premiums.

 

PRESCRIPTION DRUGS - Drugs, biologicals and compounded prescriptions that can be dispensed only pursuant to a written prescription, that are listed with approval in the United States Pharmacopoeia, National Formulary or AMA Drug Evaluations published by the American Medical Association (AMA), that are prescribed for human consumption, and that are required by law to bear the legend: 'Caution-Federal Law prohibits dispensing without prescription.'

 

PRIMARY CARE - General medical care that is provided directly to a patient without referral from another physician. Primary care is focused on preventative care and the treatment of routine injuries and illnesses.

 

PRIMARY CARE GIVER - A person designated to give direct care and emotional support to an insured as part of a hospice plan of treatment. A primary care giver may be a spouse, relative, or other individual who has personal significance to the insured such as a neighbor or friend. A primary care giver must be a volunteer who does not charge a fee or expect or claim any other compensation for services provided to the insured.

 

PRIMARY CARE PHYSICIAN (PCP) - A physician who serves as a group member's first contact with a plan's health care system. In Idaho, PCPs must include at a minimum family practice and general practice physicians, general internists, pediatricians, obstetricians, and gynecologists. Also known as a primary care provider.

 

PRIOR AUTHORIZATION - A program that requires physicians or other health care providers to obtain certification of medical necessity prior to rendering a covered service. Also known as a medical necessity review.

 

PROVIDER - A person or entity that is licensed, where required, to render or provide covered services. Facility providers include hospitals, alcoholism or substance abuse treatment facilities, ambulatory surgical facilities, freestanding dialysis facilities, psychiatric hospitals, skilled nursing facilities, hospice, rehabilitation hospitals, home health agencies, independent laboratories, and home intravenous therapy companies. Professional providers include physicians, podiatrists, physical therapists, certified registered nurse anesthetists, clinical psychologists, licensed professional counselors, certified social workers, certified speech therapists, dentists, denturists, optometrists/opticians, chiropractic physicians, pharmacists, durable medical equipment suppliers, and ambulance transportation services.

 

PSYCHIATRIC HOSPITAL - A facility provider which is principally engaged in providing diagnostic and therapeutic services and rehabilitative services for the inpatient treatment of mental or nervous conditions, alcoholism or substance abuse or addiction; and where such services are provided by or under the supervision of an organized staff of physicians, and continuous nursing services are provided under the supervision of a licensed registered nurse.

 

QM COMMITTEE - A committee responsible for oversight of an insurer's or managed care organization's quality management program including the setting of standards, review of data, feedback to providers, follow-up, and approval of sanctions and for the quality of care delivered to members.

 

QUALIFYING PREVIOUS AND QUALIFYING EXISTING COVERAGE - Benefits or coverage provided under: (1) Medicare, Medicaid, civilian health and medical program for uniformed services (CHAMPUS), the Indian health service program, a state health benefit risk pool or any other similar publicly sponsored program; or (2) any other group or individual health insurance policy or health benefit arrangement whether or not subject to the state insurance laws, including coverage provided by a health maintenance organization, hospital or professional service corporation, or a fraternal benefit society.

 

QUALITY MANAGEMENT (QM) - An organization-wide process of measuring and improving the quality of the health care provided by an insurer or managed care organization.

 

RECOGNIZED TRANSPLANT CENTER - A licensed general hospital that: 1. Is approved by the Medicare program for the requested transplant; 2. Is included in the Blue Cross and Blue Shield System’s National Transplant Network; 3. Has arrangements with another Blue Cross and/or Blue Shield Plan for the delivery of the requested transplant, based on appropriate approval criteria established by that plan; or 4. Is approved by the plan based on the recommendation of plan’s Medical Director.

 

REFERRAL - A managed care organization's authorization, based on the determination of a member's primary care physician and review by the managed care organization's medical review staff, to utilize specialty physician services for a specified regimen of care.

 

RESPITE CARE - Care provided to a homebound insured as part of a hospice plan of treatment for the purpose of providing the primary care giver a temporary period of rest from the stress and physical exhaustion involved in caring for the insured at home.

 

SHERMAN ANTITRUST ACT - A federal act which established as national policy the concept of a competitive marketing system by prohibiting companies from attempting to (1) monopolize any part of trade or commerce, or (2) engage in contracts, combinations, or conspiracies in restraint of trade. The Act applies to all companies engaged in interstate and/or foreign commerce.

 

SINGLE COVERAGE - The enrollment of only the enrollee under a policy.

 

SKILLED NURSING CARE - Nursing services that must be furnished by or under the direct supervision of a licensed registered nurse (R.N.) to maximize the safety of a patient and to achieve the medically desired result pursuant to the orders and direction of an attending physician. The following components of skilled nursing care distinguish it from custodial care, which does not require professional health training: (1) the observation and assessment of the total medical needs of the patient; (2) the planning, organization and management of a treatment plan involving multiple services where specialized health care knowledge must be applied in order to attain the desired result; and (3) the rendering of direct nursing services to the patient where the ability to provide the services requires specialized training.

 

SKILLED NURSING FACILITY - A facility provider that is principally engaged in providing inpatient skilled nursing care to patients requiring convalescent care rendered by or under the supervision of a physician. A skilled nursing facility is not, other than incidentally, a place or facility that provides minimal care, custodial care, ambulatory care, or part-time care services; or care or treatment of mental or nervous conditions, alcoholism, or substance abuse or addiction.

 

SMALL EMPLOYER - Any person, firm, corporation, partnership or association that is actively engaged in business that employed an average of at least two (2) eligible employees on the first day of the plan year, but no more than fifty (50) eligible employees, the majority of whom were employed within a given state. In determining the number of eligible employees, companies that are affiliated companies, or that are eligible to file a combined tax return for purposes of state taxation, are considered one employer.

 

SPECIAL CARE UNIT - A designated unit within a hospital that has concentrated facilities, equipment and support services for the provision of an intensive level of care for critically ill patients.

 

SPECIALIST PHYSICIAN - A physician whose scope of practice is concentrated in a specific, specialized field of medicine. In Idaho, specialist physician does not include family practice and general practice physicians, general internists, pediatricians, obstetricians, and gynecologists, who are considered primary care physicians.

 

STOP LOSS INSURANCE - A type of insurance coverage that enables provider organizations or self-funded groups to place a dollar limit on their liability for paying claims and requires the insurer issuing the insurance to reimburse the insured organization for claims paid in excess of a specified yearly maximum.

 

SUBSTANCE ABUSE OR ADDICTION - A behavioral or physical disorder manifested by repeated excessive use of a drug or alcohol to the extent that it interferes with a person's health, social or economic functioning.

 

SURGERY - The performance, within the scope of a provider's license, of: (1) generally accepted operative and cutting procedures; (2) endoscopic examinations and other invasive procedures utilizing specialized instruments; (3) the correction of fractures and dislocations; and (4) customary preoperative and postoperative care.

 

THERAPY SERVICES - Therapy services include radiation therapy, chemotherapy, renal dialysis, physical therapy, respiration therapy, occupational therapy, speech therapy, enterostomal, growth hormone therapy, and home intravenous therapy.

 

TOTALLY DISABLED (or Total Disability) - A condition resulting from disease, illness, or injury by reason of which, and as certified in writing by an attending physician: 1. The insured is unable to perform the principal duties of regular employment or occupation for which the insured is or becomes qualified by reason of education, training, or experience; and the Insured is not in fact engaged in any work, profession, or vocation for fees, gain, or profit; or 2. An enrolled eligible dependent is so disabled and impaired thereby as to be unable to engage in the normal activities of an individual of the same age and gender.

 

TOTAL OUT-OF-POCKET - The combined deductible and out-of-pocket payments made by an insured in a calendar year before specified covered benefits are paid at 100% of the maximum allowance.

 

TRADITIONAL HEALTH INSURANCE - A health insurance program under which the insurer reimburses a contracting provider up to the insurer's maximum allowance less deductible, coinsurance, and copayments for each covered service rendered to the insured. Covered services rendered by noncontracting providers are reimbursed directly to the insured.

 

TRANSPLANT - Surgical removal of a donated organ or tissue and the transfer of that organ or tissue to a recipient.

 

TWO-PARTY COVERAGE - The enrollment of the enrollee and one eligible dependent under a policy.

 

UTILIZATION MANAGEMENT - Managing the use of medical services to ensure that a patient receives necessary, appropriate, high-quality care in a cost-effective manner.

 

UTILIZATION REVIEW - The evaluation of the medical necessity, efficiency and/or appropriateness of health care services and treatment plans.

 

WORKERS' COMPENSATION - A state-mandated insurance program that provides benefits for health care costs and lost wages to qualified employees and their dependents if an employee suffers a work-related injury or disease.