A review by health plans to grant prior approval for reimbursement of health care services is called

What types of medical treatments and medications may need prior authorization?

• Medications that may be unsafe when combined with other medications
• Medical treatments that have lower-cost, but equally effective, alternatives available
• Medical treatments and medications that should only be used for certain health conditions
• Medical treatments and medications that are often misused or abused
• Drugs often used for cosmetic purposes

No Surprises Act

The No Surprises Act was enacted in 2020 and goes into effect on January 1, 2022. It provides federal consumer protections against unanticipated out-of-network bills called “surprise bills.”

Surprise bills arise in emergencies when patients typically have little or no say in where they receive care. They also arise in non-emergencies when patients at in-network hospitals or facilities receive care from providers (such as anesthesiologists) who are not in-network and whom the patient did not choose.

The law requires surprise bills must be covered without prior authorization and in-network cost sharing must apply.1

How do I get a prior authorization?

If your health care provider is in-network, they will start the prior authorization process.

If you don’t use a health care provider in your plan’s network, then you are responsible for obtaining the prior authorization. If you don’t obtain it, the treatment or medication might not be covered, or you may need to pay more out of pocket.

Review your plan documents or call the number on your health plan ID card for more information about the treatments, services, and supplies that require prior authorization under your specific plan.

How does the prior authorization process work?

Typically, within 5-10 business days of receiving the prior authorization request, your insurance company will either:

• Approve your request
• Deny your request
• Ask for more information
• Recommend you try an alternative that’s less costly, but equally effective, before your original request is approved

These responses are based on input from clinical pharmacists and medical doctors who review the requests at the health insurance company.

If you’re unhappy with your prior authorization response, you or your health care provider can ask for a review of the decision.

Is prior authorization required in emergency situations?

No, prior authorization is not required if you have an emergency and need medication. However, coverage for emergency medical costs are subject to the terms of your health plan.

Why does my health insurance company need a prior authorization?

The prior authorization process gives your health insurance company a chance to review how necessary a medical treatment or medication may be in treating your condition.

For example, some brand-name medications are very costly. During their review, your health insurance company may decide a generic or another lower-cost alternative may work just as well in treating your medical condition.

How does prior authorization help me?

The prior authorization process can help you:

• Reduce the cost of expensive treatments and prescriptions by first requiring you to try a lower-cost alternative
• Avoid potentially dangerous medication combinations
• Avoid prescribed treatments and medications you may not need or those that could be addictive

Review your plan documents or call the number on your plan ID card for more information about the treatments, services, and supplies that require prior authorization under your specific plan.

The information in this glossary is for informational purposes only. It is not an absolute source of healthcare information.

Access

A patient's ability to obtain medical care. The level of access is determined by the medical services available, the location of the services, the hours of operation, and the cost of care.

Acupuncturist

Practitioner trained in the use of acupuncture, a procedure in which fine needles are inserted into certain areas of the body. Originating in the Orient, acupuncture is used to relieve pain, increase energy, and even treat substance addictions, like nicotine. The training and licensing process of acupuncturists varies among states.

Adjudication

The processing of a claim to determine proper payment.

Advance Directive

Directions given by a patient stating that, in the event he/she becomes incapacitated, the state is to withhold care if that is in accordance with the person s wishes.

Aftercare

Services that are provided after hospitalization and/or rehabilitation in accordance the specialized needs of the individual.

Allied Health Personnel

Trained and licensed health workers outside of physicians, dentists, optometrists, chiropractors, podiatrists, and nurses. The term generally refers to paramedical personnel who are health workers performing tasks otherwise performed by a physician. It may also refer to healthcare personnel who are not engaged in an independent practice.

Allowable Charge

The maximum fee that will be paid to a healthcare provider for a particular service.

Alternate Care

Medical care received instead of inpatient hospitalization. Alternate care could be outpatient surgery, home health care, nursing facility care, and nontraditional care providers, like midwives.

Alternative Therapy

Also known as complementary care, this term encompasses unconventional treatments such as chiropractic, homeopathy, massage therapy, and acupuncture.

Ambulatory Care

Health services given on an outpatient basis, without an overnight stay, such as a visit to a surgical center or doctor s office.

Annual Out-of-Pocket maximum

A dollar amount set by an insurance plan that caps the amount the insured must pay for covered expenses over the course of a calendar year.

Audiologist

A health professional who diagnoses, treats, and provides rehabilitation for individuals suffering from hearing loss.

Authorization/Authorized Services/Pre-Authorization

A requirement of some insurance companies that asks patients or their doctors to submit plans for intended medical treatment for the company to review before any treatment is rendered. Authorization does not guarantee payment for services.

Authorization requirements can vary between insurance companies. In some case, pre-authorization may be needed before a patient is admitted to a hospital or before care is given by certain providers.

Benefit Levels

The limit or degree of service a person is entitled to receive based on his or her contract with a health plan or insurer. Benefit levels vary greatly and should be verified before treatment is sought.

Benefits

The services covered under an enrollee s health plan.

Board Certified

A physician who has passed an examination given by a medical specialty board.

Board Eligible

A physician who has graduated from an approved medical school and who is eligible to take a specialty board examination.

Cafeteria Plan

A benefit program that offers a number of benefit options and allows workers to choose benefits to suit their own needs. Benefits may include cash and certain benefits from various group life, medical expense, disability, dental, and other plans. Also called flexible benefit plans.

Calendar Year

January to December of a year.

Calendar Year Deductible

The amount that the insured person must pay before insurance payment for covered service begins.

Capitation

A fixed, monthly payment that a health care provider receives to provide certain services for a patient before treatment is actually given and for a specified length of time (usually a year).

Case Management

A cost-effective plan to efficiently utilize health care resources to achieve the optimum patient outcome after an insured person with specific health care needs is identified.

CHIP Program

A state program established to provide immunizations for children in families with no insurance.

Chiropractor

A non-medical doctor, licensed by a state board, who uses manipulation to deal with the relationship of the nervous system and spinal column in the restoration and maintenance of health.

Chronic Care

Medical care for a patient with a long-term illness.

Claim

A request for payment of medical services under the terms of an insurance policy.

Claims Examiner

The person who reviews a claim for payment of medical services to determine if all information is accurate and if payment will be made.

Claims Review

The method used to review an enrollee s health care service claims before payment is made. The purpose of this monitoring system is to validate the medical appropriateness of the service and to be sure that the cost of the service is not excessive.

COBRA - The Consolidated Omnibus Budget Reconciliation Act

A federal law that requires employers with 20 or more workers to offer continued health insurance coverage to employees whose health insurance coverage has been terminated. This includes self-insured employers, but does not apply to insurance plans sponsored by the federal government or certain church related organizations defined by federal law. COBRA also applies to dependent children who lose coverage upon reaching maximum age limits.

Under COBRA, the participant must pay the full group premium, including any part the employer had been paying, plus 2% for administrative expenses.

Coverage under COBRA can be continued for:


• 18 months OR
• 29 months if the person becomes eligible for social security disability during the first 60 days of COBRA continuation OR
• 36 months if insured through a spouse s or parent s group coverage and the spouse or parent has died, divorced, or separated.

COBRA does not apply, and coverage does not remain in force, if the employer terminates the plan, fails to pay the premium, or goes out of business and cancels the plan. COBRA only applies when the group policy remains in force, even if the employer changes group plans.

Pre-existing conditions will be covered for people who are eligible for and have purchased a conversion policy or COBRA continuation coverage. New federal and state laws require all group health plans in Pennsylvania to limit exclusion of a pre-existing condition. There are rules about what constitutes a pre-existing condition and how long a person must wait before a new group health plan will begin to pay for care for that condition. Generally, if a person joins a new group plan, the old coverage will be credited toward the pre-existing condition exclusion period, provided there was no break in coverage for more than 63 days. (See also pre-existing condition.)

Coinsurance

The share of covered expenses, usually a percentage, that a person must pay after a deductible is reached. For example, a policy may require people to pay twenty percent of the cost of a procedure up to a certain dollar amount. Coinsurance is not the same as a copayment.

Comprehensive Major Medical Policy

A health insurance policy that covers both major medical coverages (hospitalization and surgery) and basic medical expense coverages.

Conversion Policy

Allows individuals who are covered through an employer's group health plan, but who lose the coverage as a result of job termination, to buy conversion coverage. A conversion policy is an individual policy offered by the insurance company connected to the employer's group plan. To qualify, a person must have been covered under the prior group health plan for at least three months. In addition, when applying, people cannot be covered under, or be eligible for, similar benefits through a group health plan or Medicare. Notification of conversion rights must be given to employees, and people must apply for a conversion policy within 31 days of receiving the notification. Surviving spouses, divorced spouses, and dependent children covered under the group health plan also may be eligible to purchase a conversion policy.

Conversion Privileges

Ability for an employee or beneficiaries, upon job termination, to convert healthcare coverage to an individual policy under the group coverage without providing evidence of insurability. See Conversion Policy.

Coordination of Benefits (COB)

Developed to avoid duplicate payments for services that are covered under more than one policy. COB determines an order in which the policies will pay for covered services. Some policies may reduce the amount of benefits payable if benefits are payable under other insurance coverage.

Copayment (copay)

A specified dollar amount that a patient must pay for covered health care services at the time the service is rendered. A copayment is not the same as coinsurance.

Covered Person

An individual who meets the eligibility requirements in a health plan. The premium payments for specified benefits for a covered person are paid by the contract holder (employer) to the insurance carrier.

Covered Services

Those medically necessary services and benefits that enrollees are entitled to receive under their insurance plan.

Covered or Eligible Expense

An expense that can be applied to a deductible or to coinsurance in a health care plan. It is a mistake to assume that an expense that is not covered can be applied to your deductible. If an expense is a non-covered expense, it can not be considered at all under a deductible or under coinsurance. It is a denied expense.

CPT Current Procedure Terminology

A listing of descriptive terms and identifying codes used for reporting medical services and procedures performed by healthcare providers. It includes medical, surgical and diagnostic codes.

Credentialing

Examination of the credentials of a physician or health care provider to determine whether he or she should be entitled to clinical privileges at a hospital or to a contract with a managed care organization (MCO).

Deductible

The amount of covered expenses a policyholder must pay before someone else will pay. The period for a deductible runs from January to December of every year and is called Calendar Year.

A Family Deductible is the total financial responsibility of a family unit during a calendar year. Example: For a family of 3 on a plan with a $100 individual and a $300 family deductible, each person must meet their $100 deductible for the year OR all 3 insured people combined must meet a total of $300. The family then does not have to pay any more deductible for the rest of the year, if the deductible is on a calendar basis.

Defined Benefit Plan

Employer sponsored health plan to provide workers with health benefits. An employer chooses a specific package of benefits to offer workers. The employer then asks health plans for a price for this intended benefits package. A defined benefit plan is different from a defined contribution plan.

Defined Contribution Plan

Employer sponsored health plan to provide workers with health benefits. In the defined contribution plan, each employee is given a set amount of money with which he or she can make the health plan purchasing decision by himself or herself. The employer is removed from being the intermediary. A defined contribution plan is different from a defined benefit plan.

Denial

Non-payment or non-authoriztion of a request for care, services, or claim payment. Denials are made if something is not medically appropriate or if it is not included as a benefit in the insurance coverage.

Dental Benefits

Some health plans offer dental care coverage as an optional benefit or rider that may be added at an additional cost.

Department of Health - DOH

Together with the Pennsylvania Insurance Department, issues the Certificate of Authority that allows HMOs to operate in Pennsylvania.

Dependents

A spouse, parent, other family member or other individual who fits the eligibility requirements for insurance coverage under the named insured.

Disenrollment

The procedure of dismissing individuals or groups from their enrollment with a health carrier.

Dual Choice

The employer is allowed to offer employees not one, but two health plans, which best meet their needs or budgets.

Duplication of Benefits

Overlapping or identical health coverage of an insured person under two or more plans.

Durable Medical Equipment

Equipment appropriate for home use that serves a medical purpose for a person who is ill or injured. Examples include hospital beds, wheelchairs, and oxygen equipment.

Durable Power of Attorney

Advance instructions from a patient to pre-designate another individual to make health care decisions in the event of that the patient becomes incapacitated through illness or trauma. This designated person then holds a power of attorney for the patient, but only for health care decisions.

Effective Date

The date health insurance protection begins.

Elective Service

An inpatient or outpatient procedure that benefits a patient but is not essential to survival.

Eligible Dependent

A dependent of a covered employee who meets the requirements specified in the group contract to qualify for health coverage.

Eligible Employee

An employee who meets the eligibility requiremenst specified in the group contract to qualify for health coverage.

Eligibility

The employer determines if a subscriber is eligible to receive services that are covered by the insurance plan.

Elimination Period

Specified number of days that a person must be eligible for coverage or disabled before a policy begins to pay benefits.

Emergency Care

Suggested with the sudden onset of severe or painful symptoms that would place a patient in serious jeopardy. In the event of a life-threatening emergency, patients should go to the nearest emergency room for treatment. Prior authorization is not required, but patients should notify their primary care provider within 24 hours, or as soon as is reasonably possible, so that appropriate, coordinated care can be arranged. The same procedure applies to out-of-area emergency care. Emergency care is not the same as urgent care. (See Urgent Care)

Emergicenter

A health care facility, for which the primary purpose is the provision of immediate, short-term medical care for urgent medical conditions. Also called a Freestanding Outpatient Surgical Center.

Employee Contribution

The portion of the insurance premium paid by the employee.

Employee Retirement and Income Security Act - ERISA

Broad ranging federal legislation passed in1973 directed primarily to employee retirement plans. ERISA allows some large employers to operate benefit plans exempt from state government regulations. ERISA also mandates the reporting and disclosure requirements for group life and health plans.

Employer Sponsored Insurance

Group health insurance coverage that is purchased and offered by an employer. The coverage can be through a private insurance company, or it can be what is called "self-funded" or "self-insured." "Self-funded" or "self-insured" means that an employer will use its own money, not insurance money, to pay for the healthcare expenses of its employees.

It is important to know whether the health insurance coverage offered by the employer's group policy is purchased through an insurance company or whether it is self-funded. Self-funded plans can provide excellent health coverage, but they are regulated by the federal government and are not required to offer the same benefits as private insurance plans that are regulated by state insurance laws.

Enrollee

Any person (an employee or dependent) who is properly enrolled with an insurance plan. Enrollee and member are used interchangeably.

Evidence of Insurability

Form that documents an individual s eligibility for health plan coverage when the person does not enroll in the open enrollment period. When an employee wants to switch to a different health plan in the middle of a contract year, the new health plan may require written information and a physical examination as proof that it will not be accepting a high risk patient.

Exclusions and Limitations

Conditions or circumstances that limit or exclude benefits payments. Exclusions can be suicide, self-inflicted injuries, war injuries, on-the-job accidents covered by workers' compensation, eye or dental treatment, cosmetic surgery, those services for which no charge is made, and services that are not medically necessary. Some policies also may limit or exclude treatment for mental illness or substance abuse.

Experimental Procedures

Otherwise known as investigational or unproved procedures, this covers all health care services, supplies, treatments, or drug therapies that have been determined by the health plan to not be generally accepted by health care professionals as an effective means of treating the illness for which their use is proposed. Experimental procedures are said to not be proven scientifically effective in treating the condition for which their use is prescribed.

Explanation of Benefits

A form sent by the insurance company after a claim has been made detailing whether or not the claim has been paid and why.

Extended Care Facility

A nursing home or similar setting which offers skilled, intermediate, or custodial care.

FDA

The Food and Drug Administration is a department under the federal government.

Fee-for-Service Health Insurance Plans - FFS

Also known as traditional or indemnity health insurance. The insurance company pays all, or a portion of, the bills after services are received by the insured. Deductibles may have to be paid before the policy begins to pay, and co-payments may have to be paid each time there is a claim.

Flex Accounts/Flexible Benefit Plan

A benefit program that offers employees a number of benefit options to tailor to their individual needs. Also called Cafeteria plans

Formulary

A list of the drugs and medications that an insurance company will pay for when a doctor prescribes them. Formularies are used by most managed care plans and vary by insurance company and insurance plan design. A physician is required to use only formulary drugs unless there are valid medical reasons to use a nonformulary drug.

Freestanding Emergency Medical Service Center

A health care facility that is physically separate from the hospital that provides prescheduled, outpatient surgical services. Also called a surgicenter.

Gatekeeper

A primary care physician who is responsible for managing all clinical aspects of the care for a patient who is enrolled in an HMO. These responsibilities include administering the patient s treatment and coordinating and authorizing all medical services, laboratory studies, and hospitalizations. In most HMOs, if an enrollee visits a specialist without prior authorization from his/her designated primary care physician, the medical services delivered by the specialist will have to be paid in full by the patient. (Also see PCP.)

Generic Drugs

An equivalent to a brand-name drug that is usually less expensive. Most insurance companies that provide drug benefits cover generic drugs but may require a member to pay the difference between a generic and a brand-name dug or pay a higher copay, unless there is no generic equivalent.

Geritrician

A medical specialist in the field of geriatrics, the branch of medicine dealing with the physiology of aging, and the diagnosis and treatment of diseases affecting the aged.

Gerontologist

A specialist in the scientific study of the sociological, clinical, biological, historical issues involved with aging. Different from a geriatrician, who is interested generally in the biological and clinical issues of aging.

Grievance

A formal complaint.

Group Health Insurance Plans

Health insurance offered through an employer or association.

Health Care Financing Administration- HCFA

The federal agency that oversees all aspects of health financing for Medicare and also oversees the Office of Managed Care and Medicaid.

Health Care Provider

Healthcare professionals who provide medical treatment and services.

Health Maintenance Organization - HMO

Organized system for health care that provides comprehensive services directly to enrolled members for a fixed fee. HMOs provide or arrange for health care services through a network or group of health care providers that are coordinated by the enrollees' primary care physician for routine office visits, diagnostic tests, hospital care, surgical care, emergency care and preventive services.

Some HMO s employ the physicians who treat enrolled members at an HMO clinic. Other HMO s contract with individual physicians or physician groups who act as gatekeepers and treat HMO members. Services provided outside the HMO network are not covered except for emergencies or with referrals from the primary care physician that have been approved by the HMO prior to the patient obtaining services.

HIPAA (Health Insurance Portability and Accountability Act of 1996)

Various federal laws designed to be implemented over a long period of time. Some laws will pertain to the standardization of health insurance forms using common terms. Other regulations will outline ways to protect the privacy of an individual's personal health information.

HMO Act of 1973

Federal law that required employers with more than 24 employees to offer an alternative to conventional indemnity health insurance in the form of a federally qualified HMO. The main intention of the Act was to encourage HMO development.

Home Care

Medical care for a patient who is not able to make frequent office or hospital visits. For example, a health care professional can administer intravenous therapy at the patient s residence. Home care reduces the need for patient hospitalization and the associated costs.

ICD-9-CM International Classification of Diseases

A listing of diagnoses and identifying codes used by doctors and other healthcare providers to describe a patient s diagnosis. It is a uniform language that all healthcare providers use to be paid for the treatments and services they provide to patients.

Indemnity Health Insurance

Also known as traditional or fee for service health insurance. The insurance company pays all or, a portion of, the bills after services are received by the insured. Deductibles may have to be paid before the policy begins to pay, and co-payments may have to be paid each time there is a claim. Enrollees are not required to stay within a managed care system.

Individual Health Plans

Health insurance purchased directly by an individual through an insurance company. People not covered by a group plan, or who want different or additional coverage other than that offered by the employer, can buy individual health insurance coverage or determine their eligibility under government sponsored health insurance.

Individual Practice Association - IPA

A type of open-panel HMO that contracts with an association of physicians who agree to provide services for HMO members.

Inpatient Services

Services that are ordered by a doctor for a patient who is in the hospital.

Insurability - See Evidence of Insurability Joint Commission for the Accreditation of Healthcare Organizations - JCAHOOrganization that reviews and accredits hospitals and other healthcare organizations.

Length of Stay

The number of consecutive days a patient is hospitalized.

Licensed Practical Nurse (LPN)

A nurse licensed by the state to carry out specified nursing duties under the direction of a Registered Nurse (RN).

Lifetime Maximum

The maximum amount of money a plan will pay toward a healthcare service over the course of the insured's lifetime.

Limited Fee Schedule

A fee structure under which the insurance company places limits (caps) on the dollar amounts it will reimburse providers for medical procedures and services.

Living Will

A form of advance directive, whereby the patient signs a document instructing what care can be withheld or utilized in case of incapacitating illness or trauma.

Long-Term Care

Services ordinarily provided in a skilled nursing, intermediate care, personal care, supervisory care, or elder care facility.

Mail Order Pharmacy

A method of dispensing medication directly to the patient through the mail. Mail-order drug distributors can purchase drugs in larger volumes than retail or wholesale outlets.

Major Medical Insurance Plan

A traditional type of medical expense coverage providing substantial benefits for hospital surgical expenses and physician's fees.

Managed Care

A term that includes health maintenance organizations (HMOs), preferred provider organizations (PPO s), integrated delivery systems, and others. These programs vary in provider choice, convenience and costs.

Mandated Benefits

Health benefits that health care plans are required by state or federal law to provide to members.

Medical Savings Account MSA

A savings account used to pay for routine medical expenses. A high-deductible insurance policy must also be purchased with a Medical Savings Account to pay for the high costs of severe illness or injury. Funds that are not used in the account by the end of the year are rolled over to the next year.

Medical Service Organization MSO

An integrated health care delivery network that contracts with payers to provide a comprehensive array of benefits.

Medicare

Medical coverage for individuals aged 65 or older, for those who have permanent kidney failure, and for certain people under 65 years of age who have disabilities. Medicare is the nation s largest health insurance program, covering approximately 39 million Americans.

Medicare coverage is in two parts, Part A and Part B.

Medicare Part A is for in-patient hospital coverage and is free to the individual. All other covered services, except for prescriptions, fall under Part B.

Part B has a premium. Individuals can choose whether or not they want Part B.

Medicare Supplement Policy (also Medigap)

Insurance provided by carriers to supplement the monies reimbursed by Medicare for medical services. Since Medicare pays physicians for services according to their own fee schedule, regardless of what the physician charges the individual may be required to pay the difference between Medicare s reimbursable charge and the physician s fee. Medigap insurance is meant to fill this gap in reimbursement, so that the Medicare beneficiary is not at risk for the difference.

Medicaid

A jointly funded, Federal-State health insurance program intended for certain low-income and needy people. This free coverage covers approximately 36 million individuals, including children, the aged, blind, and/or disabled, as well as people who are eligible to receive federally assisted income maintenance payments.

Member

A participant in a health plan who makes up part of the plan s enrolled population.

NCQA: National Committee for Quality Assurance

A nonprofit organization that reviews the accreditation of managed care organizations. The reviews are based on quality measures.

Network

A managed care term to describe the providers who have agreed to provide specific services for a specified fee from an insurance company and who have been accredited by that insurance company.

Nonparticipating Provider

A health care provider who has not contracted with the carrier or health plan to be a participating provider of health care.

Nurse Practitioner

A registered nurse who has advanced skills in the assessment of physical and psychological health status of individuals, families, and groups in a variety of settings through medical history taking and physical examination.

Obstetrical Services

Services provided for a woman who is pregnant.

Open Access

Open access arrangements allow members to see participating providers, usually specialists, without referral from the health plan s gatekeeper.

Out- of- Network

Health care services received or given outside an organized HMO, POS or PPO network of healthcare providers.

Out- of- Pocket Expense

Any medical care cost not covered by insurance that must be paid by the insured.

Outpatient Procedures and Services

Services given at a healthcare facility on a given day. You are not admitted to the hospital as an in-patient.

Participating Provider

A health services provider who has been credentialed by an insurance company and who has a contract with that insurance company to provide covered services to the members of an insurance plan. All participating providers as a group form a network.

Patient's Bill of Rights

Referring to federal or state proposals (or signed legislation) that typically mandates that health plans offer expanded external appeals policies, faster appeals decisions than offered in the past, greater access to specialists than was previously available in managed care plans, and other specific consumer protections.

PCP See Primary Care Physician

The primary care doctor, sometimes called a "gatekeeper", is usually the first physician that a person sees for an illness or office visit. The primary care physician can treat the patient directly or refer the patient to a specialist or admit the patient to the hospital. Many times, the primary care physician is a family doctor or doctor of internal medicine (internist).

Pennsylvania Health Care Cost Containment Council - PHC4

An independent state agency with the legislative mandate to report on the cost and quality of health care services in Pennsylvania.

Per-Diem Rate

Reimbursement rate for hospitals based on a flat rate per day of the patient s stay.

Physiatrist

A physician who specializes in physical medicine and rehabilitation, and who evaluates the physical functioning of an individual and oversees the individual s rehabilitation program.

Physical Therapy

A program of special exercises that can help an injury heal without restricting movement or limiting function. Not all plans cover physical therapy.

Physician Assistant (PA)

Physician assistants practice medicine with supervision by licensed physicians. They perform a wide range of duties such as history taking, diagnosis, drawing blood samples, urinalysis, and injection under the supervision of a physician. Often acting as first or second assistants in medical surgery, PAs provide preoperative and operative care.

Point of Service - POS

Combines features of an HMO and a PPO and allows members to decide for themselves whether or not to use network providers for health care services. A POS retains the primary care physician gatekeeper like HMO and requires members to pay higher co-payments and deductibles for out-of-network services like a PPO. For the maximum level of benefits, enrollees must consult the primary care physician prior to obtaining treatment or services.

POS choices include:

• a visit to the PCP for care or referral, patient responsibility will be a lower copayment
• self-referral-in-network
• self-referral out-of-network

Policy Year

The period of time that the policy is to remain in force.

Portable Coverage

Group insurance coverage that can be continued by an insured employee who leaves the covered group.

Post Partum

The period of up to 42 days after the delivery of a baby.

Pre-Authorization/ Authorization/Authorized Services

A requirement of some insurance companies that asks patients or their doctors to submit plans for intended medical treatment for the company to review before any treatment is rendered. Authorization does not guarantee payment for services.

Authorization requirements can vary between insurance companies. In some case, pre-authorization may be needed before a patient is admitted to a hospital or before certain providers give medical care.

Pre-certification

Approval of services by the insurance company before the patient receives the service. In many cases, payment for a service will be the patient s responsibility if pre-certification has not been given.

Pre-existing Condition

An illness or condition that was treated or diagnosed before a policy was issued. Many policies will not pay benefits for pre-existing conditions, or will only cover treatments after the policy has been in force for a specified period of time that will vary according to group or individual coverage.

Recent Pennsylvania laws help to assure continued coverage when employees change jobs and obtain health insurance through a group health plan.

Insurance companies may impose only one 12-month waiting period for any pre-existing condition treated or diagnosed in the previous six months. Prior health insurance coverage will be credited toward the pre-existing condition exclusion period as long as the person maintained continuous coverage without a break of more than 63 days.

Pregnancy is not a pre-existing condition. Newborns and adopted children covered within 30 days of birth, adoption, or placement for adoption are not subject to the 12-month waiting period.

If a person had group health coverage for one year (18 months for late enrollees), then switched jobs and went to another plan, the new health plan cannot impose another pre-existing condition exclusion period, provided there is no break in the coverage for more than 63 days.

Individuals who meet certain criteria are considered an eligible individual and guaranteed the right to buy individual health coverage from Blue Cross and Blue Shield plans in Pennsylvania without a pre-existing condition exclusion period. To be an eligible, individuals must:

1. have had 18 months of continuous credible coverage, at least the last day of which was under a group health plan;
2. have used up any COBRA continuation coverage for which they were eligible;
3. not be eligible for Medicare, Medicaid or a group health plan;
4. not have other health insurance.
5. apply for health insurance for which they are eligible within 63 days of losing prior coverage.

Preferred Provider Organization - PPO

A network of doctors, hospitals, and other health care providers that have agreed to provide services at a reduced rate. PPOs do not require an enrollee to choose a single primary care physician. PPO enrollees receive higher levels of coverage (lower deductibles, coinsurance, etc.) when they use preferred providers for medical care.

Premium

A prospectively determined rate that a member pays for specific health services. Generally, a comprehensive prepaid health plan will have a premium rate established for single members and for families.

Prescription Drug Coverage

Specified coverage that provides benefits for the purchase of drugs and medicines prescribed by a physician and not available over-the-counter. Most plans provide an identification card that allows the insured to obtain medications by paying a specific copay at a participating pharmacy.

Prescription Medication

A drug which has been approved by the Food and Drug Administration and which can, under federal or state law, be dispensed only pursuant to a prescription order from a duly licensed physician.

Preventive Care

Health care emphasizing priorities for prevention, early detection, and early treatment of conditions, generally including routine physical examination, immunization, and well-person care.

Primary Care Physician - PCP

A licensed physician in family practice, general internal medicine, or general pediatrics who provides primary care services for enrollees who have selected that doctor from the provider network. The PCP maintains a complete record of a patient s health care, coordinates non-emergency urgent care, conducts preventive screenings, and refers patients to specialists or for special diagnostic services.

Prior Authorization

The process used to obtain prior approval as to the appropriateness of a service or medication. Prior authorization does not necessarily guarantee coverage.

Probationary Period

The length of time an employee must wait before becoming eligible to enroll in a group insurance plan.

Professional Review Organization (PRO)

An organization that reviews the activities and records of a health care provider, institution, or group. The reviewer is generally a physician if a physician is the subject of the review; a group of administrators, physicians, and allied health care personnel if a hospital is the subject of the review; etc. The PRO can be state-sponsored or independent.

Provider

Healthcare professionals who provide medical treatment and services.

Quality Assurance (QA)

Quality assurance or quality assessment is the activity that monitors the level of care being provided by physicians, medical institutions, or any health care vehicle in order to ensure that health plan members are receiving the best care possible. The level of care is measured against pre-established standards, some of which are mandated by state and federal law.

Quality Improvement

A continuous process that identifies problems, examines solutions to those problems, and regularly monitors solutions implemented for improvement.

Quality of Care

A desired standard of excellence in the provision of health care.

Quote

A preliminary premium amount the insured and/or group will pay per month before underwriting factors are considered.

Referral

A recommendation or order by a physician or a managed care plan for a patient to be evaluated or treated by a different physician or specialist.

Registered Nurse (RN)

A nurse who has graduated from a formal, accredited program of nursing education and who has been granted an RN license by the appropriate state authority after passing a licensing examination.

Renewal Date

The specified date when the health insurance coverage will renew for another period, typically one year.

Report Card on Health Care

A tool used by employers, the government, employer coalitions, and consumers to compare and understand the actual performance of health plans. Report cards provide health plan performance data such as health care quality and utilization, consumer satisfaction, administrative efficiencies, financial stability, and cost control.

Retrospective Review

A manner of judging medical necessity and appropriate billing practices for services that have already been rendered.

Secondary Care

Health care services provided by medical specialists who generally do not have first contact with patients, but instead are referred to them by primary care and family physicians.

Self-Funding

Also known as self-insurance, it refers to a health care plan funded entirely by employers who do not purchase insurance. Self-funded plans may be self-administered, or the employer may contract with an outside administrator for an administrative-services-only arrangement.

Skilled Nursing Facility (SNF)

Typically an institution for convalescence or a nursing home, the skilled nursing facility provides a high level of specialized care for long-term or acute illness. It is an alternative to extended hospital stays or difficult home care.

Small Group Plan

A health insurance plan that is specially designed for employers with a number of employees under a specified amount.

Specialist

A doctor whose practice is not limited to primary health care services. A specialist has additional postgraduate or specialized training and is board certified.

Stop-loss Provision

A major medical policy provision under which the insurer will pay 100% of the insured's eligible medical expenses after the insured has incurred a specified amount of out-of-pocket expenses in deductible and coinsurance payments.

Subscriber

A member of an employer group who is eligible for healthcare coverage and who is properly enrolled in the insurance plan.

Surgeon

A physician who specializes in diseases and trauma that require operative procedures. Surgeons can be general surgeons as well as specialized surgeons in specific branches of medicine, like cardiovascular surgeons, neurosurgery, and pediatric surgery.

Surgicenter

A separate, freestanding medical facility specializing in outpatient or same-day surgical procedures. Surgicenters drastically reduce the costs associated with hospitalizations for routine surgical procedures because extended inpatient care is not required for specific disorders. Also called Freestanding Outpatient Surgical Center.

Tertiary Provider

If the specialty care that an insured may require is not available within that insured s network of providers, the PPO will refer the insured to a non-participating provider who is capable of providing the needed care. This provider is considered a tertiary provider and the service will be covered the same as if the provider were an in-network provider.

Third-Party Administrator (TPA)

An organization outside of the insuring organization that handles the administrative duties and sometimes utilization review. Third-party administrators are used by organizations that actually fund the health benefits but do not find it cost effective to administer the health plan benefits themselves.

Transfer

When a patient changes primary care groups. A formal process must be followed to change to another doctor.

Underwriting

The process of identifying and classifying the degree of risk represented by a proposed insured.

Urgent Care

Needed to minimize the severity of and complications from an unexpected illness or injury that is not an emergency or life-threatening. A PCP or a qualified medical professional who is covering the practice is available 24 hours a day. Urgent care is not the same as emergency care.

Usual, Customary and Reasonable Fee

Maximum dollar amount of a covered expense considered eligible for reimbursement under a major medical policy.

Utilization

Any use of medical services.

Vision Care Coverage

Coverage that provides benefits for expenses the insured incurs in obtaining eye examinations and corrective lenses.

Waiting Period

The amount of time individuals must wait after buying a policy before coverage begins.

Waiver

An agreement attached to an insurance policy that exempts certain disabilities or injuries from those that are normally covered by the policy.

Wellness

A health care process that fosters awareness and attitudes toward unhealthy lifestyles so that individuals can make informed choices and change their behavior to achieve optimum physical and mental health.

Workers' Compensation

Workers compensation provides health care benefits if you are injured or become ill on the job due to workplace exposure. Workers' compensation does not replace your regular health insurance. More information can be obtained from the Bureau of Workers' Compensation at 1-800-482-2383.

Work-Up

The total patient evaluation, which may include assessments, radiologic series, medical history, and diagnostic procedures

Which is a review of the appropriateness and necessity of care provided to patients prior to administration of care quizlet?

Which is responsible for reviewing health care provided by managed care organizations?

What is utilization review?

Which is a review of the appropriateness and necessity?