Actual Charge
The Actual Charge made for a covered service by the provider who furnishes it.

Aggregate Maximum (Lifetime)
The maximum benefit that will be paid under the Policy for all Covered Medical Expenses incurred by a Covered Person that accumulate from one year to the next.

Aggregate Maximum (Policy Year)
The maximum benefit that will be paid under the Policy for all Covered Medical Expenses incurred by a Covered Person during the Policy Year.

Ambulatory Care
Health services provided without the patient being admitted. Also called outpatient care.The services of ambulatory care centers, hospital outpatient departments, physicians'offices and home health care services fall under this heading provided that the patientremains at the facility less than 24 hours. No overnight stay in a hospital is required.

Assistant Surgeon
Services for a primary procedure may require the technical skills of another qualified medical physician. This provider is called an assistant surgeon.

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B

Behavioral Health
An umbrella term that includes mental health, psychiatric, marriage and familycounseling, addictions treatment. Many states have "parity" laws that attempt to requirethat behavioral health insurance coverage be provided "on par" to physical healthcoverages.

Brand Name Prescription Drug or Medicine
A Prescription Drug that is protected by trademark registration.

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C

Co-Payment (Copay)
The amount that must be paid by the Covered Person at the time services are rendered by a Preferred Provider. Copay amounts are the responsibility of the Covered Person.

Co-Surgeons
Under certain circumstances, two surgeons, usually with different skills, may be required in the management of specific surgical procedures.

Coinsurance
The percentage of Covered Medical Expenses payable by the Covered Person under this Accident and Sickness Insurance Plan.
The Covered Person coinsurance amount is payable in addition to the applicable copay (preferred providers) or deductible (non-preferred providers.)

Contract Year
A period of twelve (12) consecutive months, commencing with each Anniversary Date. May or may not coincide with a calendar year.

Coordinate of Benefits (COB)
Provision regulating payments to eliminate duplicate coverage when a claimant is covered by multiple group plans. The procedures set forth in a Subscription Agreement to determine which coverage is primary for payment of benefits to Members with duplicate coverage. Used by insurers to avoid duplicate payment for losses insured under more than one insurance policy. A coordination of benefits, or "nonduplication," clause in either policy prevents double payment by making one insurer the primary payer, and assuring that not more than 100 percent of the cost is covered. Standard rules determine which of two or more plans, each having COB provisions, pays its benefits in full and which becomes the supplementary payer on a claim.

Covered Medical Expense
Those charges for any treatment, service, or supplies covered by the Policy which are:

• not in excess of the Reasonable Charges, or,
• not in excess of the charges that would have been made in the absence of this coverage, and,
• incurred while the Policy is in force as to the Covered Person, except with respect to any expenses payable under the Extension of Benefits provision

Covered Person
A covered student or dependent whose coverage is in effect under the Policy.

Creditable Coverage
A person's prior medical coverage as defined in the Federal Health Insurance Portability and Accountability Act (HIPAA) of 1996. Such coverage includes the following:

• Coverage issued on a group or individual basis
• Medicare
• Medicaid
• Military-sponsored health care
• A program of the Indian Health Service
• A state health benefits risk pool
• The Federal Employees' Health Benefit Plan (FEHBP)
• A public health plan as defined in the regulations
• Any health benefit plan under Section 5(e) of the Peace Corps Act

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D

Deductible
A specific amount of Covered Medical Expenses that must be incurred and paid for by the Covered Person before benefits are payable under the Plan. Deductible amounts are the responsibility of the Covered Person.

Drug Formulary
Varying list of prescription drugs approved by a given health plan for distribution to acovered person through specific pharmacies. See also Formulary.

Durable Medical Equipment (DME)
Items of medical equipment owned or rented which are placed in the home of an insuredto facilitate treatment and/or rehabilitation. DME generally consist of items which canwithstand repeated use. DME is primarily and customarily used to serve a medicalpurpose and is usually not useful to a person in the absence of illness or injury.

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E

Elective Treatment
Medical treatment that is not necessitated by a pathological change in the function or structure in any part of the body occurring after the Covered Person's effective date of coverage. Elective treatment includes, but is not limited to: tubal-ligation; vasectomy; breast reduction; sexual reassignment surgery; submucous resection and/or other surgical correction for deviated nasal septum, other than necessary treatment of covered acute purulent sinusitis; treatment for weight reduction; learning disabilities; immunization; vaccines; treatment of infertility; and routine physical examinations.

Electronic claim
A digital representation of a medical bill generated by a provider or by the provider'sbilling agent for submission using telecommunications to a health insurance payer.

Emergency Medical Condition
A recent and severe medical condition, including, but not limited to, severe pain, which would lead a prudent layperson possessing an average knowledge of medicine and health, to believe that their condition, Sickness, or Injury is of such a nature that failure to get immediate medical care could result in:

• Placing the person’s health in serious jeopardy; or
• Serious impairment to bodily function; or
• Serious dysfunction of a body part or organ; or
• In the case of a pregnant woman, serious jeopardy to the health of the fetus. It does include an Accident or serious illness such as heart attack, stroke, poisoning, loss of consciousness or respiration, and convulsions. It does not include elective care, routine care, or care for non-emergency illness.

Episode of care
A term used to describe and measure the various health care services and encountersrendered in connection with identified injury or period of illness.

Evidence or Explanation of Coverage (EOC) or Explanation of Benefits (EOB)
A booklet provided by the carrier to the insured summarizing benefits under an insuranceplan.

Exclusions
Conditions or situations not considered covered under contract or plan. Clauses in an insurance contract that deny coverage for select individuals, groups, locations, properties or risks. Providers will negotiate for exclusions for outliers and carve-out of certain high cost procedures, while payers will negotiate for exclusions to avoid payment of higher cost care.

Experimental or Investigational
Procedures or services with insufficient clinical documentation to be demonstrated as broadly accepted by the medical community.

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F

Fee-For-Service
Traditional method of payment for health care services where specific payment is made for specific services rendered. Usually people speak of this in contrast to capitation, DRG or per diem discounted rates, none of which are similar to the traditional fee for service method of reimbursement. Under a fee-for-service payment system, expenditures increase if the fees themselves increase, if more units of service are provided, or if more expensive services are substituted for less expensive ones. This system contrasts with salary, per capita, or other prepayment systems, where the payment to the physician is not changed with the number of services actually used. Payment may be made by an insurance company, the patient or a government program such as Medicare or Medicaid.With respect to the physicians or other supplier of service, this refers to payment in specific amounts for specific services rendered--as opposed to retainer, salary, or other contract arrangements. In relation to the patient, it refers to payment in specific amounts for specific services received, in contrast to the advance payment of an insurance premium or membership fee for coverage, through which the services or payment to the supplier are provided.

Formulary
An approved list of prescription drugs; a list of selected pharmaceuticals and their appropriate dosages felt to be the most useful and cost effective for patient care.Organizations often develop a formulary under the aegis of a pharmacy and therapeutics committee. In HMOs, physicians are often required to prescribe from the formulary. See also Drug Formulary.

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G

Gatekeeper
A primary care physician (PCP) or managed care entity responsible for determining when and what services a patient can access and receive reimbursement for. A primary care physician is involved in overseeing and coordinating all aspects of a patient's medical care. In order for a patient to receive a specialty care referral or hospital admission, the PCP must preauthorize the visit, unless there is an emergency. The term gatekeeper is also used in health care business to describe anyone (EAP, employer based case manager, Utilization Review entity, etc.) which makes the decision of where a patient will receive services.

Generic Prescription Drug or Medicine
A Prescription Drug that is not protected by trademark registration, but is produced and sold under the chemical formulation name.

Group Practice
A group of persons licensed to practice medicine in the State, who, as their principal professional activity, and as a group responsibility, engage or undertake to engage in the coordinated practice of their profession primarily in one or more group practice facilities, and who in their connection share common overhead expenses if and to the extent such expenses are paid by members of the group, medical and other records, and substantial portions of the equipment and the professional, technical, and administrative staffs.

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H

HCFA
Health Care Financing Administration

HCFA 1500
The Health Care Finance Administration's standard form for submitting provider service claims to third party companies or insurance carriers.

Health Insurance Portability and Accountability Act of 1996 (HIPAA)
Sometimes referred to as the Kennedy-Kassebaum bill, this legislation sets a precedentfor Federal involvement in insurance regulation. It sets minimum standards for regulationof the small group insurance market and for a set group in the individual insurancemarket in the area of portability and availability of health insurance. As a result of thislaw, hospitals, doctors and insurance companies are now required to share patientmedical records and personal information on a wider basis. This wide-based sharing ofmedical records has led to privacy rules, greater computerization of records andconsumer concerns about confidentiality.

Health Maintenance Organization (HMO)
HMOs offer prepaid, comprehensive health coverage for both hospital and physician services. The HMO is paid monthly premiums or capitated rates by the payers, which include employers, insurance companies, government agencies, and other groups representing covered lives. An HMO contracts with health care providers, e.g., physicians, hospitals, and other health professionals. The members of an HMO are required to use participating or approved providers for all health services and generally all services will need to meet further approval by the HMO through its utilization program. HMOs are the most restrictive form of managed care benefit plans because they restrict the procedures, providers and benefits.

Home Health Care
Full range of medical and other health related services such as physical therapy, nursing, counseling, and social services that are delivered in the home of a patient, by a provider.

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I

ICD-9 Procedure Codes
Codes which define procedures instead of diagnoses and are mandatory on hospital bills to substantiate the use of the operating room. These codes consist of two digits and there may be up to two digits more to modify the base code.

Incidental (Separate) Procedure
A procedure that is commonly performed at the same time as the primary procedure and is clinically an integral part of the total service. It usually requires minimal additional physician resource and therefore, does not warrant separate reimbursement.

Indemnity Plan (Indemnity health insurance)
A plan which reimburses physicians for services performed, or beneficiaries for medical expenses incurred. Such plans are contrasted with group health plans, which provide service benefits through group medical practice.

Injury
Bodily Injury caused by an Accident; this includes related conditions and recurrent symptoms of such Injury.

Inpatient Care
Care given a registered bed patient in a hospital, nursing home or other medical or post acute institution.

Internal Medicine
Generally, that branch of medicine that is concerned with diseases that do not require surgery, specifically, the study and treatment of internal organs and body systems; it encompasses many subspecialties; internists, the doctors who practice internal medicine, often serve as family physicians to supervise general medical care.

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J

Sorry, we have no glossary items beginning with the letter “J”.

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K

Sorry, we have no glossary items beginning with the letter “K”.

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L

Sorry, we have no glossary items beginning with the letter “L”.

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M

Managed Care
Systems and techniques used to control the use of health care services. Includes a review of medical necessity, incentives to use certain providers, and case management. The body of clinical, financial and organizational activities designed to ensure the provision of appropriate health care services in a cost-efficient manner. Managed care techniques area post often practiced by organizations and professionals which assume risk for a defined population (e.g., health maintenance organizations) but this is not always the case.

Managed care is a broad term and encompasses many different types of organizations, payment mechanisms, review mechanisms and collaborations. Managed care is sometimes used as a general term for the activity of organizing doctors, hospitals, and other providers into groups in order to enhance the quality and cost-effectiveness of health care. Managed Care Organizations (MCO) include HMO, PPO, POS, EPO, PHO, IDS, AHP, IPA, etc. Usually when one speaks of a managed care organization, one is speaking of the entity which manages risk, contracts with providers, is paid by employers or patient groups, or handles claims processing. Managed care has effectively formed a "go-between", brokerage or 3rd party arrangement by existing as the gatekeeper between payers and providers and patients. The term managed care is often misunderstood, as it refers to numerous aspects of healthcare management, payment and organization. It isbest to ask the speaker to clarify what he or she means when using the term "managedcare". In the purest sense, all people working in healthcare and medical insurance can bethought of as "managing care." Any system of health payment or delivery arrangementswhere the plan attempts to control or coordinate use of health services by its enrolledmembers in order to contain health expenditures, improve quality, or both. Arrangementsoften involve a defined delivery system of providers with some form of contractualarrangement with the plan.

Medicaid
Medicaid is a program funded jointly by federal and state governments to provide medical assistance to persons with low income and assets. Each state determines the eligibility requirements, scope of services, rates of reimbursements and administers its own Medicaid program. Medicaid programs are payers of last resort, that is, they determine eligibility and payments after Group and blanket insurance plans.

Medical Evacuation
When a member is evacuated to an appropriate medical facility due to an emergency medical situation.

Medically Necessary
A service or supply that is necessary, and appropriate, for the diagnosis or treatment of a Sickness, or Injury, based on generally accepted current medical practice. In order for a treatment, service, or supply to be considered Medically Necessary, the service or supply must:

• Be care or treatment which is likely to produce as significant positive outcome as any alternative service or supply, both as to the Sickness or Injury involved and the person’s overall health condition. It must be no more likely to produce a negative outcome than any alternative service or supply, both as to the Sickness or Injury involved and the person’s overall health condition;
• Be a diagnostic procedure which is indicated by the health status of the person. It must be as likely to result in information that could affect the course of treatment as any alternative service or supply, both as to the Sickness or Injury involved and the person’s overall health condition. It must be no more likely to produce a negative outcome than any alternative service or supply, both as to the Sickness or Injury involved and the person’s overall health condition; and
• As to diagnosis, care, and treatment, be no more costly (taking into account all health expenses incurred in connection with the treatment, service, or supply) than any alternative service or supply to meet the above tests. In determining if a service or supply is appropriate under the circumstances, the insurer may take into consideration:
• Information relating to the affected person’s health status;
• Reports in peer reviewed medical literature;
• Reports and guidelines published by nationally recognized health care organizations that include supporting scientific data;
• Generally recognized professional standards of safety and effectiveness in the United States for diagnosis, care, or treatment;
• The opinion of health professionals in the generally recognized health specialty involved; and
• Any other relevant information brought to the insurer’s attention.

Most times the insurer will not consider the following Medically Necessary:

• Those that do not require the technical skills of a medical, mental health, or dental professional; or
• Those furnished mainly for the personal comfort, or convenience, of the person, any person who cares for him or her, or any person who is part of his or her family, any health care provider, or health care facility; or
• Those furnished solely because the person is an inpatient on any day on which the person’s Sickness or Injury could safely and adequately be diagnosed or treated while not confined; or
• Those furnished solely because of the setting if the service or supply could safely and adequately be furnished, in a Physician’s or a dentist’s office, or other less costly setting.

The fact that any particular Physician may prescribe, order, recommend, or approve a service or supply does not, of itself, make the service or supply Medically Necessary.

Medicare
Medicare is a Federal health insurance program for:

• people aged 65 or older even if they continue to work
• people who have met the Social Security Administration definition of disability and have been receiving Social Security benefits for 2 calendar years. (Medicare coverage may continue up to 36 months if a claimant returns to work but has not recovered from their disabling condition). Those covered include disabled workers at any age, disabled widows, and widowers age 50 or over, beneficiaries age 18 and older who receive benefits because of disability beginning before age 22 and disabled railroad retirement annuitants.
• people who have chronic kidney disease with kidney failure and are receiving dialysis.

Midlevel Practitioner
Nurse practitioners, certified nurse-midwives and physicians' assistants who have beentrained to provide medical services that otherwise might be performed by a physician.Midlevel practitioners practice under the supervision of a doctor of medicine orosteopathy who takes responsibility for the care they provide.

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N

Negotiated Charge
The maximum charge a Preferred Care Provider has agreed to make as to any service or supply for the purpose of the benefits under the Plan.

Network
An affiliation of providers through formal and informal contracts and agreements. Networks may contract externally to obtain administrative and financial services. A listof physicians, hospitals and other providers who provide health care services to thebeneficiaries of a specific managed care organization.

Non-participating Physicians (or Provider)
A provider, doctor or hospital that does not sign a contract to participate in a health plan,usually which requires reduced rates from the provider. In the Medicare Program, thisrefers to providers who are therefore not obligated to accept assignment on all Medicareclaims. In commercial plans, non-participating providers are also called out of networkproviders or out of plan providers. If a beneficiary receives service from an out ofnetwork provider, the health plan (other than Medicare) will pay for the service at areduced rate or will not pay at all.

Non-Preferred Care Provider (or Non-Preferred Provider)
A health care provider that has not contracted to furnish services or supplies at a Negotiated Charge.

Non-Preferred Pharmacy
A Pharmacy not party to a contract with the insurance company, or a Pharmacy that is party to such a contract but which does not dispense Prescription Drugs in accordance with its terms.

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O

Out-of-Network Benefits
With most HMOs, a patient cannot have any services reimbursed if provided by ahospital or doctor who is not in the network. With PPOs and other managed careorganizations, there may exist a provision for reimbursement of "out of network"providers. Usually this will involve a higher copay or a lower reimbursement.

Out-of-Network Provider
A health care provider with whom a managed care organization does not have a contractto provide health care services. Because the beneficiary must pay either all of the costs ofcare from an out-of-network provider or their cost-sharing requirements are greatlyincreased, depending on the particular plan a beneficiary is in, out-of-network providersare generally not financially accessible to Medicaid beneficiaries.

Out-of-Pocket Expenses, Out of Pocket Costs
Portion of health services or health costs that must be paid for by the plan member,including deductibles, co-payments and co-insurance. In the age of managed care, out ofpocket expenses can also refer to the payment of services not covered by or approved forreimbursement by the health plan.

Out-of-Pocket Limit
A cap placed on out of pocket costs, after which benefits increase to provide fullcoverage for the rest of the year.

Outpatient Care
Care given a person who is not bedridden. Also called ambulatory care. Many surgeriesand treatments are now provided on an outpatient basis, while previously they had beenconsidered reason for inpatient hospitalization.

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P

Participating Provider
Any provider licensed in the state of provision and contracted with an insurer. Usuallythis refers to providers who are a part of a network. That network would be a panel ofparticipating providers. Each payer assembles their own provider panels.

PCP (Primary Care Physician)
Primary care physician who often acts as the primary gatekeeper in health plans. That is,often the PCP must approval referrals to specialists. Particularly in HMOs and somePPOs, all members must choose or are assigned a PCP.

Pharmacy
An establishment where Prescription Drugs are legally dispensed.

Physician
A legally qualified Physician licensed by the state in which he/she practices, and any other practitioner who must by law be recognized as a doctor legally qualified to render treatment.

Physician Organization
This term describes physician linkages and alliances that allow physicians to manage riskand capitation. Information systems, physician relationships, and financial integrationallow these organizations to be more integrated than the traditional solo practice or IPArelationship between healthcare providers and/or managed care organizations that areworking to develop a "seamless" continuum of healthcare services.

Point-of -Service Plan (POS)
Managed care plan which specifies that those patients who go outside of the plan forservices may pay more out of pocket expenses. A health insurance benefits program inwhich subscribers can select between different delivery systems (i.e., HMO, PPO andfee-for-service) when in need of health care services and at the time of accessing theservices, rather than making the selection between delivery systems at time of openenrollment at place of employment. Typically, the costs associated with receiving carefrom the "in network" or approved providers are less than when care is rendered by noncontracting providers. Or the costs are less if provided by approved providers in either the HMO or PPO rather than "out of network" or "out of plan" providers. This is a method of influencing patients to use certain providers without restricting their freedom of choice too severely.

Pre-existing Condition
A medical condition developed prior to issuance of a health insurance policy which mayresult in the limitation in the contract on coverage or benefits. Some policies excludecoverage of such conditions is often excluded for a period of time or indefinitely.

Preadmission Review, Pre-Admission Certification, Pre-Certification, or Preauthorization
Review of "need" for inpatient care or other care before admission. This refers to adecision made by the payer, MCO or insurance company prior to admission. The payerdetermines whether or not the payer will pay for the service. Most managed care plansrequire pre-cert. This is a method of controlling and monitoring utilization by evaluatingthe need for service prior to the service being rendered. The practice of reviewing claimsfor inpatient admission prior to the patient entering the hospital in order to assure that theadmission is medically necessary. A method of monitoring and controlling utilization byevaluating the need for medical service prior to it being performed. The process ofnotification and approval of elective inpatient admission and identified outpatientservices before the service is rendered. An administrative procedure whereby a healthprovider submits a treatment plan to a third party before treatment is initiated. The thirdparty usually reviews the treatment plan, monitoring one or more of the following:patient's eligibility, covered service, amounts payable, application of appropriatedeductibles, copayment factors and maximums. Under some programs, for instance,predetermination by the third party is required when covered charges are expected toexceed a certain amount. Similar processes: preauthorization, precertification, preestimate of cost, pretreatment estimate, prior authorization.

Preferred Care
Care provided by a Preferred Care Provider; or any health care provider for an emergency condition when travel to a Preferred Care Provider is not feasible.

Preferred Care Provider (or Preferred Provider)
A health care provider that has contracted to furnish services or supplies for a Negotiated Charge, but only if the provider is, with the insurance company's consent, included in the Directory as a Preferred Care Provider for the service or supply involved, and the class of which the Covered Person is a member.

Preferred Pharmacy
A Pharmacy which is party to a contract with the insurance company to dispense drugs to persons covered under the Policy, but only while the contract remains in effect; and when the Pharmacy dispenses a Prescription Drug under the terms of its contract with the insurance company.

Preferred Provider Organization (PPO)
Some combination of hospitals and physicians that agrees to render particular services toa group of people, perhaps under contract with a private insurer. The services may befurnished at discounted rates and the insured population may incur out-of-pocketexpenses for covered services received outside the PPO if the outside charge exceeds thePPO payment rate. A PPO can also be a legal entity or it may be a function of an alreadyformed health plan, HMO or PHO. The entity may have a health benefit plan which isalso referred to as a PPO. PPOs are a common method of managing care while stillpaying for services through an indemnity plan. Most PPO plans are point of service plans,in that they will pay a higher percentage for care provided by providers in the network.Many insurers will offer PPOs as well as HMOs. Generally PPOs will offer more choicefor the patient and will provide higher reimbursement to the providers.

Prescription
An order of a prescriber for a Prescription Drug. If it is an oral order, it must be promptly put in writing by the Pharmacy.

Principal diagnosis
The medical condition that is ultimately determined to have caused a patient's admissionto the hospital. The principal diagnosis is used to assign every patient to a diagnosisrelated group. This diagnosis may differ from the admitting and major diagnoses.

Prior Authorization
A formal process requiring a provider obtain approval to provide particular services orprocedures before they are done. This is usually required for non-emergency services thatare expensive or likely to be abused or overused. A managed care organization willidentify those services and procedures that require prior authorization, without which theprovider may not be compensated.

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Q

Sorry, we have no glossary items beginning with the letter “Q”.

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R

Reasonable and Customary (R & C)
The charges which are the smallest of: (a) the Actual Charge; (b) the charge usually made for a covered service by the provider who furnishes it; and (c) the prevailing charge made for a covered service in the geographic area by those of similar professional standing.

Reasonable Charge
Only that part of a charge which is reasonable is covered. The reasonable charge for a service or supply is the lowest of:

• the provider's usual charge for furnishing it
• the charge the insurance company determines to be appropriate, based on factors such as the cost of providing the same or a similar service or supply and the manner in which charges for the service or supply are made
• the charge The insurance company determines to be the prevailing charge level made for it in the geographic area where it is furnished

In some circumstances The insurance company may have an agreement, either directly or indirectly through a third party, with a provider which sets the rate that The insurance company will pay for a service or supply. In these instances, in spite of the methodology described above, the Reasonable Charge is the rate established in such agreement.
In determining the Reasonable Charge for a service or supply that is unusual, not often provided in the area, or provided by only a small number of providers in the area, the insurance company may take into account factors such as:

• complexity
• degree of skill needed
• type of specialty of the provider
• range of services or supplies provided by a facility
• prevailing charge in other areas

Referral
The process of sending a patient from one practitioner to another for health care services.Health Plans may require that designated primary care providers authorize a referral forcoverage of specialty services.

Repatriation
(always refers to a live person) When the member’s condition is stable and/or deemed fit to fly by an attending physician they can then be transported back to their school site or home residence.

Retrospective Review Process
System for analyzing medical necessity and appropriateness of services rendered. Areview that is conducted after services are provided to a patient. The review focuses ondetermining the appropriateness, necessity, quality, and reasonableness of health careservices provided. Becoming seen as least desirable method; supplanted by concurrentreviews.

Return of Mortal Remains
Transportation of mortal remains to home residence or place of burial/ceremony.

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S

Sickness
A disease or illness including related conditions and recurrent symptoms of the Sickness. Sickness also includes pregnancy and complications of pregnancy.

Skilled Nursing Facility (SNF)
A licensed institution, as defined by Medicare, which is primarily engaged in theprovision of skilled nursing care. SNFs are usually located within hospitals, but, sometimes are located in rehab facilities or nursing homes.

Sound Natural Tooth
Free from decay or in good repair and firmly attached to the jaw bone at the time of injury. The following are not considered natural teeth:

• Tooth roots (usually there is a crown/cap placed over the root)
• Congenitally missing teeth
• Diastema (a space between two adjacent teeth in the same arch)

Subrogation
Procedure where the insurance company recovers from a third party when the actionresulting in medical expense (e.g. auto accident) was the fault of another person. Therecovery of the cost of services and benefits provided to the insured of one health planwhen other parties are liable.

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T

Tertiary Care
Services provided by highly specialized providers such as neurosurgeons, thoracicsurgeons and intensive care units. These services often require highly sophisticatedtechnology and facilities.

Third Party Administrator (TPA)
An independent organization that provides administrative services including claimsprocessing and underwriting for other entities, such as insurance companies oremployers. Often insurance companies will contract as TPAs with other insurancecompanies or health plans. TPAs are not always insurance companies. TPAs areorganizations with expertise and capability to administer all or a portion of the claimsprocess. Self-insured employers will often contract with TPAs to handle their insurancefunctions. Insurance companies will sometimes outsource the claims, UR or membershipfunctions to a TPA. Sometimes TPAs will only manage provider networks, only claimsor only UR. Hospitals or provider organizations desiring to set up their own health planswill often outsource certain responsibilities to TPAs.

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U

UB-92-Uniform Billing Code of 1992
Bill form used to submit hospital insurance claims for payment by third parties. Similarto HCFA 1500, but reserved for the inpatient component of health services.

Unbundling
The practice of providers billing for a package of health care procedures on an individualbasis when a single procedure could be used to describe the combined service.

Usual, Customary and Reasonable (UCR)
Commonly charged fees for health services in a certain area. The use of fee screens todetermine the lowest value of provider reimbursement based on: (1) the provider's usualcharge for a given procedure, (2) the amount customarily charged for the service by otherproviders in the area (often defined as a specific percentile of all charges in thecommunity), and (3) the reasonable cost of services for a given patient after medicalreview of the case. Most health plans provide reimbursement for usual and customarycharges, although no universal formula has been established for these rates.

Utilization
Use of services and supplies. Utilization is commonly examined in terms of patterns orrates of use of a single service or type of service such as hospital care, physician visits,prescription drugs. Measurement of utilization of all medical services in combination isusually done in terms of dollar expenditures. Use is expressed in rates per unit ofpopulation at risk for a given period such as the number of admissions to the hospital per1,000 persons over age 65 per year, or the number of visits to a physician per person peryear for an annual physical.

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V

Sorry, we have no glossary items beginning with the letter “V”.

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W

Sorry, we have no glossary items beginning with the letter “W”.

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X

Sorry, we have no glossary items beginning with the letter “X”.

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Y

Sorry, we have no glossary items beginning with the letter “Y”.

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Z

Sorry, we have no glossary items beginning with the letter “Z”.