Insurance Dictionary (A-D) To Clear It All Up

Below, you will find the most frequently used insurance terms. It is not completely comprehensive but it should cover the overwhelming majority of your questions.

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A

access: A person's ability to obtain affordable medical care on a timely basis.

accreditation1: An evaluative process in which a healthcare organization undergoes an examination of it's operating procedures to determine whether the procedures meet designated criteria as defined by the accrediting body, and to ensure that the organization meets a specified level of quality.

ACF: See ambulatory care facility.

acquisition: The purchase of one organization by another organization.

ACR: See adjusted community rating.

actuaries: The insurance professionals who perform the mathematical analysis necessary for setting insurance premium rates.

adjusted community rating (ACR): A rating method under which a health plan or MCO divides its members into classes or groups based on demographic factors such as geography, family composition, and age, and then charges all members of a class or group the same premium. The plan cannot consider the experience of a class, group, or tier in developing premium rates. Also known as modified community rating or community rating by class.

administrative services only (ASO) contract: The contract between an employer and a third party administrator.

adverse selection: See antiselection.

agent: A person who is authorized by an MCO or an insurer to act on its behalf to negotiate, sell, and service managed care contracts.

aggregate stop-loss coverage: A type of stop-loss insurance that provides benefits when a group's total claims during a specified period exceed a stated amount.

ambulatory care facility (ACF): A medical care center that provides a wide range of healthcare services, including preventive care, acute care, surgery, and outpatient care, in a centralized facility. Also known as a medical clinic or medical center.

ancillary services2: Auxiliary or supplemental services, such as diagnostic services, home health services, physical therapy, and occupational therapy, used to support diagnosis and treatment of a patient's condition.

annual maximum benefit amount: The maximum dollar amount set by an MCO that limits the total amount the plan must pay for all healthcare services provided to a subscriber in a year.

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.

appropriate care3: A diagnostic or treatment measure whose expected health benefits exceed its expected health risks by a wide enough margin to justify the measure.

appropriateness review: An analysis of healthcare services with the goal of reviewing the extent to which necessary care was provided and unnecessary care was avoided.

ASO contract: See administrative services only contract.

associate medical director4: Manager whose duties are often defined as a subset of the overall duties of the medical director.

at-risk: Term used to describe a provider organization that bears the insurance risk associated with the healthcare it provides.

autonomy5: An ethical principle which, when applied to managed care, states that managed care organizations and their providers have a duty to respect the right of their members to make decisions about the course of their lives:

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B of the Insurance Dictionary

behavioral healthcare: The provision of mental health and substance abuse services.

beneficence6: An ethical principle which, when applied to managed care, states that each member should be treated in a manner that respects his or her own goals and values and that managed care organizations and their providers have a duty to promote the good of the members as a group.

benefit design: The process an MCO uses to determine which benefits or the level of benefits that will be offered to its members, the degree to which members will be expected to share the costs of such benefits, and how a member can access medical care through the health plan.

blended rating: For groups with limited recorded claim experience, a method of forecasting a group's cost of benefits based partly on an MCO's manual rates and partly on the group's experience.

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.

business integration: The unification of one or more separate business (nonclinical) functions into a single function:

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C of the Insurance Dictionary

capitation7: A method of paying for healthcare services on the basis of the number of patients who are covered for specific services over a specified period of time rather than the cost or number of services that are actually provided.

capped fee: See fee schedule.

captive agents: Agents that represent only one health plan or insurer.

carve-out: Specialty health service that an MCO obtains for 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 healthcare needs, developing a health-care strategy that meets those needs, and coordinating and monitoring the care, with the ultimate goal of achieving the optimum healthcare outcome in an efficient and cost-effective manner. Also known as large case management (LCM).

case-mix adjustment: See risk-adjustment.

categorically needy individuals: Enrollees in Medicaid programs who meet traditional Medicaid age and income requirements.

certificate of authority (COA): The license issued by a state to an HMO or insurance company which allows it to conduct business in that state.

CHAMPUS: See Civilian Health and Medical Program of the Uniformed Services.

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.

CHIP: See Children's Health Insurance Program.

Civilian Health and Medical Program of the Uniformed Services (CHAMPUS): A program of medical benefits available to inactive military personnel and military spouses, dependents, and beneficiaries through the Military Health Services System of the Department of Defense. See also TRICARE.

claim: An itemized statement of healthcare services and their costs provided by a hospital, physician's office, or other provider facility. Claims are submitted to the insurer or managed care plan by either the plan member or the provider for payment of the costs incurred.

claim form: An application for payment of benefits under a health plan.

claimant: The person or entity submitting a claim.

claims administration: The process of receiving, reviewing, adjudicating, and processing claims.

claims analysts: See claims examiners.

claims examiners8: Employees in the claims administration department who consider all the information pertinent to a claim and make decisions about the MCO's payment of the claim. Also known as claims analysts.

claims investigation9: The process of obtaining all the information necessary to determine the appropriate amount to pay on a given claim.

claims supervisors: Employees in the claims administration department who oversee the work of several claims examiners.

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.

clinic model: See consolidated medical group.

clinical integration: A type of operational integration that enables patients to receive a variety of health services from the same organization or entity, which streamlines administrative processes and increases the potential for the delivery of high-quality healthcare.

clinical practice guideline: A utilization and quality management mechanism designed to aid providers in making decisions about the most appropriate course of treatment for a specific clinical case.

clinical status: A type of outcome measure that relates to improvement in biological health status.

closed access: A provision which specifies that plan members must obtain medical services only from network providers through a primary care physician to receive benefits.

closed formulary10: The provision that only those drugs on a preferred list will be covered by a PBM or MCO.

closed-panel HMO: An HMO whose physicians are either HMO employees or belong to a group of physicians that contract with the HMO.

closed PHO: A type of physician-hospital organization that typically limits the number of participating specialists by type of specialty.

closed plans: According to the NAIC's Quality Assessment and Improvement Model Act, managed care plans that require covered persons to use participating providers.

CMP: See competitive medical plan.

COA: See certificate of authority.

COBRA: See Consolidated Omnibus Budget Reconciliation Act.

coinsurance: A method of cost-sharing in a health insurance policy that requires a group member to pay a stated percentage of all remaining eligible medical expenses after the deductible amount has been paid.

community rating: A rating method that sets premiums for financing medical care according to the health plan's expected costs of providing medical benefits to the community as a whole rather than to any sub-group within the community. Both low-risk and high-risk classes are factored into community rating, which spreads the expected medical care costs across the entire community.

community rating by class (CRC): The process of determining premium rates in which a managed care organization categorizes its members into classes or groups based on demographic factors, industry characteristics, or experience and charges the same premium to all members of the same class or group. See adjusted community rating (ACR).

compensation committee:. Committee of the board of directors that sets general compensation guidelines for a managed care plan, sets the CEO's compensation, and approves and issues stock options.

competitive advantage: A factor, such as the ability to demonstrate quality, that helps a managed care organization compete successfully with other MCOs for business.

competitive medical plan (CMP): A federal designation that allows a health plan to enter into a Medicare risk contract without having to obtain federal qualification as an HMO.

concurrent authorization: Authorization to deliver healthcare service that is generated at the time the service is rendered.

conflict of interest: For an MCO board member, a conflict between self-interest and the best interests of the plan.

consolidated medical group: A large single medical practice that operates in one or a few facilities rather than in many independent offices. The single-specialty or multi-specialty practice group may be formed from previously independent practices and is often owned by a parent company or a hospital. Also known as a medical group practice or clinic model.

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.

consolidation: A type of merger that occurs when previously separate providers combine to form a new organization with all the original companies being dissolved.

contract management system: An in- formation system that incorporates membership data and reimbursement arrangements, and analyzes transactions according to contract rules. The system may include features such as decision support, modeling and forecasting, cost reporting, and contract compliance tracking.

copayment: A specified dollar amount that a member must pay out-of-pocket for a specified service at the time the service is rendered.

corporation: A type of organizational structure that is an artificial entity, invisible, intangible, and existing only in contemplation of the law.

CRC: See community rating by class.

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 MCO's preestablished criteria for participation in the network.

credentialing committee11: Committee, which may be a subset of the QM committee, that oversees the credentialing process.

credibility: A measure of the statistical predictability of a group's experience.

cure provision: A provider contract clause which specifies a time period (usually 60-90 days) for a party that breaches the contract to remedy the problem and avoid termination of the contract.

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D of the Insurance Dictionary

deductible: A flat amount a group member must pay before the insurer will make any benefit payments.

demand management: The use of strategies designed to reduce the overall demand for and use of healthcare services, including any benefit offered by a plan that encourages preventive care, wellness, member self-care, and appropriate utilization of health services.

dental health maintenance organization (DHMO): An organization that provides dental services through a network of providers to its members in exchange for some form of prepayment.

dental point of service (dental POS) option.12: A dental service plan that allows a member to use either a DHMO network dentist or to seek care from a dentist not in the HMO network. Members choose in-network care or out-of-network care at the time they make their dental appointment and usually incur higher out-of-pocket costs for out-of-network care.

dental POS option12: See dental point of service option.

dental PPO: See dental preferred provider organization.

dental preferred provider organization (dental PPO): An organization that provides dental care to its members through a network of dentists who offer discounted fees to the plan members.

DHMO: See dental health maintenance organization.

diagnostic and treatment codes13: Special codes that consist of a brief, specific description of each diagnosis or treatment and a number used to identify each diagnosis and treatment.

direct response marketing: See direct marketing.

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

disease state management: See disease management.

DM: See disease management.

drive time: A measure of geographic accessibility determined by how long members in the plan's service area have to drive to reach a primary care provider.

drug cards: See pharmaceutical cards.

drug utilization review (DUR)14: A review program that evaluates whether drugs are being used safely, effectively, and appropriately.

due process clause: A provider contract provision which gives providers that are terminated with cause the right to appeal the termination.

DUR: See drug utilization review.

I hope that you are finding my insurance insurance dictionary to be informative. Of course, if you have any further questions, please contact me.