A health care provider who has been contracted to render medical services or supplies to insured persons at a pre-negotiated fee. Providers include hospitals, physicians, and other medical facilities that are part of a PPO or HMO network.
Coverage that can be continued relatively indefinitely (such as to age 65 for most permanent health insurance policies) as long as the policyholder makes scheduled premium payments and refrains from actions that would invalidate the policy (such as misrepresentations on the application)
The insurance agreement or contract.
The twelve month period beginning with the effective date or renewal date of the policy.
The insured person named on the insurance policy.
The ability for an individual to transfer from one health insurer to another health insurer with regard to pre-existing conditions or other risk factors.
A review of an individual’s health care status or condition, prior to an individual being admitted to a hospital or inpatient health care facility. Pre-admission reviews are often conducted by case managers or insurance company representatives (usually nurses) in cooperation with the individual, his or her physician or health care provider, and hospitals.
Medical tests that are completed for an individual prior to being admitted to a hospital or inpatient health care facility.
Under a pre-authorization provision of a health insurance policy, the insured must contact the health insurance company prior to a hospitalization or surgery, and receive authorization for the service.
This is a requirement that a insured person call their health insurance company and advise them a doctor has stated certain medical treatment is required. This is done before receiving treatment from the doctor or hospital. A health insurance policy will normally list the medical conditions that require pre-certification before receiving treatment. When pre-certification is not received, benefits will be reduced or possibly not covered.
A health problem that existed before the date your insurance became effective. Each health insurance company uses its own particular definitions of pre-existing condition. However, the following statement is in line with most insurance company provisions: “A pre-existing condition is a medical condition that would cause a normally prudent person to seek treatment during the twelve months prior to the beginning of coverage.”
PREFERRED PROVIDER ORGANIZATION (PPO):
A network of health care providers with which a health insurer has negotiated contracts for its insured population to receive health services at discounted costs. Health care decisions generally remain with the patient as he or she selects providers and determines his or her own need for services. Patients have financial incentives to select providers within the PPO network.
Federal maternity legislation, enacted in 1978, requires that employers engaged in interstate commerce who have 15 or more employees provide the same benefits for pregnancy, childbirth, and related medical conditions as for any other sickness or injury.
The amount you or your employer pays in exchange for health insurance coverage.
An approach to health care which emphasizes preventive measures and health screenings such as routine physicals, well-baby care, immunizations, diagnostic lab and x-ray tests, pap smears, mammograms and other early detection testing. The purpose of offering coverage for preventive care is to diagnose a problem early, when it is less costly to treat, rather than late in the stage of a disease when it is much more expensive, or too late to treat.
PRIMARY CARE PHYSICIAN (PCP):
Under a health maintenance organization (HMO) plan, the primary care physician is usually an insured person’s first contact for health care. This is often a family physician, internist, or pediatrician. A primary care physician monitors patient health, treats most patient health problems, and refers patients, if necessary, to specialists.
Review of need for health care items or services before services are rendered or products are provided. This refers to a decision made by the health plan to cover or not cover the charges before the services are provided.
Any person (doctor or nurse) or institution (hospital, clinic, or laboratory) that provides medical care.