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Member Support Glossary

Account

A record of financial transactions and balances.

Agent

An independent representative licensed to sell and service health plans.

Allergist

A specialist who treats allergies, or the body’s reaction to substances, situations or physical state.

Allowed amount

The dollar amount that a health plan determines is the appropriate charge for a covered service or supply. The allowed amount may vary from one provider to another.

Amount paid by other insurance

The amount paid by another health plan, such as Medicare or a spouse’s health plan.

Anesthesiology

A branch of medicine that involves pain management and support of a patient’s life functions during surgery.

Appeal

A formal request by a member or health care provider to reconsider a decision about a service, a benefit payment or an administrative action.

Audiology

A branch of medicine dealing with hearing.

Available balance

Dollars remaining in an account that the account holder may use to pay for eligible expenses for the rest of the plan year.

Behavioral health care

The practice evaluating and treating mental health, chemical dependency, autism and eating disorders.

Benefits

The payments or value of services available under the coverage of a plan for treatment of medical costs.

Calendar year

The period starting on January 1st of each year and ending at midnight December 31st of that year.

Cardiovascular disease

A disease involving the heart and blood vessels.

Cardiology

Diagnosis and treatment of diseases of the heart and blood vessels.

Carryover

Amount applied from a previous plan year’s balance. If applicable for your plan, the carryover amount may include eligible costs incurred during the last three months.

Case manager

A health care professional (nurse, doctor or social worker) who works with providers and plans to coordinate care for patients.

Chiropractic care

Treatment to restore normal function through manipulation and adjustment of the body; particularly of the spinal column.

Claim

A medical claim is a request for payment under the terms of a health benefits plan. A reimbursement account, spending account or similar account claim is a request to be reimbursed from that account’s available funds.

Claim number

The unique number assigned by the health plan to identify each request for payment (claim) from a provider. The claim number is listed on the Explanation of Health Care Benefits (EOB) statement.

Claim status

  • In Process --- The claim has been received in our office and is being considered.
  • Finalized -- The claim has been processed.
  • Adjusted -- A previously finalized claim that is being reviewed due to additional information or documentation.

COBRA

Cobra stands for Consolidated Omnibus Budget Reconciliation Act. A federal law passed in 1985 that permits many people who lose eligibility under a group health plan to continue using that coverage.

Coinsurance (Co-ins)

The percent of covered health care costs that a member pays. (For example: If the allowed amount for an office visit is $125.00, your deductible has been met, the coinsurance is 20% then your responsibility would be $25.00).

Contributions

Dollars put into an account. Depending on the rules for the account, contributions can be paid by the employer, the employee or both parties.

Coordination of benefits

In cases where a person has more than one plan, coordination of benefits means one plan pays first (primary) and one plan pays second (secondary).

Co-payment (Co-pay)

The dollar amount that you pay for certain covered services. (Example: Your plan may have a $50.00 co-payment for an emergency room visit.)

Coverage type

Reflects the number of individuals carried under the health plan coverage (e.g., single coverage, family coverage).

Credentialing

The process of reviewing providers who apply to participate in a health plan to make sure they meet the plans’ requirements.

Date (contributions)

The date the contribution dollar amount was credited to the account.

Date (withdrawls)

The date the withdrawl dollar amount was paid out from the account.

Date paid

The date the payment was sent. This may reflect the date the check was issued or the date the direct deposit or other automatic payment was sent to the account.

Date of Service

The date the provider performed health care services or the date prescription drugs were dispensed.

Deductible

The amount you must pay for certain covered services each year before your health insurance plan begins to pay. The deductible may not apply to all services. (Example: If your deductible is $500.00, your plan will not pay anything until you have paid your deductible).

Denied claim

A claim that has been processed but not paid, usually due to services not being covered under the terms of your health plan.

Dependent

A spouse, domestic partner or a child who is enrolled as part of another member’s health plan.

Dermatology

Diagnosis and treatment of skin disorders.

Diagnostic services

X-ray, laboratory and pathology services that help diagnose or treat an illness or injury.

Drug formulary

A list of prescription drugs which are eligible for coverage under the plan.

Durable medical equipment

Medical equipment that is able to withstand repeated use and is used primarily for a medical purpose. (Example: wheelchairs, crutches and hospital beds).

EAP (Employee Assistance Program)

A confidential counseling and referral service for personal and work-related problems.

Effective date

The date the coverage period begins.

Election amount

The dollar amount chosen to be contributed to the plan for the entire plan year.

Eligibility

The conditions a person must satisfy to be covered by the health plan contract.

Eligible charges

Services covered according to the health plans contract.

Emergency

Any unexpected condition that the patient feels requires immediate medical or surgical attention.

Endocrinology

A science dealing with the endocrine glands, which produce secretions that help control metabolism.

ERISA

ERISA stands for Employee Retirement Income Security Act. An act which places regulations on employee benefit plans, including health insurance.

Exclusions

Services or supplies that are not covered by your health plan.

Explanation of benefits (EOB)

A notice sent from the health plan to the member describing the resolution of a claim. It includes services provided, amount billed, payment made and any costs that are the member’s responsibility.

Family deductible

The combined amount that covered family members must pay toward covered services each plan year before the plan will begin to pay benefits.

Family out-of-pocket maximum

The most that covered family members together must pay toward covered services. After a family reaches the out-of-pocket maximum, the plan pays 100 percent of the allowed amount for covered services for the rest of the plan year.

Family practice

A medical specialty that focuses on health care for the entire family, including obstetric care and minor surgical procedures.

FSA dependent care

FSA stands for flexible spending account. A dependent care FSA reimburses the participant for qualified dependent care cost through a pre-tax account.

FSA medical

FSA stands for flexible spending account. A medical FSA reimburses the participant for qualified health care costs through a pre-tax account.

Gastroenterology

Diagnosis and treatment of stomach, intestine, liver and pancreas diseases.

General practitioner

A physician who does not limit his or her field of practice to a specialty.

Generic drug

Bioequivalent, lower cost version of a brand-name drug, available when patent protection expires on a brand-name drug.

Geriatrics

Diagnosis and treatment of diseases and conditions specific to aging.

Group name

The name of the employer or association to which the group health coverage contract is issued.

Group number

The unique number assigned to the employer or association to which the group health coverage contract is issued. This number is listed on the member ID card.

Gynecology

Medical and surgical treatment for disorders and diseases of the female productive and urinary systems.

Health care provider

A hospital, clinic, physician or other facility providing health care services.

Health cost summary

Shows health plan and any financial account use and costs for calendar year-to-date. The summary is for a subscriber and any covered dependents.

Health plan

Sometimes referred to as medical plan. Health plan generally means a health benefits plan provided by an employer to its employees. Health plans typically pay some portion of medical costs, and may include coverage for behavioral health, pharmacy and other health-related expenses.

Health plan responsibility

The amount or portion of the total charges for health care services that the health plan must pay.

Health risk assessment

A confidential tool that helps users identify their individual health risks and offers suggestions to reduce those risks.

Home health care

Health care services provided in the patient’s home. This care is provided by health care professionals or home health aides.

Hospice

Services that provide comfort and support to those that are suffering from a terminal disease or condition.

HRA

HRA stands for health reimbursement arrangement, but it is sometimes referred to as a health reimbursement account. An HRA is an employer-funded account through which the participant is reimbursed for qualified health care expenses that are not paid by their health plan (for example, copayments).

HSA (Health Savings Account)

Health savings accounts can include funds contributed by the account holder and/or the employer to pay for eligible health care expenses.

Immunization center

A location where providers administer vaccinations, such as public health center, pharmacy or mall. May also include a physician office setting.

Immunology

The study of immunity and immune responses.

In-network

Providers that have entered into a specific network contract with the health plan. In network providers are also referred to as Participating Providers. Based on the contract, in network providers have agreed to accept our allowed amount as payment in full.

Individual deductible

The fixed dollar amount an individual (or each individual family member covered by a subscriber) must pay toward certain covered services each plan year before the plan will begin to pay benefits.

Individual out-of-pocket maximum

The most an individual covered person (or each individual family member covered by a subscriber) must pay toward the allowed amount for covered services. After a person reaches the out-of-pocket maximum, the plan pays 100 percent of the allowed amount for covered services for the rest of the plan year.

Inpatient

A facility other than psychiatric, which primarily provides diagnostic, therapeutic (both surgical and non-surgical), and rehabilitation services by, or under, the supervision of physicians to patients admitted for a variety of medical conditions.

Internal medicine

A branch of medicine that focuses on treating diseases of adults. Doctors who specialize in internal medicine are called internists.

Internists

A doctor who specializes in internal medicine.

Investigative

A drug, device, diagnostic procedure, technology, or medical treatment or procedure is investigative if reliable evidence does not permit conclusions concerning its safety, effectiveness, or effect on health outcomes.

Long-term care insurance

Coverage designed to reduce the risk that the contract holder would need to deplete his or her assets to pay for long-term care.

Medical summary plan description

The medical summary plan description (SPD) is an important document that tells participants what the plan provides and how it operates. It provides information on when an employee can begin to participate in the plan, how service and benefits are calculated, when benefits become vested, when and in what form benefits are paid, and how to file a claim for benefits.

Medically necessary

Health care services that are: (a) in accordance with generally accepted standards of medical practice; (b) clinically appropriate; (c) not primarily for the convenience of the patient or health care provider; and (d) not more costly than an alternative service.

Member

A person covered by a health plan.

Member ID

The identification number assigned to a member.

Member ID card

A card that identifies members of a plan. It lists the identification number, group number and effective date of the plan and includes important phone numbers.

Neonatology

Diagnosis and treatment of disorders in newborns.

Nephrology

Diagnosis and treatment of fluid and electrolyte disorders and hypertension, including kidney disorders.

Neurology

Diagnosis and treatment of diseases and injuries of the nervous system (brain, spinal cord, nerves).

Non preferred drug

A drug that has not been approved by the Pharmacy and Therapeutics (P&T) committee for inclusion in the drug formulary.

Nurse midwife

A licensed health care professional who provides services and care for women during and after normal pregnancy and labor.

Nurse Practitioner

A licensed registered nurse who has gained additional knowledge and skills through an organized program of study and clinical experience.

Obstetrics

Health care during and after a woman’s pregnancy.

Obstetrics/gynecology (ob/gyn)

The medical specialty that focuses on women’s health care issues like pregnancy, childbirth, family planning and annual checkups.

Occupational therapy

A branch of medicine that involves a program of activities to help patients regain a degree of independence or return to employment.

Office

Location, such as a clinic, where the health professional routinely provides health examinations, diagnosis and treatment of illness or injury.

Oncology

The medical science or specialty concerned with the diagnosis and treatment of tumors, commonly various forms of cancer.

Out-of-pocket maximum

The most an individual or family must pay each plan or calendar year towards the allowed services. Once the out-of-pocket maximum is reached, the plan will pay 100% of the allowed amount for covered services for the rest of the plan or calendar year.

Open enrollment

The period of time when an employee may change enrollment status or benefit plans, usually without evidence of good health or waiting periods.

Ophthalmology

Diagnosis and treatment of glaucoma and muscle disorders of the eye, including cataract surgery and laser treatment, and vision evaluation and prescribing of corrective lenses.

Optometry

The profession of examining the eye for defects and prescribing corrective lenses or exercises to correct the defect.

Oral and maxillofacial surgery

Diagnosis and treatment of disorders of the mouth, teeth, jaws and facial structures, including surgical correction of facial deformities and fractures.

Oral Surgery

Field of dentistry dealing with surgery of the mouth and its related structures.

Orthotics

Specialized field relating to orthopedic appliances, braces and other devices used to support weight, prevent or correct deformities, or align and improve the function of movable parts of the body.

Osteopath

Similar to medical doctors, osteopaths (also referred to as doctors of osteopathic medicine or DOs) emphasize the role of the bones, muscles, and joints in the healthy functioning of the human body.

Otolaryngology

The diagnosis and treatment of diseases and disorders of the ear, nose, and throat. Also referred to as ENT.

Out-of-network

Providers that have not entered into a specific contract with the health plan. Out of network providers are also referred to as Non-Participating Providers. Because there is no contract the member shares more of the cost for the care received.

Out-of-network benefits

The option to see health care providers who don’t have a contract with the health plan. When benefit plans include this option, members share more of the costs when receiving care from out-of-network providers.

Out-of-pocket costs

The portion of health care costs that a member must pay, including copays, coinsurance, deductibles and noncovered services. Also referred to as “patient responsibility.”

Outpatient Care

Services provided in a hospital setting that do not require a patient to be admitted for an overnight stay.

Paid claims

Claims for which the plan has made payment to the provider or participant.

Patient

The covered member receiving health services or prescription drugs.

Pediatrics

The prevention, diagnosis and treatment of diseases in children, from birth through the teenage years.

Pending claims

Claims that have begun to be processed but have not yet been completed. Amounts listed under this heading reflect the total dollar amount of pending claims for all claims associated with this account.

Pharmacy

A facility or location where drugs and other medically related items and services are sold, dispensed or otherwise provided directly to patients.

Physiatry:

The diagnosis, treatment and prevention of disease with the aide of physical agents such as light, heat, cold and water, or with medical apparatus. Physiatry is focused on rehabilitative medicine.

Physical Therapy

Treatment of bodily ailments and muscular function through various physical and nonmedicinal means (the use of heat, water, exercise, massage and electric current, for example).

Physician

A licensed doctor of medicine with full training in traditional medical practice. Physicians undergo a broad-based medical school education, extensive experience in residency and a comprehensive series of medical board examinations prior to being licensed.

Plan year

A 12-month period which begins on the effective date of the Plan, as stated in the Introduction section, and each succeeding 12-month period thereafter. .

Plastic Surgery

Plastic surgical procedures fall into two major subdivisions: reconstructive procedures, which involve the restoration of form and/or function of body parts that are abnormal due to injury, disease, or congenital defects, and cosmetic procedures, which are performed to enhance the appearance of body parts which fall within the normal range of appearance and function.

Podiatry

The diagnosis and treatment of feet disorders.

Preadmission Certification

This is a process to provide a review and determination related to a specific request for care or services. This is required prior to a nonemergency admission. Preadmission certification is required for the following:

  1. Acute rehabilitation admissions
  2. Long-term acute care admissions
  3. Skilled nursing facilities

Preadmission Notification

This is a process where the provider or you inform the Claims Administrator that you will be admitted to the hospital. This is required prior to a nonemergency admission. Preadmission notification is required for the following:

  1. Hospital acute care admissions
  2. Residential behavioral health treatment facilities
  3. Mental health and substance abuse admissions

Pre-existing condition

A condition, excluding genetic information or an existing pregnancy, that existed prior to your enrollment date and for which medical advice, diagnosis, care, or treatment was recommended or received. . If a condition is pre-existing, it may not be covered for a specific period of time under some contracts.

Preferred drug

A list of drugs that are covered by your plan.

Premium

The amount an individual pays their Employer for health insurance coverage. In some cases, the individual pays a portion and the employer pays the rest.

Preventive care

Proactive healthcare to prevent diseases, injuries or medical conditions before they happen. This often includes immunizations, screenings and appropriate lifestyle changes.

Primary care

Basic or general health care usually provided by general practitioners, family practitioners, internists and pediatricians.

Prior authorization

A process that involves a benefit review and determination of medical necessity before a service is rendered.

Process date

The date a claim was administered or adjusted.

Prosthetics

The study or artificial limbs- their design, construction and fitting to a patient.

Provider responsibility amount

The amount that the cost of health care services is reduced based on a contract between the health plan and the provider.

Provider

Any individual or group that provides health care services, such as doctors, hospitals, group practices, nursing homes or pharmacies.

Psychiatry

The study, diagnosis, treatment and prevention of mental illness.

Psychologist

A practitioner of clinical psychology, counseling and guidance.

Psychotherapy

The psychological techniques used in behavioral health care.

Pulmonary medicine

Diagnosis and treatment of lung diseases and conditions such as bronchitis, emphysema and cancer.

Radiology

A branch of medicine concerned with the use of X-rays and radium in the diagnosis and treatment of disease.

Reasonable and customary

Refers to the dollar amount allowed for a particular service and is often set by the insurance company or third-party payer. Companies typically establish this amount based on the average cost of the procedure in your geographical area.

Rheumatology

The diagnosis and treatment of muscle and joint diseases and conditions, particularly arthritis.

Self-insured plan

A benefit plan offered by a company in which the company pays for its employees’ health care claims.

Service from

Beginning date of the service.

Service to

Ending date of the service.

Skilled nursing care

Services provided in your home or a nursing home by licensed nurses or other licensed healthcare professionals.

Skilled nursing facility

A facility which primarily provides inpatient skilled nursing care and related services to patients who require medical, nursing or rehabilitative services but does not provide the level of care or treatment available in a hospital.

Specialist

A doctor with specialized medical training.

Speech therapy

The therapeutic treatment of speech defects, such as lisping and stuttering.

Sports medicine

A medical specialty concerned with the prevention and treatment of injuries and diseases that are related to participation in sports.

Subscriber

The person whose employment is the basis for the health plan and who is responsible for payment of premiums.

Subscriber ID

The unique health plan identifier for the contract holder, which is usually a series of numbers and/or letters. The subscriber ID (identification number) is printed on the member ID card.

Termination date

The date the coverage period ends.

TPA (Third Party Administrator)

An organization that administers the healthcare benefits, mostly for self-funded employers.

Urgent Care

Care provided for a condition that is not serious enough to receive care at an Emergency Room.

Urology

A branch of medicine that involves diagnostic and treatment of diseases and disorders of the kidneys, bladder, and urinary tract. Also includes the treatment of disorders affecting the male reproductive organs.

VEBA

VEBA stands for voluntary employee beneficiary association and it refers to a type of consumer-directed health plan that is available to employer groups that belong to the Minnesota Services Cooperative. A VEBA account is an employer-funded account through which the participant is reimbursed for qualified health expenses that are not paid by their health plan.

Withdrawl

The dollar amount reimbursed to the account holder from the account.


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