Special Specialists
A complementary/alternative system of medical theory, oriental diagnosis and treatment used to promote health and treat organic or functional disorders. Treats specific points or meridians.
Acupuncture
Your share of the costs of a covered health care service, calculated as a percent of the allowed amount for the service.
Co-insurance
Covers hospital care. This generally includes inpatient care in hospitals (such as critical access hospitals, inpatient rehabilitation facilities, etc.).
Medicare Part A
Individually-identifiable information created and kept by a covered health care organization. Includes: Information about members past, present, future physical or mental health.
Protected Health Information (PHI)
The amount owed to the provider which includes both payment made by the insurance company and the member share of cost when applicable. Its usually based on an agreed upon contract.
Allowed Amount
This medicine department specializes in disorders of the skeletal system.
Orthopedics
The entire family deductible must collectively be met before copayments/coinsurance apply for all family members.
Aggregate
This is a legal document that assists a patient in expressing their wishes & views about medical treatment, most especially about life support.
Advance Directive
Governmental agency or non-profit entity that meets the applicable standards of this part and makes Qualified Health Plan's available to qualified individuals and qualified employers.
Healthcare Exchange
A request for your health insurer or plan to review a decision or a grievance again.
Appeal
Surgery and follow-up treatment needed to correct or improve a part of the body because of birth defects, accidents, injuries or medical conditions.
Reconstructive Surgery
The first approved version of a drug. Marketed and sold under a proprietary, trademark-protected name by the pharmaceutical company that holds the original patent.
Brand Name Drug
This is a supplemental health insurance policy marketed by outside private companies to fill holes in Original Medicare coverage or to cover a range of expenses that Medicare Part C does not offer such as overseas travel medical insurance.
Medigap
This a federal agency within the US Department of Health and Human Services that administers the Medicare program and works in partnership with State governments to administer Medicaid, the State Children's Health Insurance Program (SCHIP), and health insurance portability standards.
CMS
When a provider bills you for the difference between the provider’s charge and the allowed amount.
Balance Billing
These highly skilled professionals are licensed through their state Board. They can practice independently, as part of a partnership, or within a team. Most commonly specialized in adult, family, pediatrics, women's health, and acute care. They can write prescriptions for most medications, except those that are experimental.
Nurse practitioners
When two or more group health insurance plans cover the insured and dependents one plan becomes the primary plan and the other plan the secondary plan.
COB
A request to disenroll Medicare from a carrier prior to the usual and customary policy of "effective the first of the following month" of the written request for disenrollment. Usually requested to coincide with the date of services received out of plan.
Retro Disenrollment
This committee tracks the quality of care delivered by the nation’s health plans.
National Committee for Quality Assurance. NCQA
This tells the provider how the claim was adjudicated and if the member is responsible for any or all of the payment – copayments, coinsurance, deductibles, noneligible coverage, etc.
Remittance Advice
This type of care focuses on providing patients with relief from the symptoms, pain, and stress of a serious illness - whatever the diagnosis - with the goal to improve quality of life for both the patient and the family.
Palliative care
Non-standard benefits that may be purchased by a client such as: Chiropractic Care, Infertility Treatment, Transgender Services, and Vision Care.
Benefit riders
It begins with the first day a member is admitted to a hospital or nursing home and ends with the 60th consecutive day thereafter during which the member was not a patient in a hospital or nursing home.
Medicare Benefit Period
This national program asks consumers and patients about their experiences with health care. Survey topics include getting care quickly and shared decision-making.
Consumer Assessment of Healthcare Providers and Systems (CAHPS)
This is the common method of determining the allowed amount for non-contracted providers. Generally based on the “going rate” in a geographic area, usually based on zip code.
Reasonable & Customary (R&C)