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Home > Members > Glossary
This glossary of terms to help our members
better understand the terminology we commonly use. It is intended as
a general guide. Please refer to your Evidence of Coverage or Group
Certificate to determine the specific definitions applicable to you
and your specific health care coverage.
A B C D E F
G H I J K L M N O P Q R S T U V W X Y Z
A
Adult: A person who
is 18 years of age or older.
Ancillary
charge: The difference between the cost of a brand name drug and the equivalent generic drug after payment of the
appropriate copayment. The term
"ancillary charge" is also used to describe a charge
applicable to a hospital stay in addition to room and board.
Anniversary
date: The date on which the Group
Agreement is renewed automatically from year to year for
additional 12-month periods, unless terminated by either party.
B
Balance
billing: A specified amount you may be billed and owe to a non-participating/non-preferred physician, health care practitioner or
facility. The amount is the difference between what the health plan pays along with your co-insurance, copayment
and any deductible and the non-participating/non-preferred physician's, health care practitioner's or
facility's charge.
Board-certified:
Any physician who has completed medical school, an internship and
residency in his or her chosen specialty, and has successfully
completed an examination conducted by a group (or board) of peers.
Brand name
drug: A drug manufactured under a trademark by a specific drug
manufacturer.
C
Child: Any person
who is under 18 years of age.
Clinical
care coordination: The processes used by the health plan to establish appropriate
policies, procedures and criteria to carry out pre-authorization/pre-certification, inpatient hospital
review/discharge planning and case management.
Co-insurance:
A traditional method of paying for covered health services in which
portions of the covered expenses are
shared by the health plan and the member. Co-insurance is a defined percentage of
the covered charges for services rendered. For example, under a contract the health plan
may pay 80 percent of the fee maximum for
a particular covered service rendered
by a preferred physician and the member will pay 20 percent of the fee maximum. Or, under a contract
the health plan may pay 70 percent of the
fee maximum for a particular covered service rendered by a non-preferred physician and the member will pay 30 percent and may be required
to pay the difference between the health plan's
fee maximum and the non-preferred physician's requested
payment amount.
Consultant
Treatment Plan: A document used to facilitate written
communication between a specialist and a Primary Care Physician about a
particular HMO member.
Contract: The
employer's group policy or certification, the group specification
summary, any master application, any individual application, any
riders, endorsements, and any amendments to be effective on the
group policy effective date.
Contract year:
Each consecutive 12-month period beginning with the effective date of the Group Agreement.
Conversion
coverage: Coverage that certain members may elect within a certain period of time when
group coverage ends. The conversion coverage does not provide the
same type or level of benefits as the group coverage. Conversion
coverage will be provided under a separate individual conversion
agreement. Members
should read their Evidence of Coverage,
Group Certificate or any associated
riders and endorsements for specific details about conversion
coverage.
Conversion
period: The period of days that follows the date the group coverage terminates for a covered person in
which conversion coverage must be
elected.
Coordination
of Benefits (COB): A provision in a contract
that applies when a person is covered under more than one group health benefits program or other insurance.
It requires that payment of benefits be coordinated by all programs
to eliminate duplication of payments.
Copayment: A
specified sum of money a member is required to
pay in connection with receiving certain services.
Covered
expense: The portion of a physician's, health care practitioner's or
facility's charge for a service that is payable by the health plan.
Covered
service: The items or services payable under the member's contract.
Credentialing:
A process that reviews a health
care practitioner's credentials against the credentials required
to participate in a network. To participate
in our network, physicians, health care practitioners and
facilities are credentialed before being admitted and are
recredentialed every three years.
D
Deductible:
The amount a member must pay out-of-pocket
each contract year for covered services before the health plan will pay. See your Evidence of Coverage, Group Certificate or any associated
riders and endorsements for more details.
Dependent: A
person eligible for coverage under an employee benefits plan because
of that person's relationship to the policyholder. Spouses, children
and adopted children are often eligible for dependent coverage.
Directory
of Health Care Professionals: A listing of physicians, health care practitioners and facilities participating
in our network. Members may refer to the directory to select participating or preferred
physicians, health care
practitioners or
facilities. You can also search the Directory
of Health Care Professionals online. The directory is
accurate as of the date of printing and is subject to change. Members should contact the
physician, health care
practitioner or facility to confirm participation in the network.
Disenrollment:
Termination of one's contract with the health plan.
E
Eligibility:
Provisions contained in each contract that
specify who qualifies for coverage.
Effective date:
The date an eligible employee, retiree or dependent's
coverage becomes effective.
Enrollee: An
eligible employee, eligible retiree or dependent
who is an a health plan member.
Enrollment
date: The date the member applied for
membership into a health plan.
Evidence
of Coverage (EOC): The legal document(s) describing covered
health care services, copayments, all
exceptions, reductions, limitations and exclusions
for HMO members. The EOC is
amended by any riders and endorsements. The policy document for
MD-Individual Practice Association, Inc. (M.D. IPA) federal members is the Federal Employees Health Benefit
(FEHB) brochure, RI 73-100.
Exclusion: An
item or service that is not covered under a policy.
Explanation
of Benefits (EOB): A statement provided by the health plan that identifies the services or
items payable and/or not payable under the contract,
the allowable reimbursement amounts, any deductibles,
co-insurance or other adjustments taken
and the net amount paid. MAMSI Life and Health Insurance Company
(MLH) members typically receive an EOB with a
claim reimbursement check or as confirmation that a claim has been
paid directly to the physician, health
care practitioner or facility. Normally, HMO
members do not receive an EOB.
F
Fee-for-service:
A method of paying for services rendered by physicians or health care practitioners based
on each procedure billed.
Fee maximum:
The allowable charge established by the health
plan for services and procedures.
Fraud: Intentional
misrepresentation, deception or concealment of information for the
purpose of obtaining payment for medical, surgical and diagnostic
services.
Full-time
student: A student who is enrolled in and attending a recognized
course of study or training on a full-time basis (no less than 12
credit hours a semester) at an accredited high school or vocational
school; an accredited college or university; or a licensed technical
school, beautician school, automotive school or other institution of
similar training. Because coverage for a full-time student varies, members should review their Evidence of Coverage or Group Certificate and any associated
riders and endorsements for more details.
G
Grace period:
A specified number of days following the due date of a premium
within which an employer or individual may submit premium payments
without penalty. If payment is not received by the expiration of the
grace period, coverage may be terminated by the health plan.
Group: The legal
entity that has contracted with a MAMSI health plan, which offers
benefits to the group's employees and their dependents.
Group
Agreement: The contract or agreement
between the group and the health
plan to provide specified benefits to employees and dependents.
Group
Certificate: The legal document(s) describing covered services, limitations and exclusions for MAMSI Life and Health
Insurance Company (MLH) members. The Group
Certificate includes all riders and endorsements.
H
Health
care practitioner: Any individual licensed
under the state law in which the treatment is received to
provide health care services (e.g., physical therapist, podiatrist,
chiropractor, nurse). The individual must be practicing within the
scope of that license.
Health Maintenance
Organization (HMO): An organization that arranges for a network of physicians, health care practitioners and
facilities to provide a wide spectrum of health care services to members covered under contracts
issued by the HMO. Our HMOs include: MD-Individual Practice
Association, Inc. (MD IPA), Optimum Choice, Inc.(OCI) and Optimum
Choice of the Carolinas, Inc. (OCCI).
Health plan:
This term is used to refer to one or more of the following MAMSI
subsidiaries: MD-Individual Practice Association, Inc. (MD IPA),
Optimum Choice, Inc. (OCI), Optimum Choice of the Carolinas, Inc.
(OCCI) and MAMSI Life and Health Insurance Company (MLH).
Health Plan Employer
Data and Information Set (HEDIS®): HEDIS is a set
of standardized performance measures designed to ensure that
purchasers and consumers have the information they need to reliably
compare the performance of managed health care plans. HEDIS is
sponsored, supported and maintained by the National
Committee for Quality Assurance (NCQA).
Health plan
identification (ID) card: Health plan ID cards are issued to all
members for identification purposes only.
Health plan ID cards help health
care practitioners verify eligibility
for coverage and contain important information about you, your Primary Care Physician (if
applicable), your copayments and some of the benefits for which you
are eligible. You should present your health plan ID card each time
you receive health care services. Possession of a card confers no
right to services or other benefits.
L
Late enrollee: An
eligible employee or dependent who requests
enrollment following the initial enrollment period provided under
the terms of the Group Agreement.
M
Maximum
out-of-pocket expense: The maximum amount of copayments, deductibles and co-insurance
an individual or family is obligated to pay for covered services per year. Please refer
to your Evidence of Coverage or Group Certificate and any associated
riders and endorsements for more details and to understand how your
maximum out-of-pocket expense is calculated.
Medicare: Parts
A and/or B of the Social Security Act, Title XVIII, that provides
payment for medical and health services to the population aged 65
and over, regardless of income, as well as certain disabled persons
and persons with end-stage renal disease.
Member:
Individuals covered under contracts issued
by MAMSI Life and Health Insurance Company (MLH), MD-Individual
Practice Association, Inc. (MD IPA), Optimum Choice, Inc. (OCI)
and/or Optimum Choice of the Carolinas, Inc. (OCCI).
N
National Committee for
Quality Assurance (NCQA): An independent, not-for-profit
organization dedicated to assessing and reporting on the quality of
managed care plans, managed behavioral health care organizations, preferred provider organizations, new health plans,
physician organizations and credentials verification organizations.
Network:
Physicians, health care
practitioners and facilities under contract
with an insurer, HMO or other entity to provide
health care services to certain individuals.
Non-participating
physician, health care practitioner and facility (provider): A
physician, health care
practitioner or facility who does not have a contract
to participate in our HMO network.
Non-preferred
physician, health care practitioner and facility (provider): A
physician, health care
practitioner or facility who does not have a contract
to participate in our network for MAMSI Life
and Health Insurance Company (MLH) and Alliance PPO, LLC (Alliance).
P
Participant:
A person covered under a policy from a third-party payor with a contract with Alliance PPO, LLC (Alliance) or
its behavioral health product, Mid Atlantic Psychiatric Services,
Inc. (MAPSI).
Participating
physician, health care practitioner and facility (provider): The
term used to describe the physicians, health care practitioners and facilities included in
the network for our HMOs [MD-Individual Practice Association, Inc. (MD
IPA), Optimum Choice, Inc. (OCI) and Optimum Choice of the
Carolinas, Inc. (OCCI)].
Point-of-Service
(POS) plan: An HMO plan, such as
MD-Individual Practice Association, Inc. (MD IPA) Preferred,
Optimum Choice, Inc. (OCI) Preferred or Optimum Choice of the
Carolinas, Inc. (OCCI) Preferred, which allows the member to receive covered health care services
with or without a referral from his or her Primary Care Physician (PCP). In a POS plan, when the PCP gives the member
a referral, the member's
covered services will be paid in
accordance with the HMO benefits. When the member receives covered health care services
without a referral, these services will be
paid in accordance with the POS benefits. For M.D. IPA and OCI, POS
benefits are underwritten by MAMSI Life and Health Insurance Company
(MLH).
Pre-authorization:
The prior approval needed from the health plan
for planned elective admissions, durable medical equipment and
certain prescription drugs. In some
contracts, it is the member's
responsibility to obtain pre-authorization. Be sure to check
your Evidence of Coverage or Group Certificate and any associated
riders and endorsements for more details.
Pre-certification:
The prior approval needed from the Health Plan
before receiving certain non-emergency, outpatient health care
services. In some contracts, it is the member's responsibility to obtain
pre-certification. Be sure to check your Evidence of Coverage or Group Certificate and any associated
riders and endorsements for more details.
Preferred
physicians and/or health care practitioners (providers): The
term used to describe the physicians, health care practitioners and
facilities included in the network for MAMSI
Life and Health Insurance Company (MLH) and Alliance PPO, LLC
(Alliance) who have agreed to accept the health
plan's payment plus any deductible, co-insurance or copayment
as payment in full.
Preferred provider
organization (PPO) plan: A network-based
plan that encourages members to receive covered services from preferred physicians, health care practitioners or
facilities. Members may elect to use non-preferred physicians, health care practitioners or
facilities but generally will have higher out-of-pocket costs and
more administrative tasks if they do.
Prescription
drug: A drug that has been approved by the Food and Drug
Administration (FDA) that can only be dispensed according to a
physician's prescription order.
Primary
Care Physician (PCP): A physician, who usually specializes in
family practice, general practice, internal medicine or pediatrics,
who provides or coordinates an HMO member's non-emergency services covered under
the member's contract.
Each covered family member chooses his or her
own PCP from the HMO's network
of participating physicians and health care practitioners.
Services rendered by a PCP may include: writing referrals
for specialists, arranging for planned
hospitalizations, arranging for outpatient services and surgery,
arranging for approvals required from the HMO for
certain covered health care services and coordinating urgent and
emergency care when appropriate.
R
Referral: If a Primary Care Physician (PCP)
determines that an HMO member
has a condition which requires the attention of a specialist, the PCP makes a referral to a specialist. For most HMO
members (including those with POs coverage
using their in-plan benefits) a referral by the PCP is required to obtain most
services from specialists or other health care practitioners.
Requested
charges: The charge the physician or health care practitioner
requests for a service.
S
Service area:
The geographical area covered by an HMO or PPO network.
Special
enrollment period: A period of 30 days, under most plans, during
which the eligible employee and his or her eligible dependents may enroll in the health plan following the loss of coverage
by the employee or his or her eligible dependents.
This also includes the period of 30 days in which the eligible
employee and his or her dependents may
enroll in the health plan following the
birth, placement for adoption, adoption of a child,
court or testamentary appointment of guardianship of a minor, or
marriage to an eligible employee.
Specialists:
Physicians whose practices are limited to treating a specific
disease (e.g., oncologists), specific parts of the body (e.g., ear,
nose and throat), a specific age group (e.g., pediatricians), or
specific procedures (e.g., oral surgery).
Status change:
A life event that may cause a person to modify his or her health
benefits coverage category. Examples include, but are not limited
to, the birth of a child, divorce or marriage.
Subscriber: An
eligible employee or eligible retiree who, through his or her place
of employment, has enrolled in a health plan.
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