Health Care Terms

ambulatory care: Medical care given outside a hospital, or within the hospital without the patient being admitted.

ancillary services: Services during your hospital stay other than room, board and nursing. Examples are prescriptions, operating room services and laboratory tests.

appeal: The procedure by which you can question and attempt to reverse a decision made by your health plan, such as denial of coverage for a certain procedure.

benefits package: The services you are entitled to by being part of your health plan.

board certified: A physician who has completed medical school, internship and residency in a medical specialty and who has passed an examination developed and given by a professional organization or society in that specialty.

case management: Process of review by a case manager of conditions that require complex treatment; case manager ensures that a patient is getting the proper services and making the most of his or her benefits.

certificate of coverage: A document describing the benefits you receive as a member of your health plan.

claim: The bill your health plan pays for any health care you receive.

coinsurance: The percentage of covered medical bills that you pay once an annual deductible is met. This percentage is set by your health plan.

coordination of benefits: When you are covered by more than one health insurance company, your primary health plan works with your other health insurance companies to ensure that you are covered by both plans at the maximum benefit level.

copayment: The set amount you pay at the time you go for an office visit or receive other health care services.

covered benefits: Services that are paid for by your health plan, such as regular office visits with your primary care physician.

credentialing: The review of a health care provider's education, licensing, training and performance to determine whether he or she is eligible to be on a hospital's medical staff or part of a health plan's network.

deductible: Set amount of money you must pay for health care coverage, above which your health plan coverage kicks in.

dependent: Any person you support, such as your spouse or child.

drug formulary: List of generic and brand-name medications covered by a health plan.

durable medical equipment: Equipment such as wheelchairs, crutches, walkers and other assistive devices that are usually rented for temporary use rather than purchased.

employee assistance program: A service offered by some companies to help employees deal with emotional or physical health problems or substance abuse issues that are affecting job performance.

formulary: See drug formulary.

health care provider: The people and facilities within the network or your area of coverage that provide health care, including physicians, nurse practitioners, nurses, physician's assistants, pharmacists, therapists, social workers, ambulance services, hospitals, nursing facilities, respiratory therapists and physical therapists.

health maintenance organization (HMO): A type of health care plan that provides health care services from providers in a network to its members.

individual practice association (IPA) model: A health maintenance organization in which physicians provide health care services from their private practices.

identification (ID) card: Cards for you and each covered family member that show that you are part of a health plan. ID cards list important phone numbers at the health plan, your primary care physician's name and phone number, and your member ID number. Always carry your ID card. Show your ID card whenever you seek medical services.

Joint Commission on Accreditation of Healthcare Organizations (JCAHO): an independent, not-for-profit organization that evaluates and accredits health care organizations or institutions such as hospitals, nursing homes, rehabilitation centers and laboratories.

managed care: A health care system in which care provided is reviewed and authorized by the health care plan.

NCQA accreditation: Certification that a managed care organization has been reviewed by the National Committee on Quality Assurance and has demonstrated quality performance in preventive health care, health promotion, and other areas.

network: A group of physicians and other health care providers who are contracted with your health plan to provide health care services in a geographic area.

out-of-network care: Medical services or supplies that are provided by someone outside your network.

out-of-pocket costs: Any money paid by the member for health care services that are not covered by your health plan.

participating provider: A primary care physician, specialist, hospital or other provider that is part of a network within a health care plan.

point-of-service plan: A type of coverage that requires you to pay a deductible for using out-of-network services.

preadmission certification: Sometimes called preauthorization. This is an approval required by many health plans before any scheduled hospital stays and in some cases, before some scheduled outpatient procedures.

preferred provider organization (PPO): A network of providers, including physicians and hospitals, that has a contract with a health plan to provide health care services at a discount for members.

primary care physician: A physician who is responsible for providing, prescribing and coordinating all your health care and treatment.

prior authorization: See preadmission certification.

provider: See health care provider.

Provider network: See network.

referral: When your primary care physician determines that you need to see a specialist to receive specialty care for a medical condition. A referral may be written, phoned in or made via computer, depending on the guidelines set by your health plan.

service area: The geographic area served by your health plan's networks.

staff model: A health maintenance organization (HMO) that employs the physicians and other health care providers who work at the health care centers operated by the HMO.